title: ERCP in potentially resectable malignant biliary obstruction is frequently unsuccessful when performed outside of a comprehensive pancreaticobiliary center.
abstract: OBJECTIVE
  ERCP prior to pancreaticoduodenectomy is unnecessary in select patients. When performed, it should be in conjunction with endoscopic ultrasound (EUS) to increase diagnostic sensitivity and allow for metal stent placement. The aim of this study was to determine differences in endoscopic practice patterns at community medical centers (CMC) and a comprehensive pancreaticobiliary referral center (PBRC).
  
  
  METHODS
  Retrospective cohort study of all patients seen at a PBRC for endoscopic and/or surgical management of potentially resectable malignant distal biliary obstruction from 1/2011 to 6/2014.
  
  
  RESULTS
  Of 75 patients, 30 underwent endoscopic management at a CMC and 45 were initially managed at our PBRC. ERCP was attempted in 92% of patients. EUS was performed more frequently (100% vs. 13.3 %, P < 0.0001), ERCP was more successful (93% vs. 69%, P = 0.02), and metal stent placement more likely (41% vs. 5%, P = 0.005) at our PBRC compared to a CMC. The majority (81%) of patients undergoing initial endoscopy at a CMC required repeat endoscopy at our PBRC.
  
  
  CONCLUSIONS
  Patients who are candidates for pancreaticoduodenectomy frequently undergo ERCP. At a CMC, ERCP is often unsuccessful, is rarely accompanied by EUS, and often requires repeat endoscopy. Our findings support regionalizing the management of suspected pancreatic malignancy into dedicated specialty centers. J. Surg. Oncol. 2016;113:647-651. © 2016 Wiley Periodicals, Inc.
authors.affiliation: Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Erica
authors.initials: E
authors.lastname: Donnan
authors.affiliation: Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
authors.affiliation: Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Srinadh
authors.initials: S
authors.lastname: Komanduri
authors.affiliation: Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: David M
authors.initials: DM
authors.lastname: Mahvi
authors.affiliation: Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Rajesh N
authors.initials: RN
authors.lastname: Keswani
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000150:complications*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods / Q000706:statistics & numerical data*; D002779:Cholestasis / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D019160:Endosonography; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006764:Hospitals, Community / Q000706:statistics & numerical data*; D006801:Humans; D007087:Illinois; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D063728:Secondary Care Centers / Q000706:statistics & numerical data*; D015607:Stents / Q000706:statistics & numerical data; D062606:Tertiary Care Centers / Q000600:supply & distribution*; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
keywords: cholangiopancreatography, endoscopic retrograde; endoscopic ultrasound-guided fine needle aspiration; pancreatic neoplasm