Outcomes of ERCP’s Performed in the AM vs. PM: Does Procedural Timing Matter?

Aims Endoscopic retrograde cholangiopancreatography (ERCP) is an establisheddiagnostic and therapeutic tool for hepatobiliary disease. Given its technicaldemands, it remains one of the highest-risk endoscopic procedures with reportedadverse event rates of up to 12%. Addressing modifiable factors, such as operatorfatigue, may mitigate procedural risk. In colonoscopy, there is conflicting data onwhether procedure time of day, as a surrogate of operator fatigue, affectsoutcomes, with some literature demonstrating decreased procedure completion andpolyp detection rates in the afternoon. There is a paucity of data evaluating thispotential relationship in ERCP. The aim of this study is to evaluate the impact ofprocedure time of day on procedural success and short-term adverse outcomes inpatients undergoing ERCP. Methods The records of 5755 consecutive ERCP procedures performed on adult patients atour tertiary referral center from January 1, 2010 to December 31, 2020 wereretrospectively reviewed. The primary outcome was the procedural success rate,defined as successful navigation to the papilla, selective duct cannulation andcholangiography, and realization of the intended therapeutic goals. Secondaryoutcomes included procedure duration, rate of deep ductal cannulation, rate ofsphincterotomy, and short-term (30-day) adverse events (immediate bleeding,pancreatitis, perforation). Statistical analysis was conducted using R. Categoricalvariables were compared using the Chi-square test of independence or Fisher’sexact test. Continuous variables were compared using T-tests or the Mann- Whitney-U test. The normality of a given variable was assessed using the Shapiro- Wilk’s test. Results A total of 5755 ERCP’s were performed between 8 AM – 6 PM; 2863 wereperformed before 12PM (AM group) and 2892 after 12PM (PM group). Baselinecharacteristics were similar between the two cohorts, with the exception ofhypertension (33.7% AM vs 30.1% PM; p=0.003), and anticoagulation (20.3% AMvs 18.3% PM; p=0.05) (Table 1). In both groups, the most common ERCPindication was choledocholithiasis. The primary operators in both cohorts werepredominantly clinical fellows. There was no difference in procedural success rate(87.0% AM vs 86.7% PM; p=0.72), procedure duration (33.6 minutes AM vs 32.9minutes PM; p=0.29), rates of deep cannulation (82.9% AM vs 83.0% PM;p=0.81) and sphincterotomies (63.2% vs 62.7%; p=0.68). Rate of adverse eventswere similar, with slightly higher rates of immediate bleeding in the AM group (5.0%AM vs 3.8% PM; p=0.03). Results were similar in a subgroup analysis of patientswith altered anatomy and procedures without fellow involvement. Conclusions In conclusion, the procedure time of day did not impact procedural success rate.There were slightly higher rates of immediate bleeding in the AM group, though thismay be explained by higher rates of anticoagulation in that group Publication History Article published online: 15 April 2024 © 2024. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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