Association Between Endoscopist and Center Endoscopic Retrograde Cholangiopancreatography Volume With Procedure Success and Adverse Outcomes: A Systematic Review and Meta-analysis

BACKGROUND & AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) has become a predominantly therapeutic intervention with a resultant increase in complexity. The relationship between ERCP volume and outcomes is unclear. We aimed to conduct a systematic review and meta-analysis assessing the relationship between endoscopist and center ERCP volume with ERCP success and adverse event (AE) rates. METHODS: A comprehensive search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted from inception to January 2017. Studies providing outcomes stratified by endoscopist and/or center volume were included in the final analysis. Endoscopist/center volume was stratified as low volume (LV) and high volume (HV). The definition of ERCP success varied between studies. The overall AE rate was a composite rate including pancreatitis, perforation, and bleeding. RESULTS: A literature search resulted in 1264 citations. Of those, 13 articles (n = 59,437 ERCPs) met inclusion criteria. LV endoscopist (< 25 to < 156 annual ERCPs) and center (< 87 to < 200 annual ERCPs) definitions varied between studies. HV endoscopists were significantly more likely to achieve ERCP success compared with LV endoscopists (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.2-2.1). HV centers were significantly more likely to achieve ERCP success (OR, 2; 95% CI, 1.6-2.5). The post-ERCP AE risk was lower for HV endoscopists (OR, 0.7; 95% CI, 0.5-0.8) but not HV centers (OR, 0.7; 95% CI, 0.3-1.5). CONCLUSIONS: This study identifies a significant relationship between increasing endoscopist and center ERCP volume with overall procedure success. Increasing endoscopist volume also was associated with a decreased AE rate. Given these compelling findings, we propose that providers and payers consider consolidating ERCP to HV endoscopists to improve ERCP outcomes and value.