ERCP Training

Training in ERCP

Training in endoscopy entails both cognitive and technical elements that are required to safely and proficiently perform these procedures. Before embarking on learning ERCP, trainees are required to master standard upper endoscopy. This includes thorough visualization of the upper gastrointestinal tract, with proper identification of normal and abnormal findings, while minimizing patient discomfort and achieving proficiency in basic therapeutic techniques. Understanding procedural indications, contraindications, risks, and limitations and learning how to interpret endoscopic findings (including interpretation of cholangiograms and pancreatograms) and incorporate them into medical and endoscopic management are an integral part of this process. Cognitive education through reading, reviewing videos and atlases, and attending lectures and conferences is combined with supervised hands-on experience under the mentorship of expert endoscopists. A core curriculum for training in ERCP by the American Society for Gastrointestinal Endoscopy (ASGE) has become the standard in the United States.

The training process usually begins by observing a primary endoscopist perform ERCP and becoming acquainted with the unique endoscopic view of the duodenoscope and the function of the elevator. After this, the trainee traditionally will move on to attempt passing the duodenoscope. As with general endoscopy, one of the initial challenges is intubating the esophagus. Once in the esophagus, the duodenoscope is gently advanced until the gastric mucosa is visualized. The duodenoscope is then navigated along the greater curvature of the stomach and positioned in the antrum such that the pylorus is visualized in the “setting sun” position. The pylorus is then traversed and the duodenal sweep is negotiated. Once in the second part of the duodenum, the duodenoscope can be reduced to the “short” position, which usually brings the major papilla into view. In the “short” position, the duodenoscope can be seen in the classic “hockey stick” configuration under fluoroscopy. Attaining proficiency in the use of accessory devices and in the judicious and effective use of fluoroscopy is also crucial to performing safe and successful ERCP. This process involves performing supervised procedures, engaging in interactive observation with the primary endoscopist, and assisting the endoscopy nurse or technician in the handling of devices. In the early stages of their ERCP experience, it is reasonable for trainees to have hands-on experience in lower-risk cases, such as routine stent exchange or cannulation in the setting of prior sphincterotomy. Additionally, ERCP training should take place at a center fitted with all the basic equipment necessary to perform ERCP and where an adequate number of experienced trainers are present who have a track record of adequate case volume and effective endoscopic teaching. The key endpoints of training in ERCP are highlighted in Box 9.1 . Trainees should maintain a procedure log of only those procedures during which hands-on experience occurred. This log should also include the indication, grade of difficulty ( Table 9.1 ), and specific endpoints achieved by the trainee. This will be helpful not only for credentialing purposes but also to allow for the assessment of competency.

Current Status of ERCP Training

In the past, training in ERCP in the United States was a part of a traditional fellowship in gastroenterology for a limited subset of trainees. The ASGE core curriculum for ERCP, however, currently requires a minimum of 12 months of dedicated training, which in most cases takes place in the form of an additional year of training. During this time, trainees work toward developing their skill set with the goal of becoming capable of performing ERCP independently.

At present, international societal thresholds for competence in ERCP are based on procedural volumes. The currently set thresholds are extrapolated from limited data and expert opinion. As per the Gastroenterology Core Curriculum, trainees are required to perform a minimum of 200 ERCPs, after which competency may be assessed. The ASGE ERCP core curriculum requires the same minimum procedural volume as the Gastroenterology Core Curriculum, with the caveat that at least half of these procedures are therapeutic. The Canadian Association of Gastroenterology, similar to the Gastroenterological Society of Australia, requires at least 200 unassisted ERCPs, including 80 supervised procedures with independently performed sphincterotomies and the placement of a minimum of 60 biliary stents. The British Society of Gastroenterology ERCP Working Party has also recently modified their guidelines, which now include key performance indicators for training programs. Trainees are required to participate in at least 300 ERCPs, with a target unselected cannulation rate of ≥80% during the last 50 cases. Additionally, trainees should also be able to appropriately select and consent patients, work within a multidisciplinary team, identify and manage procedural complications, and demonstrate the ability to perform level 1 and 2 procedures without verbal or physical assistance. These guidelines also suggest that trainees be mentored during the first 2 years of independent practice to ensure a safe and effective transition. After the completion of training, trainees are required to meet the minimum requirements for a competent ERCP practitioner within 2 years of mentored practice.

These current guidelines lack validation with regard to competence and feasibility of training. Additionally, they do not account for the fact that trainees differ considerably in the rates at which they learn and develop endoscopic skills. In fact, available data and expert opinion suggest that the majority of trainees are not competent at the above-defined thresholds and require double the number of proposed procedures to achieve competence in ERCP. Thus, the number of procedures completed during training alone does not ensure competence and is a suboptimal marker of competence in ERCP.

Over the past 15 years, the number of advanced endoscopy fellowship programs (typically a 1-year training program of combined training in ERCP and EUS) has increased dramatically in the United States. These programs are currently not recognized by the Accreditation Council for Graduate Medical Education (ACGME). Due to the lack of a fixed mandatory curriculum, there are limited data on the composition and outcomes of ERCP training among advanced endoscopy trainees completing these programs. Results from a recent prospective multicenter study evaluating competence among advanced endoscopy trainees showed that the median number of ERCPs performed per trainee was 350 (range 125 to 500) at the conclusion of training. The vast majority of procedures performed were for a biliary indication of grade 1 difficulty (77%), and a minority were performed for pancreatic indications (14%). The mean time allowed for cannulation was 5.7 minutes (standard deviation [SD] 4.8 minutes) in cases with a native papilla and 6.2 minutes (SD 5 minutes) in cases in which the trainee did not achieve cannulation. There was no change in the time allowed for native papilla cannulation during the 1-year training period. Trainees were also involved in a small proportion of cases requiring advanced cannulation techniques. At the end of training, the majority of trainees expressed comfort with performing ERCP independently (100%), cannulation (92%), sphincterotomy (85%), stone clearance (92%), and the placement of biliary (100%) and pancreatic stents (92%). Nearly half of the trainees planned to practice at an academic center and expected a majority of their practice to be in advanced endoscopy.