Failures and complications of attempted therapeutic ERCP: Impact on outcomes and costs

Although complications are obvious negative outcomes of ERCP, the relative impact and costs of technical failures has not been formally studied. METHODS: Consecutive ERCP's attempted at 11 centers (6 private, 5 university) were prospectively studied. Procedure data were recorded at time of ERCP and outcomes at 30 days. Complications were defined by consensus criteria, but also included indirectly-related events. All cases of biliary obstruction plus those designated by the endoscopist were considered intended biliary therapeutic (Tx). Biliary Tx was considered complete only if all components were successful at that procedure; partial for incomplete stone extraction or stricture drainage; and failed if the bile duct was not accessed and drained for any reason. ERCP-related hospital days (= ERCP-hosp days) were denned as total nights in-hospital for observation, treatment of complications, and for Additional Procedures (subsequent unplanned endoscopic, radiological, surgical or other interventions due to failures or complications of ERCP). Costs of post-ERCP hospital care were estimated using 1996 HCFA reimbursements for ERCP-hosp days, additional procedures, MD and ER visits. RESULTS: Of 1,586 ERCP's, 1,019 (64%) were intended for biliary Tx; 341 Dx cases and 226 pancreatic Tx cases were excluded as intended goals vary widely between centers. Outcomes of 1,019 Biliary Tx ERCP (*P<0.05 vs complete success) Complete 88.1% Partial failed 5.4% Failed 6.5% Complication rate 10.3% 17.5% 16.4% Additional procedure 3.8% 40.4%*62.7%*ERCP-hosp days 1.2 ± 2.0 2.8*± 3.0 5.2*± 7.6 Post-ERCP cost $370 ± 684 $1170*± 1310 $2186*± 2264 Overall, there were 11% complications with a mean cost of $1844, and 12% failures or partial failures with a mean cost of $1720. CONCLUSIONS: For ERCP performed with intention of biliary therapeutics: 1. Technical failures are as common and as expensive as complications. 2. Complication rates are similar for successful and failed procedures. 3. Technical success is pivotal in determining overall outcome of ERCP.