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Diagnostic and Therapeutic Indications for Endoscopic Ultrasound (EUS) in Patients with Pancreatic and Biliary Disease—Novel Interventional Procedures. Curr Oncol 2022; 29:6211-6225. [PMID: 36135057 PMCID: PMC9497766 DOI: 10.3390/curroncol29090488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/20/2022] Open
Abstract
There is growing evidence supporting the substantial, essential and indispensable role of endoscopic ultrasound (EUS) as a key diagnostic armamentarium for upper GI oncologic surgery. Well described in countless publications, EUS holds that position in gastroenterological expert centers all over Europe. Despite its undisputable contributions to oncologic upper GI surgery, the availability of this technique at the expert level shows up in an irregular spread pattern. Endoscopic ultrasound’s primary use during the first few years after its creation was the detection of pancreatic cancer. From then on, EUS developed in different directions, becoming a diagnostic tool that increasingly better defines its status as a method of minimally invasive therapeutic applications and a useful addition to surgical options. As a result, several surgical interventions could even be replaced by ultrasound-targeted interventions. This process took place in just a few years and was made possible by technical development that sensibly combined high-resolution ultrasound with therapeutic endoscopy. The present article will serve to cover the most prevalent uses with supporting data considering the growing list of suggested indications for EUS while also examining cutting-edge initiatives that might soon become the standard of clinical practice. Endoscopic centers with high expertise are needed to train future experts in the growing field of EUS interventions.
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DE Angelis CG, Rizza S, Rizzi F, Debernardi-Venon W, Caronna S, Gaia S, Bruno M. Training in advanced bilio-pancreatic endoscopy. Minerva Gastroenterol (Torino) 2021; 68:121-132. [PMID: 33793163 DOI: 10.23736/s2724-5985.21.02869-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
As the clinical applications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) take more and more root in everyday practice and these endoscopic procedures become increasingly more complex and interventional with a higher chance for complications, the demand for expert bilio-pancreatic endoscopists continues to increase. In response to this growing need, specific postgraduate fellowships have been developed, however the standardization of training programs and the assessment of the achieved competence still remains an open debate. ERCP and EUS competency often requires training beyond the scope of a standard GI fellowship program, which lasts at least 1-2 years, and there are some differences in the way to face the issues of advanced bilio-pancreatic endoscopy training between Europe, America and the Asian regions. Today there is no role for the self-teaching of ERCP and EUS through trial and error without supervision and, in the near future, it is necessary to critically revise current training guidelines, to establish a standardized curriculum for advanced bilio-pancreatic endoscopists and to implement universally validated skill assessment tools, able to ensure constant and targeted feedback to trainees.
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Affiliation(s)
- Claudio G DE Angelis
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy -
| | - Stefano Rizza
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy.,Gastroenterology and Digestive Endoscopy Unit, FPO-IRCCS Candiolo Cancer Institute, Candiolo, Turin, Italy
| | - Felice Rizzi
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Wilma Debernardi-Venon
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Stefania Caronna
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Silvia Gaia
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Mauro Bruno
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
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ERCP and video assessment: Can video judge the endoscopy star? Gastrointest Endosc 2021; 93:924-926. [PMID: 33741092 DOI: 10.1016/j.gie.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 09/07/2020] [Indexed: 02/08/2023]
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Cappell MS, Friedel DM. Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States. World J Gastroenterol 2019; 25:3468-3483. [PMID: 31367151 PMCID: PMC6658394 DOI: 10.3748/wjg.v25.i27.3468] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/16/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023] Open
Abstract
Endoscopic-retrograde-cholangiopancreatography (ERCP) is now a vital modality with primarily therapeutic and occasionally solely diagnostic utility for numerous biliary/pancreatic disorders. It has a significantly steeper learning curve than that for other standard gastrointestinal (GI) endoscopies, such as esophagogastroduodenoscopy or colonoscopy, due to greater technical difficulty and higher risk of complications. Yet, GI fellows have limited exposure to ERCP during standard-three-year-GI-fellowships because ERCP is much less frequently performed than esophagogastroduodenoscopy/colonoscopy. This led to adding an optional year of training in therapeutic endoscopy. Yet many graduates from standard three-year-fellowships without advanced training intensely pursue independent/unsupervised ERCP privileges despite inadequate numbers of performed ERCPs and unacceptably low rates of successful selective cannulation of desired (biliary or pancreatic) duct. Hospital credentialing committees have traditionally performed ERCP credentialing, but this practice has led to widespread flouting of recommended guidelines (e.g., planned privileging of applicant with 20% successful cannulation rate, or after performing only 7 ERCPs); and intense politicking of committee members by applicants, their practice groups, and potential competitors. Consequently, some gastroenterologists upon completing standard fellowships train and learn ERCP "on the job" during independent/unsupervised practice, which can result in bad outcomes: high rates of failed bile duct cannulation. This severe clinical problem is indicated by publication of ≥ 12 ERCP competency studies/guidelines during last 5 years. However, lack of mandatory, quantitative, ERCP credentialing criteria has permitted neglect of recommended guidelines. This work comprehensively reviews literature on ERCP credentialing; reviews rationales for proposed guidelines; reports problems with current system; and proposes novel criteria for competency. This work advocates for mandatory, national, written, minimum, quantitative, standards, including cognitive skills (possibly assessed by a nationwide examination), and technical skills, assessed by number performed (≥ 200-250 ERCPs), types of ERCPs, success rate (approximately ≥ 90% cannulation of desired duct), and letters of recommendation by program director/ERCP mentor. Mandatory criteria should ideally not be monitored by a hospital committee subjected to intense politicking by applicants, their employers, and sometimes even competitors, but an independent national entity, like the National Board of Medical Examiners/American Board of Internal Medicine.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
- Oakland University William Beaumont School of Medicine, William Beaumont Hospital, MI 48073, United States
| | - David M Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY 11501, United States
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Training in EUS and ERCP: standardizing methods to assess competence. Gastrointest Endosc 2018; 87:1371-1382. [PMID: 29709305 DOI: 10.1016/j.gie.2018.02.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
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Rodrigues-Pinto E, Macedo G, Baron TH. Training pathways and competency assessment in endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Shahidi N, Ou G, Telford J, Enns R. When trainees reach competency in performing ERCP: a systematic review. Gastrointest Endosc 2015; 81:1337-1342. [PMID: 25841579 DOI: 10.1016/j.gie.2014.12.054] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ERCP is an advanced endoscopic procedure that is technically more challenging and carries a higher risk of adverse events compared with standard endoscopy. A discrepancy currently exists among guidelines regarding the number of ERCPs that a trainee needs to complete before procedural competency should be assessed. Our aim was to assess the learning curve for performing ERCP. METHODS Two authors independently searched MEDLINE (1946 to November 25, 2014) along with the gray literature to identify relevant citations. To warrant inclusion, citations were required to report successful trainee cannulation rate. Successful cannulation rate, set at a value of 80% or higher, was used as our baseline reference for competency. RESULTS Nine studies, assessing 137 trainees and 17,100 ERCPs, were included in our analysis. Overall, competency was achieved among the included studies between 70 to 400 ERCPs. In the 2 studies that used pancreatic duct cannulation rate, competency was achieved by 70 to 160 ERCPs. Of the 5 studies that used selective duct cannulation rate, competency was achieved by 79 to 300 ERCPs. Finally, in the 4 studies that used common bile duct cannulation rate, 2 studies reached the reference competency threshold by 160 to 400 ERCPs. On further stratification, when assessing native papilla deep common bile duct cannulation, only 1 study reached the reference competency threshold by 350 to 400 ERCPs. CONCLUSIONS Our findings suggest that as ERCP has evolved from a predominantly diagnostic to therapeutic procedure, procedural thresholds have risen well above North American training guidelines. Therefore, advanced endoscopy training programs need to reassess their current structure to ensure that procedural competency is being reached.
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Affiliation(s)
- Neal Shahidi
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - George Ou
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Telford
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Robert Enns
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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Verma D, Gostout CJ, Petersen BT, Levy MJ, Baron TH, Adler DG. Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointest Endosc 2007; 65:394-400. [PMID: 17321237 DOI: 10.1016/j.gie.2006.03.933] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2005] [Accepted: 03/31/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Deep cannulation of the common bile duct (CBD) in patients with native papillary anatomy can be used as a marker of competence at ERCP. OBJECTIVE The primary aim of this study was to analyze a single-operator learning curve for supervised ERCPs in patients with native papillary anatomy and to assess the development of endoscopic competence, defined as the ability to deeply cannulate the CBD in the setting > or =80% of the time. Posttraining outcomes were evaluated as proof of training. DESIGN A retrospective review: 1097 ERCP procedures were analyzed, 697 were performed during ERCP training (July 2002-July 2003), 400 were performed after training as an independent operator, 499 and 303 procedures for training and posttraining periods, respectively, were performed with the intent of deep cannulation of CBD in patients with native papillary anatomy. Procedures were chronologically grouped into subsets. Success rates were plotted against time. SETTING Single center. MAIN OUTCOME MEASUREMENTS Rate of successful deep biliary cannulation. RESULTS The successful cannulation rate increased from 43% at the beginning of training to > or =80% after 350 to 400 supervised procedures. The success rate continued to improve posttraining with an aggregated success rate of >96% for the next 300 procedures performed as an independent operator. LIMITATIONS Single operator. CONCLUSIONS Achievement of a satisfactory success rate for deep biliary cannulation in patients with native papillary anatomy should be tracked by ERCP trainers and trainees. The consistent achievement of > or =80% success at deep biliary cannulation in such patients should become a standard for ERCP training programs to produce skilled and competent therapeutic biliary endoscopists.
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Affiliation(s)
- Dharmendra Verma
- Division of Gastroenterology, Department of Internal Medicine, University of Texas-Houston Medical School, 6431 Fannin, Houston, TX 77030, USA
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Tajiri H. HOW SHALL WE EFFECTIVELY TRAIN GASTROINTESTINAL FELLOWS IN THE NEAR FUTURE? Dig Endosc 2006. [DOI: 10.1111/j.1443-1661.2006.00648.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Kowalski T, Kanchana T, Pungpapong S. Perceptions of gastroenterology fellows regarding ERCP competency and training. Gastrointest Endosc 2003; 58:345-9. [PMID: 14528206 DOI: 10.1067/s0016-5107(03)00006-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The adequacy of ERCP training in the United States may be suboptimal because many training programs do not provide fellows with the exposure to the procedures necessary to achieve competence. METHODS A short survey questionnaire, which assesses the training program, the personal ERCP experience, the perceptions regarding training adequacy, and the post-training practice plans, was sent to all fellows graduating from gastroenterology training programs. RESULTS Graduating fellows performed a median of 140 ERCPs and 35 sphincterotomies during training, with an associated median comfort level for independently performing sphincterotomy of 7.5 on a scale of 1 to 10. The median estimated success rate for independent free cannulation was 75%. Based on nonparametric correlation and regression analysis, 180 ERCPs would be necessary to achieve a free cannulation rate of 80% and 69 sphincterotomies to achieve a comfort level of 8 on a scale of 1 to 10. Thirty-six percent of fellows achieved the number of procedures and cannulation success determined by this study to indicate procedural competence. Sixty-four percent of fellows did not achieve procedural competence and 33% reported inadequate ERCP training. Nevertheless, 91% of fellows expected to perform unsupervised ERCP after training. CONCLUSIONS The results of this study are consistent with those of previously published studies demonstrating that 160 to 200 ERCP procedures are necessary to achieve competence to perform ERCP. The majority of graduating fellows do not achieve an acceptable success rate during training, yet still intend to perform ERCP after training.
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Affiliation(s)
- Thomas Kowalski
- Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Watkins JL, Etzkorn KP, Wiley TE, DeGuzman L, Harig JM. Assessment of technical competence during ERCP training. Gastrointest Endosc 1996; 44:411-5. [PMID: 8905359 DOI: 10.1016/s0016-5107(96)70090-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Successful performance of diagnostic and therapeutic ERCP requires skillful manipulation of the duodenoscope and accessories. The evaluation process for assessing competency is still in evolution. Recommendations for the number of examinations has ranged from 35 to 200, made without the benefit of prospective data. METHODS Pancreatic and common bile duct cannulation rates were prospectively recorded for 21 trainees and 9 proctors over 6 years in a large university-based training program. Trainee success rates were compared to those of the proctor and learning curves were constructed. RESULTS Trainees performed 641 examinations over 6 years. Each did an average of 31 examinations (range, 10 to 96). For both pancreatic duct and common bile duct cannulation, there was a rapid linear rise of the success curve extending up to the fortieth procedure. Pancreatic duct cannulation rates exceeded those of the common bile duct. CONCLUSIONS This is the first prospective evaluation of acquisition of skills in ERCP. Although the rapid rise of the learning curve ends at the fortieth examination, the 85% level of selective cannulation is not reached for the pancreas duct until the seventieth procedure and is not reached for the common bile duct even at 100 procedures. These data suggest a threshold of at least 100 procedures.
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Affiliation(s)
- J L Watkins
- University of Illinois at Chicago, Department of Medicine, USA
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Sapienza PE, Levine GM, Pomerantz S, Davidson JH, Weinryb J, Glassman J. Impact of a quality assurance program on gastrointestinal endoscopy. Gastroenterology 1992; 102:387-93. [PMID: 1732109 DOI: 10.1016/0016-5085(92)90081-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The impact of a quality assurance committee on documentation and use of gastrointestinal endoscopy was assessed. The committee, fulfilling Joint Commission on Accreditation of Healthcare Organizations criteria, performed retrospective (1984-1985) and prospective (1986-1988) reviews of all endoscopies. Criteria were developed from American College of Physicians and American Society for Gastrointestinal Endoscopy guidelines. All reviews of procedures that were questioned were returned to physicians for clarification. After reconsideration of the response, procedures were judged either justified or unjustified. There has been significant improvement in the quality of endoscopy reporting and documentation. The rate of questioned procedures decreased from 21.6% (95% confidence interval (CI), 20.1-23.1) in 1984-1985 to 9.2% (95% CI, 7.9-10.4) (P less than 0.01) in 1988. Improvement in use was reflected in the significant decrease in the rate of unjustified procedures from 8.2% (95% CI, 7.2-9.2) in 1984-1985 to 1.5% (95% CI, 1.0-2.0) (P less than 0.01) in 1988. Most importantly, this process curtailed the previously noted 10% annual increase in the number of endoscopic procedures (P less than 0.01).
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Affiliation(s)
- P E Sapienza
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania
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Affiliation(s)
- J F Morrissey
- Department of Medicine, University of Wisconsin Medical School, Madison 53792
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Pitcher JL. Presidential address 1988. The future of gastrointestinal endoscopy and the A/S/G/E: will we continue to lead or be led? Gastrointest Endosc 1988; 34:377-80. [PMID: 3181696 DOI: 10.1016/s0016-5107(88)71398-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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