
==== Front
Therap Adv Gastroenterol
Therap Adv Gastroenterol
TAG
sptag
Therapeutic Advances in Gastroenterology
1756-283X
1756-2848
SAGE Publications Sage UK: London, England

10.1177/17562848241272973
10.1177_17562848241272973
Original Research
Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures—a propensity score match analysis of the Hungarian ERCP Registry
Tajti Máté *Division of Gastroenterology, Department of Medicine, University of Szeged, Szeged, Hungary
Conceptualization Methodology Project administration Resources Writing – original draft Writing – review & editing
https://orcid.org/0000-0003-0499-6004
Pécsi Dániel *Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
Division of Interventional Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
Conceptualization Data curation Formal analysis Investigation Methodology Project administration Validation Visualization Writing – original draft Writing – review & editing
Mátrai Péter Institute for Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
Formal analysis Methodology Software Visualization Writing – original draft Writing – review & editing
Gódi Szilárd Division of Interventional Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
Conceptualization Methodology Project administration Supervision Writing – original draft Writing – review & editing
Hegyi Péter Centre of Translational Medicine, Semmelweis University, Budapest, Hungary
Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
Conceptualization Funding acquisition Methodology Supervision Writing – original draft Writing – review & editing
Szentesi Andrea Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
Conceptualization Data curation Project administration Resources Supervision Validation Writing – original draft Writing – review & editing
Altorjay István Gastroenterology Clinic, University of Debrecen, Debrecen, Hungary
Conceptualization Data curation Project administration Supervision Writing – original draft Writing – review & editing
Bakucz Tamás Department of Gastroenterology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
Data curation Project administration Resources Validation Writing – original draft Writing – review & editing
Orbán-Szilágyi Ákos Department of Gastroenterology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
Data curation Project administration Resources Validation Writing – original draft Writing – review & editing
Szepes Zoltán Division of Gastroenterology, Department of Medicine, University of Szeged, Szeged, Hungary
Conceptualization Data curation Investigation Methodology Project administration Resources Writing – original draft Writing – review & editing
Patai Árpád First Department of Gastroenterology and Medicine, Markusovszky University Teaching Hospital, Szombathely, Hungary
Conceptualization Investigation Methodology Resources Validation Writing – original draft Writing – review & editing
Gyökeres Tibor Department of Gastroenterology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
Conceptualization Data curation Investigation Methodology Resources Writing – original draft Writing – review & editing
Fejes Roland First Department of Medicine, Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
Data curation Investigation Project administration Validation Writing – original draft Writing – review & editing
Dubravcsik Zsolt Bács-Kiskun County University Teaching Hospital, Kecskemét, Hungary
Conceptualization Data curation Investigation Methodology Validation Writing – original draft Writing – review & editing
https://orcid.org/0000-0003-2217-7686
Vincze Áron Division of Interventional Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
Conceptualization Data curation Funding acquisition Methodology Project administration Supervision Validation Writing – original draft Writing – review & editing
Czakó László Division of Gastroenterology, Department of Medicine, University of Szeged, Kálvária Sgt. 57, Szeged H6725, Hungary
Conceptualization Data curation Investigation Methodology Project administration Resources Validation Writing – original draft Writing – review & editing
czako.laszlo@med.u-szeged.hu
* Co-first authors, contributed to the article equally

5 9 2024
2024
17 175628482412729737 2 2024
16 7 2024
© The Author(s), 2024
2024
SAGE Publications Ltd unless otherwise noted. Manuscript content on this site is licensed under Creative Commons Licenses
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Background:

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for the minimally invasive management of biliary and pancreatic disorders. Under certain indications, performing ERCP without delay during the weekend can be important for improving outcomes.

Objectives:

To compare the outcomes of ERCP performed on weekends and holidays with those of regular weekday ERCPs.

Design:

Propensity score match analysis of the data from the Hungarian ERCP Registry.

Methods:

A total of 116 ERCPs were performed during weekends or holidays, and 3144 during weekday working hours. The analyses were performed on 1:2 propensity-matched groups (116 weekend and 232 weekday cases).

Results:

Weekend ERCPs were mostly performed for acute cholangitis and acute biliary pancreatitis (70% of cases), whereas in the weekday group, only 32% of cases were performed for these indications. No significant difference was found between weekday and weekend ERCPs in terms of the rates of successful (91.38% vs 93.1%, p = 0.565) and difficult (33.62% vs 36.64%, p = 0.511) biliary cannulations. We found no significant differences in the number of adverse events (bleeding, post-ERCP pancreatitis, and 30-day mortality) in ERCPs performed during weekends or weekdays. Moreover, no significant differences in the aforementioned outcomes were detected between the propensity-matched groups.

Conclusion:

In this propensity-matched study, no significant differences were found in the outcomes of weekend and weekday ERCPs.

advanced cannulation
adverse events
cannulation
endoscopic retrograde cholangiopancreatography
outcome
weekend
European Union (European Regional Development Fund) within the framework of Program Széchenyi 2020 EFOP-3.6.2-16-2017-0006 LIVE LONGER European Union (European Regional Development Fund) within the framework of Program Széchenyi 2020 GINOP-2.3.2-15-2016-00048 STAY ALIVE cover-dateJanuary-December 2024
typesetterts1
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pmcIntroduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used, minimally invasive procedure that is invaluable for the management of various pancreatobiliary disorders and requires a highly qualified healthcare team.

In some cases, urgent ERCP is required to achieve the best outcomes. For example, in cases of severe acute cholangitis, according to the 2018 Tokyo guidelines, ERCP should be performed as soon as possible, even during the weekend, to avoid deterioration of the patient’s condition. 1 During weekends and off-hours, personnel (e.g. ERCPists and endoscopy assistants) and supportive backgrounds (e.g. surgeons and interventional radiologists) are not optimally available, which could lead to worse outcomes.

Multiple studies have shed light on the financial aspect of performing ERCPs during the weekend: by performing the procedure earlier, the length of stay could be shorter, and the cost of care could potentially be lower.2,3 For example, personnel can perform multiple urgent procedures during off-hours. However, the outcomes of ERCP performed on weekends are unknown.

Therefore, in this study, we analyzed data from the Hungarian ERCP Registry (H-ERCP) to compare the outcomes of weekend and weekday ERCPs.

Methods

General considerations

In this cohort study, data from the H-ERCP, initiated by the Hungarian Endoscopy Study Group in 2016, were analyzed to compare weekend and weekday ERCPs. The Registry included 3260 cases from 7 tertiary referral centers and 15 endoscopists at the time of analysis. All participating endoscopists were experienced practitioners with high yearly case numbers. Participating endoscopists uploaded all ERCP procedures performed consecutively and a 30-day telephone follow-up was conducted to detect late adverse events. As previously discussed, the Registry has a four-step checking system to ensure data quality (1, local check from administrator; 2, endoscopist; 3, central check by chief administrator; 4, registry coordinator (ÁV, DP)). 4 This cohort study conforms with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. 5

Inclusion and exclusion criteria

All the cases available for analysis were included. A total of 116 ERCP procedures were performed during weekends or holidays, and 3144 ERCP procedures were performed during weekday working hours. Patients with missing data were excluded from the analysis (Figure 1).

Figure 1. Flowchart of case selection.

Outcomes and definitions

The primary outcome of this study was the success rate of biliary cannulation. The secondary outcomes were difficult cannulation, adverse event rates (post-ERCP pancreatitis (PEP), bleeding, and 30-day mortality), and cannulation and fluoroscopy time.

Indications for ERCP were included in the registry protocol and were based on current guidelines. 6 The cannulation algorithm established by the European Society of Gastrointestinal Endoscopy (ESGE) was implemented in all centers. 7 Adverse events such as bleeding and PEP were defined according to the current ESGE guidelines. 8

Propensity score matching analysis with a 1:2 ratio was performed to minimize confounding factors that could influence the outcomes.

Analyzed dataset

Demographic data and patient characteristics (sex, age, American Society of Anesthesiology status) as well as procedural data were analyzed: the presence of juxtapapillary diverticulum (JPD), the success rate of biliary access, use of advanced cannulation techniques, PEP prophylaxis measures such as the use of non-steroid suppositories and prophylactic pancreatic stent (PPS) placement, adverse event rates (bleeding, PEP), and cannulation and fluoroscopy time.

Statistical analysis

To compare weekend and weekday ERCP outcomes, we performed nearest-neighbor matching using propensity scores as a distance measure. The use of matched data was necessary because the weekend and weekday groups differed in many aspects that could also affect the outcome variables; therefore, bias could have been introduced. We selected covariates for matching for which we thought a balance was required for comparison: indication, age, sex, objective difficulty, native papilla, JPD, and advanced cannulation use. We assessed the balance of the matched variables using density and distribution plots to compare the distributions of the matched variables between the two groups before and after matching. We also compared the standardized mean differences between the groups before and after matching to assess the matching success. Based on these plots and measures, the matching procedure was successful, and the distribution of the matched variables was very similar between the two groups after matching. We had 116 weekend and 3144 weekday ERCP procedures in the raw dataset, which made it possible to perform 1:2 matching while maintaining good matching quality. In the matched sample, 116 weekend and 232 weekday ERCPs were performed. To calculate the differences in outcome variables, we fitted a simple linear model for continuous variables and a logistic model for binary variables, with weekends as the only covariate. To calculate the standard error of the difference between the groups in the outcome variables, we used cluster-robust standard errors that considered the dependence between matched observations, as recommended by Ho et al. 9 To assess the differences, we created summary plots in which we visualized the estimated mean differences of continuous variables and the risk differences of binary variables with their corresponding 95% confidence intervals. For the statistical evaluation, R version 4.1.0 was used. For the matching, we used the “MatchIt” version 4.5.3 and “marginaleffects” version 0.12.0 packages.

Results

General characteristics of the cohort

The weekend and weekday procedures were matched in a 1:2 ratio according to the parameters that could influence the outcomes (Supplemental Table 1).

Indications of ERCP

Most cases were performed for acute cholangitis (40.5%) and acute biliary pancreatitis (29.3%) during the weekend, although obstructive jaundice (18.1%) and diseases of the bile ducts (10.3%) were also frequent non-urgent indications.

During working hours, most procedures were performed for obstructive jaundice (31.5%) and diseases of the bile ducts (33.0%), whereas cholangitis and pancreatitis were rare (Figure 2).

Figure 2. Distribution of ERCP indications.

ERCP, endoscopic retrograde cholangiopancreatography.

Biliary cannulation success rates

No significant differences were found in the biliary cannulation success rates between weekend and weekday ERCPs (91.38% vs 93.1%, p = 0.565). The rate of difficult biliary cannulations was not higher on weekends (33.62% vs 36.64%, p = 0.511; Figure 3).

Figure 3. Comparison of biliary cannulation success rates and difficult biliary cannulation rates in the propensity score matched groups.

Adverse event rates

Relatively low PEP rates were observed in the weekend and weekday groups (1.72% vs 0.86%, p = 0.528). No difference in the bleeding rate was observed between the groups (0.86% vs 0.43%, p = 0.656). The 30-day mortality rates were similar between the two groups (16.9% vs 14.71%, p = 0.661; Figure 4).

Figure 4. Comparison of adverse event rates and 30-day mortality in the propensity score matched groups (PEP). Thirty-day mortality was collected prospectively, not in all cases could have been ascertained this outcome, these cases were left out of analysis.

ERCP, endoscopic retrograde cholangiopancreatography; PEP, post-ERCP pancreatitis.

PEP prophylaxis

Indomethacin suppository use was lower on weekends (43.1% vs 56.03%, p = 0.019). No difference was found between the PPS insertion rates (13.04% vs 10.78%, p = 0.523; Figure 5).

Figure 5. Analysis of post-ERCP pancreatitis prophylaxis use in the propensity score matched groups (supp., impl.). One weekend ERCP case was excluded from analysis because a pancreatic stent was already in place.

ERCP, endoscopic retrograde cholangiopancreatography; impl., implantation; supp., suppository.

Cannulation and fluoroscopy time

The average cannulation time was similar in weekend and weekday procedures (166.6 vs 194.4 s, p = 0.371). In addition, no difference was observed in fluoroscopy time between weekend and weekday ERCPs (151.5 vs 132.4 s, p = 0.42; Figure 6).

Figure 6. Comparison of cannulation and fluoroscopy time in the propensity score matched groups (SE). Only cases with data of cannulation and fluoroscopy time were analyzed.

SE, standard error.

Discussion

Based on our data, weekend ERCP outcomes were not worse than those of weekday working hours. The biliary cannulation success and adverse event rates were similar; only indomethacin suppository use was lower on weekends.

The suboptimal use of PEP prophylaxis with below 50% use of indomethacin suppositories was unexpected, although it is possible and understandable that suppository placement could be forgotten and left out during weekends in a hurry. However, a very low rate of PEP was observed, which is unexpected in urgent procedures involving substandard PEP prophylaxis. This could be explained by the fact that all cases were handled at tertiary centers by expert endoscopists, and 25% of the ERCPs were non-native papilla cases, which lowers the risk of adverse events.

Our findings are consistent with those of previous studies that reported similar rates of adverse events in off-hours ERCPs. 10

Several studies have addressed the financial aspects of weekend ERCP.2,3,11 Based on the registry data, we could not analyze the length of hospital stay (LOS) because it was not included in the questionnaire. However, it is desirable to reduce the financial burden and, possibly, antibiotic use. The availability of expert endoscopists during weekends is limited; therefore, the feasibility of performing non-urgent procedures is currently questionable.

In their retrospective study, Kruit et al. 12 showed that higher radiation doses were measured in ERCPs performed during weekends. In contrast, we found no significant difference in fluoroscopy time between the two groups.

The main strength of our study was that the data were prospectively gathered from the H-ERCP, which includes seven high-volume centers. Good data quality was achieved for most outcomes. Quality control and multiple checks by different personnel improved data quality. We used propensity score matching to reduce confounding biases by balancing the factors in the two groups that could alter outcomes.

A limitation of our study is that this analysis was performed using post hoc questions raised in prospectively collected data, which could have included confounding factors. The generalizability of the findings is hindered by the fact that all cases were obtained from high-volume tertiary centers by expert endoscopists. The case distribution varied between the centers. The possibility of selection bias cannot be excluded, as this was an observational study.

Recommendations for clinical practice: Weekend ERCP has similar outcomes in tertiary centers performed by expert endoscopists. These procedures should not be delayed if strongly indicated.

Recommendations for research: A feasibility study of performing weekend non-urgent ERCPs to lower LOS and cost of care should be conducted.

Conclusion

In this propensity-matched study, no significant differences were found in outcomes between weekend and weekday ERCPs.

Supplemental Material

sj-docx-1-tag-10.1177_17562848241272973 – Supplemental material for Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures—a propensity score match analysis of the Hungarian ERCP Registry

Supplemental material, sj-docx-1-tag-10.1177_17562848241272973 for Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures—a propensity score match analysis of the Hungarian ERCP Registry by Máté Tajti, Dániel Pécsi, Péter Mátrai, Szilárd Gódi, Péter Hegyi, Andrea Szentesi, István Altorjay, Tamás Bakucz, Ákos Orbán-Szilágyi, Zoltán Szepes, Árpád Patai, Tibor Gyökeres, Roland Fejes, Zsolt Dubravcsik, Áron Vincze and László Czakó in Therapeutic Advances in Gastroenterology

sj-docx-2-tag-10.1177_17562848241272973 – Supplemental material for Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures—a propensity score match analysis of the Hungarian ERCP Registry

Supplemental material, sj-docx-2-tag-10.1177_17562848241272973 for Weekend endoscopic retrograde cholangiopancreatography has similar outcomes as weekday procedures—a propensity score match analysis of the Hungarian ERCP Registry by Máté Tajti, Dániel Pécsi, Péter Mátrai, Szilárd Gódi, Péter Hegyi, Andrea Szentesi, István Altorjay, Tamás Bakucz, Ákos Orbán-Szilágyi, Zoltán Szepes, Árpád Patai, Tibor Gyökeres, Roland Fejes, Zsolt Dubravcsik, Áron Vincze and László Czakó in Therapeutic Advances in Gastroenterology

We want to thank Editage editing services for revising the English of the manuscript.

Declarations

ORCID iDs: Dániel Pécsi https://orcid.org/0000-0003-0499-6004

Áron Vincze https://orcid.org/0000-0003-2217-7686

Supplemental material: Supplemental material for this article is available online.

Ethics approval and consent to participate: All patients in the prospective data collection consented to participating in the study. The Scientific and Research Ethics Committee of the Medical Research Council approved this H-ERCP study (TUKEB-35523/2016/EKU and BMEÜ/714-1/2022/EKU).

Consent for publication: All patients in the prospective data collection consented to the publication of their anonymized data.

Author contributions: Máté Tajti: Conceptualization; Methodology; Project administration; Resources; Writing – original draft; Writing – review & editing.

Dániel Pécsi: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Validation; Visualization; Writing – original draft; Writing – review & editing.

Péter Mátrai: Formal analysis; Methodology; Software; Visualization; Writing – original draft; Writing – review & editing.

Szilárd Gódi: Conceptualization; Methodology; Project administration; Supervision; Writing – original draft; Writing – review & editing.

Péter Hegyi: Conceptualization; Funding acquisition; Methodology; Supervision; Writing – original draft; Writing – review & editing.

Andrea Szentesi: Conceptualization; Data curation; Project administration; Resources; Supervision; Validation; Writing – original draft; Writing – review & editing.

István Altorjay: Conceptualization; Data curation; Project administration; Supervision; Writing – original draft; Writing – review & editing.

Tamás Bakucz: Data curation; Project administration; Resources; Validation; Writing – original draft; Writing – review & editing.

Ákos Orbán-Szilágyi: Data curation; Project administration; Resources; Validation; Writing – original draft; Writing – review & editing.

Zoltán Szepes: Conceptualization; Data curation; Investigation; Methodology; Project administration; Resources; Writing – original draft; Writing – review & editing.

Árpád Patai: Conceptualization; Investigation; Methodology; Resources; Validation; Writing – original draft; Writing – review & editing.

Tibor Gyökeres: Conceptualization; Data curation; Investigation; Methodology; Resources; Writing – original draft; Writing – review & editing.

Roland Fejes: Data curation; Investigation; Project administration; Validation; Writing – original draft; Writing – review & editing.

Zsolt Dubravcsik: Conceptualization; Data curation; Investigation; Methodology; Validation; Writing – original draft; Writing – review & editing.

Áron Vincze: Conceptualization; Data curation; Funding acquisition; Methodology; Project administration; Supervision; Validation; Writing – original draft; Writing – review & editing.

László Czakó: Conceptualization; Data curation; Investigation; Methodology; Project administration; Resources; Validation; Writing – original draft; Writing – review & editing.

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Hungarian National Research, Development, and Innovation Office (K128222 to LC), the Géza Hetényi Research Grant (5S 259 to LC), and the Faculty of Medicine, University of Szeged. The funders played no role in designing or executing this study, analyzing and interpreting the data, or deciding to submit the results for publication.

The authors declare that there is no conflict of interest.

Availability of data and materials: All relevant data are presented in the paper and the Supporting Information files. Additional data are available upon request.
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