EUS-guided pancreatic drainage: A steep learning curve

Abstract

Background and Objective:

EUS-guided pancreatic drainage (EUS-PD) is an efficacious, acceptable risk option for patients with pancreatic duct obstruction who fail conventional ERCP. The aim of this study was to define the learning curve (LC) for EUS-PD.

Methods:

Consecutive patients undergoing EUS-PD by a single operator were included from a dedicated registry. Demographics, procedural info, adverse events, and follow-up data were collected. Nonlinear regression and cumulative sum (CUSUM) analyses were conducted for the LC.

Results:

Fifty-six patients were included (54% of male, with a mean age of 58 years). Technical success was achieved in 47 patients (84%). Stent placement was antegrade in 36 patients (77%) and retrograde in 11 (23%). Clinical success was achieved in 46/47 (98%) patients who achieved technical success. Adverse events were seen in 13 patients (6 of whom did not achieve technical success) and included bleeding requiring embolization ( n = 5), bleeding treated with clips peri-procedurally ( n = 1), pancreatitis ( n = 5), and a pancreatic fluid collection drained via EUS-drainage ( n = 2). The median procedural time was 80 min (range 49–159 min). The CUSUM chart showed that 80-min procedural time was achieved at the 27 ^th procedure. Durations further reduced 40 ^th procedure onward, reaching a plateau indicating proficiency (nonlinear regression P < 0.0001).

Conclusion:

Endoscopists experienced in EUS-PD are expected to achieve a reduction in procedural time over successive cases, with efficiency reached at 80 min and a learning rate of 27 cases. Continued improvement is demonstrated with additional experience, with plateau indicating mastery suggested at the 40 ^th case. EUS-PD is probably one of the hardest therapeutic endosonographic procedures to learn.