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| n = number of cases where information was provided |
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APPROPRIATE PROCEDURE?
| Key point |
14% of procedures were judged as inappropriate and 17% of procedures were performed
at an inappropriate time. |
Advisors were asked to decide in the light of the severity of the patient’s condition, whether the type and the timing of the procedure were appropriate for the clinical scenario (Table 11).
| Table 11. Appropriateness of procedure as determined by the advisors
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| |
Yes |
No |
Insufficient information to assess |
| Type of procedure appropriate |
1,395 |
230 |
193 |
| Timing of procedure appropriate |
1,287 |
258 |
273 |
| Type and timing of procedure appropriate |
1,225 |
0 |
593 |
The type of endoscopy was appropriate in 86% (1,395/1,625) of patients, and at an appropriate time in the admission in 83% (1,287/1,545). 63% of the procedures, where the type of procedure was deemed inappropriate, were thought to be futile (145/230) and the remainder were unnecessary. Amongst the 258 procedures where the timing was deemed inappropriate, 135 were too late to be of any benefit and 21 were too early. Almost all of the patients in these two categories had PEGs placed, and further details can be found in the chapter on PEGs.
Inappropriate ERCPs were also common; these were performed especially on patients with disseminated malignancy.
| Case Study |
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An elderly patient had a pancreatic mass and metastases in the liver, with no evidence
of bile duct dilatation on either ultrasound or CT scanning. The pre-procedural INR was 1.7. The patient received 8 mg of midazolam and 50 mg of pethidine. The ERCP showed
a duodenal stricture and narrowing of the common bile duct with no proximal dilatation.
A “palliative stent” was inserted. The patient died three weeks later. |
This was a procedure that would not have been of any benefit to the patient, who also received excessive sedation, compounded by the effect of the liver disease on drug breakdown.
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