Background: Despite progress in non-invasive imaging methods of the bile and pancreatic duct, ERCP and endoscopic sphincterotomy are live methods and continue to provide the means for therapeutic intervention and cytological diagnostics. Because of the invasive and high-risk character of these methods, health professionals worldwide are attempting to minimize complication rates. There is a growing opinion throughout the scientific community that invasive procedures such as ERCP and EPT should only be performed at large centers with a high examination frequency and consequently practice related lower rates of complications. In Germany, this aim is currently supported by law. There is an existing trend to close down smaller hospitals – predominantly in rural areas. To a certain degree,the political agendas that would make these closures are motivated by economics. However, long travel times for patients, the lack of social support, the lack of knowledge of a patient’s entire medical history and the ties of a patient to a near-by hospitals are set off against quality. The aim towards specialization is further accelerating this development. In this study, we were able to show that a small hospital with a welltrained medical staff can provide an equal or even better quality of care than major centers.
Methods: For the present study we retrospectively analyzed the complication rates of endoscopic papillotomies over a period of six years (from 2006 to 2011) in the gastroenterological department of the Kreiskrankenhaus Schongau [Schongau Hospital], part of a community hospital in Upper Bavaria. Overall 543 examinations were evaluated. Our data were then contrasted with international studies.
Results: Several studies were identified that evaluated ERCP and endoscopic papillotomies with comparable criteria and a comparable group of patients. With a success rate of 93.74%, the Schongau Hospital had significantly higher result than the studies. The success rate is specified from 88% (n = 176), 90% (n =1242) to 91.6% (n = 2553). Additionally, with regard to moderate or severe post-interventional pancreatitis, the Schongau Hospital is well below the figures given in the literature: there is a mild pancreatitis in 44.8% (n = 262), moderate in 43.8% (n = 256) and severe in 11.4% (n = 67) of all patients. In Schongau, a moderate post-interventional pancreatitis occurred in 0.37% (n = 2) and a severe case in 0.18% (n = 1) of all patients. Our data shows outstandingly low rates of bleeding, acute post-interventional cholangitis or perforation when compared to the relevant literature.
Conclusions: Although the Schongau Hospital is relatively small (180 beds), it achieved equal or even better results in terms of endoscopic sphincterotomy than major centers. This may be due to the experienced endoscopic staff, regular and intensive skill enhancement as well as the strict indication for endoscopic sphincterotomy. Our study shows that size does not matter as long as personal motivation and skill sets are excellent, and quality assessments should note this.
Cholecystolithiasis occurs in about 66% of the elderly population over 70 years of age . More than 98% of bile duct disorders are caused by gallstones  . 10 to 33% of patients with gallstone related symptoms suffer from choledocholithiasis [3-6]. Patients with common bile duct stones suffer from a variety of symptoms such as cholestasis, pain, cholangitis or pancreatitis [7,8] . In addition to common bile duct stones, there are other causes of biliary obstruction such as tumors or trauma . Via abdominal ultrasound, an acute cholecystitis and variations in the biliary tract such as bile duct expansion can be displayed [10,11]. To diagnose common bile duct stones, ultrasound must be combined with other imaging techniques . In this case, intraoperative high-resolution sonography is indeed superior to intraoperative cholangiography in the diagnosis of small bile duct stones, assuming there is an experienced examiner available ; however, it does not provide a type of therapy.