Factors associated with adherence to standard guidelines for ERCP in the management of bile duct stones

Objective Clinical guidelines provide evidence-based recommendations on common bile duct (CBD) stone management, though there is little guidance on best practice for sphincterotomy or X-ray acquisitions. Little is known about adherence to these guidelines. Design/method A national survey was distributed to endoscopic retrograde cholangiopancreatography (ERCP) practitioners (British Society of Gastroenterology (BSG) Endoscopy Quality Improvement Programme). Responses to four clinical scenarios were graded as correct or incorrect in relation to guidelines. These related to the decision to proceed to ERCP based on initial imaging (question 1), management of large CBD stones (question 2), irretrievable stones (question 3) and prophylactic pancreatic duct stent placement (question 4). Adherence to guidelines was evaluated according to practitioner characteristics. Variation in sphincterotomy technique and intraprocedural imaging was analysed. Results Responses were received from 389 ERCP practitioners (74% response rate). Most were consultant physicians (84%), 37% aged ≥55 years and 4% female. Endoscopic ultrasound (EUS) was performed by 31%. Regular attendance at ≥2 ERCP-related continued professional development (CPD) activities/year was reported by 58%. Responses aligned with BSG/European Society of Gastrointestinal Endoscopy guidelines in 90.3% (q1), 72.1% (q2), 89.7% (q3) and 75.8% (q4). Greater adherence was noted in q2 with physician specialty (p=0.002); in q3 in physicians (p=0.026) that practise EUS (p=0.006); in q4 in physicians (p<0.001), younger age (p<0.001), EUS practise (p<0.001), fewer years of experience (p=0.003) and more recent CPD attendance (p=0.003). Sphincterotomy size was most commonly based on papillary anatomy and stone size (57%). 58% described sphincterotomy size by the balloon that passes. Most captured an occlusion cholangiogram balloon-at-papilla image (92%), fewer routinely obtained control films (55%) or final postprocedure imaging (45%). Conclusion Despite broad alignment with core clinical guidelines, adherence is variable.