Should the patient stay or go after ERCP: the promise of patient-reported experience measures

While minimally invasive, endoscopic retrograde cholangiopancreatograpy (ERCP) involves the most delicate regions of the human body. Even technically “perfect” procedures may be complicated by adverse events. Indeed, post-ERCP pancreatitis (PEP) is the leading endoscopic complication occurring in 10.2% overall and 14.1% of patients with intrinsic (e.g. suspected sphincter of Oddi dysfunction) or technical (e.g. difficult cannulation) risk factors [1]. Despite decades of effort dedicated to prediction of PEP, it remains an imperfect science [2] [3].

“Practitioners should consider using patient-reported experience measures to make critical decisions regarding admission of patients after ERCP and utilization of preventive measures.”

In this issue of Endoscopy, Ceccacci et al. highlight the potential role of the Patient-reported Scale for Tolerability of Endoscopic Procedures (PRO-STEP) patient-reported experience measure (PREM) to forecast complications and improve management [4]. The authors used a large cohort of 3434 patients from the Canadian ERCP registry, and showed that the PRO-STEP metric of patient-reported outcomes strongly correlated with adverse events [4]. PRO-STEP is a validated scale of procedure tolerability, which quantifies elements including post-procedure pain and distension measured using a recovery room questionnaire [5]. An increased abdominal pain score (>3) was associated with PEP (OR 3.7, 95%CI 2.4–5.7) and very high scores (>6) with perforation (OR 9.5, 95%CI 1.1–59.4).

The finding that pain scores correlate with PEP and other adverse events is self-evident as this is part of the Cotton Consensus definitions. However, the granularity of the PRO-STEP PREM, rigor of the authors’ analysis, and consideration of a wide array of clinically important outcomes enabled the authors to uncover novel insights, including a linear correlation of nausea levels with PEP in those without severe pain. The authors demonstrated a correlation of pain as both a continuous and dichotomous predictor of adverse outcomes, and identified that the odds of PEP increases incrementally by 1.2 (95%CI 1.1–1.3) for each additional point (0–10) on the PRO-STEP abdominal pain score.

Additionally, this patient-centric paradigm may guide decision making regarding the use of potentially expensive preventive strategies and admission for observation after ERCP. Current synthesis of the literature suggests that aggressive hydration may prevent PEP [6]. However, as Thiruvengadam et al. have demonstrated, admission to apply this therapy in average-risk patients is not cost effective [7]. Additionally, as new agents such as selective calcium release-activated channel inhibitors show promise for acute pancreatitis therapy, consideration for preventive use will likely follow [8]. Nevertheless, the use of costly new therapies will likely require a better definition of patients who are most likely to develop this adverse event. PREMs, including PRO-STEP, are poised to play a vital role in the contemporary health care environment where practitioners may be challenged to appropriately steward resources

Ceccacci et al. have returned to the critical approach of listening to the patient, albeit in a quantitative manner, to guide next steps [4]. They convincingly demonstrate that PREMs are associated with the development of ERCP adverse events. While further refinement is needed to operationalize this approach, it carries great promise in guiding post-procedural management and advancing the field of procedural safety. Practitioners should consider using PREMs to make critical decisions regarding admission of patients after ERCP and utilization of preventive measures.

Publication History

Article published online:
08 January 2025

• References

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