Endoscopic retrograde cholangiopancreatography is more than just a technical procedure: Distinctions between gastroenterologist and surgeon

Abstract

This commentary addresses the recent article by Yılmaz et al, featured in the May 2025 issue of this journal. Even though endoscopic procedures are common for both gastroenterologists and surgeons, there are clear differences between the two fields regarding when to use endoscopy, how to prepare for it, and how to monitor patients afterward. A primary determinant of these discrepancies lies in the variations in the duration and pedagogical frameworks of endoscopy training inherent to each discipline. These basic differences are very important for keeping patients safe and ensuring the procedures are done correctly, especially for treatments like endoscopic retrograde cholangiopancreatography (ERCP). This article aims to outline specific criticisms related to this topic, particularly in response to information shared about ERCP procedures performed in Türkiye.

Key Words: Endoscopic retrograde cholangiopancreatography; Gastroenterologist; Surgeon; Training; Türkiye

Core Tip: Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic endoscopic procedure that requires the practitioner to possess much more than just technical skills. There are differences in the general approach to ERCP procedures among gastroenterologists and surgeons. Differences in both theoretical and practical training in general endoscopy, particularly concerning ERCP education, can lead to varying outcomes in terms of complications and procedural quality.

TO THE EDITOR

We read with great interest the article by Yılmaz et al[1], published in the May 2025 issue of your journal. However, as the Turkish Society of Gastroenterology Endoscopic Retrograde Cholangiopancreatography Study Group, we request clarifying several points regarding the article, which addresses endoscopic retrograde cholangiopancreatography (ERCP), a procedure primarily performed by the gastroenterologists worldwide.

Discussion

In gastrointestinal endoscopy field, surgeons and gastroenterologists, often collaboratively, have made significant contributions to advancing instruments and the discipline itself. ERCP is a therapeutic endoscopic procedure that requires more than technical proficiency. This procedure necessitates establishing optimal referral pathways for complex cases, comprehensive preprocedural assessment and detailed informed consent, complex clinical decision-making, team-based preprocedural, periprocedural, and postprocedural management, systems for complication management, and contribution with other specialties, including interventional radiology[2]. A study comparing surgeon and gastroenterologist perspectives on ERCP revealed distinct disciplinary approaches to organize ERCP tasks. Gastroenterologists tended to employ a more rational, principle-oriented or theory-based approach, whereas surgeons favored a practical approach, technically driven methodology. The accompanying commentary suggested that these results correlated with the basic training model of the respective disciplines at the pre-specialization level. In other words, gastroenterologists developed a strong foundation in cognitive problem-solving skills during their core training, reflecting the practice patterns of internal medicine, while surgical training prioritizes procedural skills and technical proficiency. These findings explain why gastroenterologists and surgeons approach the structure and teach of advanced procedures such as ERCP, differently; it is due to differences in the training paradigm prior to pre-specialization or sub-specialty-specific skill acquisition[3].

Although the first initiative for ERCP procedural techniques worldwide was pioneered by a surgeon, subsequent developments, techniques, and guidelines including procedure nomenclature were established by gastroenterologists[4,5]. As noted in the article, ERCP history in Türkiye began in 1976, when Dr. Şahin B, a faculty member in the Gastroenterology Department at Türkiye Yüksek İhtisas Hospital, performed the first procedure. Since then, ERCP has been incorporated into the routine training program of gastroenterology clinical education. According to a recent survey conducted by our ERCP study group, 82% of physicians performing ERCP reported receiving training at an institution where they trained as fellows or later as specialists[6]. Although the duration of ERCP training varies across institution, most focus on therapeutic endoscopic procedures, including ERCP, during the latter half of fellowship training. Thus, ERCP training within gastroenterology is not separate, post-specialization program but rather an integrated theoretical and practical training during fellowship.

This article claims that ERCP procedures in Türkiye are predominantly performed by general surgeons alongside gastroenterology specialists; however, these data do not reflect reality. Our aforementioned survey revealed that gastroenterology specialists perform ERCP procedures across all regions of Türkiye. Additionally, based on an assessment by the Turkish Society of Gastroenterology, approximately 50000 procedures were performed solely by gastroenterology specialists in Türkiye by 2024. The rising number of gastroenterologists in Türkiye suggests that the alleged shortage of ERCP endoscopists, as cited in this article, can be resolved through this growth.

Regarding the issue of patient selection for ERCP, as discussed in the article, this is determined by national laws, professional guidelines, Ministry of Health regulations, and patient demand. Current institutional regulations governing medical education and legal ruling issued by the high court confirm that only gastroenterologists are authorized for ERCP in Türkiye.

In the article’s conclusion, a comment suggested that surgeons performing ERCP poses no concerns; however, this assertion should not be relied on a single study finding. Moreover, the rationale for deriving such conclusions from this study results remains unclear. The standards and success criteria for ERCP training are well-defined. Publications aimed at influencing the decisions of authorized institutions regarding which physician group should perform ERCP, particularly those that may misleadingly guide these decisions, are inconsistent with academic integrity.

CONCLUSION

In conclusion, ERCP is the safest and most effective procedure when performed by well-trained, experienced gastroenterologists. As with any medical procedure, complications associated with ERCP may occur; however, selecting a highly qualified physician can minimize this risk. Additionally, having gastroenterologist perform the procedure in a fully equipped center ensuring that all identified gastrointestinal conditions are treated by a single physician at a single location. This approach improves efficiency and continuity of care, both of which contribute better patient outcomes.

ACKNOWLEDGEMENT

The article has also been read and approved for publication by its members of the Turkish Society of Gastroenterology ERCP Working Group.