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Loganathan P, Mohan B, Baraka A, Gajendran M, Saligram S, Aloysius M, Echavarria J, Goyal H. Trainee Involvement and ERCP Complications: A Systematic Review and Meta-Analysis. Dig Dis Sci 2024; 69:2363-2369. [PMID: 38713275 DOI: 10.1007/s10620-024-08452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/15/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Therapeutic endoscopy and gastroenterology fellows often participate in endoscopic retrograde cholangiopancreatography (ERCP) during their training period. However, it is generally feared that trainee involvement may increase ERCP-related complications, mainly because of the side-viewing nature of the endoscope and the higher risk of pancreatic duct cannulation. There is no concrete evidence to support this notion. This systematic review and meta-analysis aims to investigate the resultsof trainee participation on adverse events related to ERCP. METHODS PubMed, EMBASE, Google Scholar, SCOPUS, and Web of Science databases were searched from inception to 31 May 2023 for studies evaluating the ERCP outcomes defined as success rates, procedure time, failed attempts, and adverse events with and without trainee participation. A random effect model was used to perform the meta-analysis, and heterogeneity was assessed using the I2 statistics. RESULTS Seven studies were included in the final analysis, including 17,088 ERCPs. The pooled odds ratio (pOR) of success rate, incomplete/failed attempts in the trainee and no trainee groups were 0.466 (95% CI 0.13 to 1.66, I2 = 97.8%, p = 0.239) and 3.2 (95% CI 0.70 to 14.55), I2 = 98.5%, p = 0.134), respectively. The pOR of post-ERCP pancreatitis and bleeding in the trainee vs. no trainee groups was 0.97 (95% CI 0.76 to 1.23, I2 = 0%, p = 0.78) and 1.3 (95% CI 0.59 to 2.83, I2 = 49%, p = 0.54). The pOR of all adverse events in both groups was 1.028 (95% CI 0.917 to 1.152, I2 = 0%, p = 0.636). Surprisingly, the pooled std mean difference for the procedure time was 0.217 (95% - 0.093 to 0.05, I2 = 98.5%, p = 0.17). CONCLUSION This meta-analysis comprising of 17,088 ERCPs in seven studies demonstrated comparable ERCP outcomes related to trainee participation regarding success rates, procedure time, and adverse events. Trainees' involvement in ERCP within a proper teaching setting appears safe and does not compromise the overall procedure's success.
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Affiliation(s)
- Priyadarshini Loganathan
- Internal Medicine, University Medical Associates, UT Health San Antonio, 302 West Rector, San Antonio, TX, 78216, USA.
| | - Babu Mohan
- Gastroenterology & Hepatology, Orlando Gastroenterology PA, Orlando, FL, USA
| | - Abakar Baraka
- Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Mahesh Gajendran
- Gastroenterology & Hepatology Division, UT Health San Antonio, San Antonio, TX, USA
| | - Shreyas Saligram
- Gastroenterology & Hepatology Division, UT Health San Antonio, San Antonio, TX, USA
| | - Mark Aloysius
- Gastroenterology & Hepatology, Upstate University Hospital, Syracuse, NY, USA
| | - Juan Echavarria
- Gastroenterology & Hepatology Division, UT Health San Antonio, San Antonio, TX, USA
| | - Hemant Goyal
- Therapeutic Endoscopist at Boreland Groover Downtown, Jacksonville, FL, USA
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Teles de Campos S, Arvanitaki M, Boskoski I, Deviere J. Vade Mecum in ERCP, a roadmap to success: Tips from experts for excelling in ERCP. Endosc Int Open 2024; 12:E613-E620. [PMID: 38681145 PMCID: PMC11052645 DOI: 10.1055/a-2290-1479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/12/2023] [Indexed: 05/01/2024] Open
Abstract
Background and study aims Training in endoscopic retrograde cholangiopancreatography (ERCP) is operator-dependent and traditionally, the apprenticeship model, in which experts are considered to be role models, has been adopted for it. The aim of this study was to develop a practical guide compiling tips from experts to help guide trainees to succeed in ERCP. Methods A web-based survey was created to understand the professional development of ERCP experts, the investments they made, the obstacles they overcame, and the quotes that guided their professional life. ERCP experts worldwide were invited to participate. Results Fifty-three experts (of 71; 74.6%) from 24 countries answered the survey. Experts started ERCP training early (average age 31 years; range, 24-52 years) and it often was combined with training for endoscopic ultrasound. A long training period (average 21 months; range, 3-120 months) was needed to achieve competence, frequently in another department, and it was commonly complemented with research in the field (76.5%). "Time and practice" were the most worthwhile investments they made to achieve success. "Sports" were an area outside endoscopy frequently considered to be important to acquire the skills necessary to excel in ERCP. "Lack of dedicated time for training" and "peer competition" were the biggest obstacles the experts faced. Several pieces of advice were given to the experts, such as to be resilient, careful, patient, responsible, and hard-working. "Personal life" was mentioned as an undeniably crucial factor for achieving long-term success that should not be forgotten. Conclusions This survey is the first to provide insight regarding the professional trajectory of renowned ERCP experts worldwide, providing valuable recommendations to help trainees excel in ERCP.
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Affiliation(s)
- Sara Teles de Campos
- Université Libre de Bruxelles, Bruxelles, Belgium
- Gastroenterology department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal
- Fondation Michel Cremer, Bruxelles, Belgium
| | - Marianna Arvanitaki
- Université Libre de Bruxelles, Bruxelles, Belgium
- Service de Gastroentérologie, d’Hépato-Pancréatologie et d’Oncologie digestive, Hôpital Erasme, Bruxelles, Belgium
| | - Ivo Boskoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Jacques Deviere
- Université Libre de Bruxelles, Bruxelles, Belgium
- Gastroenterology department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal
- Fondation Michel Cremer, Bruxelles, Belgium
- Service de Gastroentérologie, d’Hépato-Pancréatologie et d’Oncologie digestive, Hôpital Erasme, Bruxelles, Belgium
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Chen JH, Wang HP. Endoscopic retrograde cholangiopancreatography training and education. Dig Endosc 2024; 36:74-85. [PMID: 37792821 DOI: 10.1111/den.14702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/02/2023] [Indexed: 10/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used to diagnose and treat biliary and pancreatic diseases. It is one of the most technically demanding endoscopic procedures. ERCP training programs must ensure trainees have adequate knowledge of the anatomy and physiology associated with biliopancreatic diseases. The variety of ERCP procedures included in training programs should provide sufficient basic training for novice trainees and advanced training for experienced endoscopists. The main endoscopic procedures should be trained in ascending order of difficulty. Incorporating models capable of simulating various clinical and anatomical conditions could provide an effective means of fulfilling training requirements, although they are not easily available due to expensive facilities and void of standard assessment. Competency assessment is crucial in ERCP training to ensure trainees can independently and safely perform ERCP. Because of the rapid advancement of diagnostic and therapeutic methods, postgraduate training is critical for ERCP practitioners. Once certificates are attained, practitioners are solely responsible for maintaining their competency, credentialing, and quality.
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Affiliation(s)
- Jiann-Hwa Chen
- Department of Internal Medicine, Tzu Chi University College of Medicine, Hualien, Taiwan
- Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
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El Menabawey T, McCrudden R, Shetty D, Hopper AD, Huggett MT, Bekkali N, Carroll NR, Henry E, Johnson GJ, Keane MG, Love M, McKay CJ, Norton S, Oppong K, Penman I, Ramesh J, Ryan B, Siau K, Nayar M. UK and Ireland Joint Advisory Group (JAG) consensus statements for training and certification in diagnostic endoscopic ultrasound (EUS). Gut 2023; 73:118-130. [PMID: 37739777 PMCID: PMC10715553 DOI: 10.1136/gutjnl-2023-329800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/02/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK. METHODS Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved. RESULTS 39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers. CONCLUSIONS An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.
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Affiliation(s)
- Tareq El Menabawey
- Pancreatobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Gastroenterology, Homerton University Hospital, London, UK
| | - Raymond McCrudden
- Department of Gastroenterology, University Hospitals Dorset NHS Trust, Bournemouth, UK
| | - Dushyant Shetty
- Department of Radiology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Andrew D Hopper
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Noor Bekkali
- Department of Gastroenterology and Hepatology, University of Oxford, Translational Gastroenterology Unit, Oxford, UK
| | - Nicholas R Carroll
- Radiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Henry
- Department of Gastroenterology, NHS Tayside, Dundee, UK
| | - Gavin J Johnson
- Pancreatobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Margaret G Keane
- Gastroenterology and Hepatology, Johns Hopkins, Baltimore, Maryland, USA
| | - Mark Love
- Radiology, Belfast City Hospital, Belfast, UK
| | - Colin J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Sally Norton
- Upper Gastrointestinal Surgery, Bristol Royal Infirmary, Bristol, UK
| | - Kofi Oppong
- HPB Unit & Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Ian Penman
- Centre for Liver & Digestive Disorders, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Jayapal Ramesh
- Department of Gastroenterology, Royal Liverpool Hospital NHS Trust, Liverpool, UK
| | - Barbara Ryan
- Department of Gastroenterology, Trinity College Dublin, Dublin, Ireland
| | - Keith Siau
- Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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Voiosu TA, Benguș A, Bronswijk M, Lyutakov I, Klarin I, Voiosu B, Bălănescu P, Diaconu C, Busuioc B, Boskoski I, Voiosu AM, Mateescu RB, Wani S. A simple clinical score to stratify the risk of procedure-related adverse events in ERCP procedures with trainee involvement. Endoscopy 2023; 55:804-811. [PMID: 36828031 DOI: 10.1055/a-2042-6288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND : Optimal training strategies in endoscopic retrograde cholangiopancreatography (ERCP) remain controversial despite the shift toward competence-based training models, with limited data available on patient safety during training. We aimed to assess whether pre-procedural clinical predictors could identify patients at low risk of developing procedure-related adverse-events (AEs) in a training environment. METHODS : We performed a prospective, multicenter, cohort study in five training centers. A data collection system documenting indication, clinical data, trainee performance (assessed using a validated competence assessment tool), technical outcomes, and AEs over a 30-day follow-up was utilized. We developed a clinical risk score (Trainee Involvement in ERCP Risk Score [TIERS]) for patients undergoing ERCP and compared the rate of AEs in a training environment between low-risk and high-risk groups. The association between trainee performance and AE rate was also evaluated. RESULTS : 1283 ERCPs (409 [31.9 %, 95 %CI 29.3 %-34.4 %] with trainee involvement) performed by 11 trainers and 10 trainees were analyzed. AEs were more frequent in the high-risk compared with the low-risk group: 26.7 % (95 %CI 20.5 %-34.7 %) vs. 17.1 % (95 %CI 12.8 %-22.2 %). TIERS demonstrated a high negative predictive value for AEs (82.9 %, 95 %CI 79.4 %-85.8 %) and was the only predictor of AEs on multivariable analysis (odds ratio 1.38, 95 %CI 1.09-1.75). Suboptimal trainee performance was associated with an increase in AE rates. CONCLUSION : Simple, clinical-based predictive tools could improve ERCP training by selecting the most appropriate cases for hands-on training, with the aim of increasing patient safety.
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Affiliation(s)
- Theodor A Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Andreea Benguș
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Imelda GI Research Center, Bonheiden, Belgium
| | - Ivan Lyutakov
- Department of Gastroenterology, University Hospital "Tsaritsa Yoanna - ISUL", Sofia, Bulgaria
- Department of Gastroenterology, Medical University Sofia, Sofia, Bulgaria
| | - Ivo Klarin
- Department of Health Studies, University of Zadar, Zadar, Croatia
- Gastroenterology Department, General Hospital Zadar, Zadar, Croatia
| | - Bianca Voiosu
- Gastroenterology Department, Cantacuzino Hospital, Bucharest, Romania
| | - Paul Bălănescu
- Internal Medicine Department, Carol Davila School of Medicine, Bucharest, Romania
- Clinical Immunology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Claudia Diaconu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Bogdan Busuioc
- Gastroenterology Department, Cantacuzino Hospital, Bucharest, Romania
| | - Ivo Boskoski
- Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Radu B Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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6
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Khan R, Homsi H, Gimpaya N, Lisondra J, Sabrie N, Gholami R, Bansal R, Scaffidi MA, Lightfoot D, James PD, Siau K, Forbes N, Wani S, Keswani RN, Walsh CM, Grover SC. Validity evidence for observational ERCP competency assessment tools: a systematic review. Endoscopy 2023; 55:847-856. [PMID: 36822219 DOI: 10.1055/a-2041-7546] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND : Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is critical for supporting learning and documenting attainment of skill. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated. METHODS : We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively. RESULTS : From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one for simulated ERCP, and one for simulated and clinical ERCP. Validity evidence scores ranged from 2 to 12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence, with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality (maximum score 13.5) was strong, with scores ranging from 10 to 12.5. CONCLUSIONS : The BESAT, ERCP DOPS, and TEESAT had strong validity evidence compared with other assessments. Integrating tools into training may help drive learners' development and support competency decision making.
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Affiliation(s)
- Rishad Khan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Hoomam Homsi
- Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Canada
| | - James Lisondra
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Canada
| | | | - Reza Gholami
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Canada
| | - Rishi Bansal
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | | | - David Lightfoot
- Health Science Library, Unity Health Toronto, St. Michael's Hospital, Toronto, Canada
| | - Paul D James
- Division of Gastroenterology, University Health Network, Toronto, Canada
| | - Keith Siau
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, United Kingdom
- Immunology and Immunotherapy, University of Birmingham College of Medical and Dental Sciences, Birmingham, United Kingdom
| | - Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Catharine M Walsh
- The Wilson Centre, University of Toronto, Toronto, Canada
- SickKids Research and Learning Institute, The Hospital for Sick Children, Toronto, Canada
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Samir C Grover
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Toronto, Canada
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van der Wiel SE, Rauws E, Van Gool S, Wang D, Hu B, Kylanpaa L, Webster GJ, James M, Koch AD, Bruno M. Impact of ERCP simulator training on early ERCP learning curves of novice trainees: a cohort study. Endosc Int Open 2023; 11:E690-E696. [PMID: 37564331 PMCID: PMC10411077 DOI: 10.1055/a-2114-2842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 05/31/2023] [Indexed: 08/12/2023] Open
Abstract
Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees. Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boškoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC). Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs. Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.
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Affiliation(s)
| | - Erik Rauws
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Stijn Van Gool
- Gastroenterology and Hepatology, AZ Sint-Jozef Turnhout, Turnhout, Belgium
| | - Dong Wang
- Gastroenterology and Hepatology, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Endoscopy Center, Shanghai Eastern Hepatobiliary Hospital, Shanghai, China
| | - Leena Kylanpaa
- Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - George J.M. Webster
- Department of Gastroenterology, Nottingham City Hospital NHS Trust, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Martin James
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Arjun Dave Koch
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Marco Bruno
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
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Gupta R, Khalaf RT, Morrison J, Amankwah E, Ruan W, Fishman DS, Barth BA, Liu QY, Giefer M, Kim KM, Martinez M, Dall'oglio L, Torroni F, De Angelis P, Faraci S, Bitton S, Dua K, Werlin S, Gugig R, Huang C, Mamula P, Quiros JA, Zheng Y, Piester T, Grover A, Fox VL, Wilsey M, Troendle DM. Impact of Trainee Involvement on Pediatric ERCP Procedures: Results From the Pediatric ERCP Initiative. J Pediatr Gastroenterol Nutr 2023; 77:126-130. [PMID: 36976177 DOI: 10.1097/mpg.0000000000003782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
This study examines the role of trainee involvement with pediatric endoscopic retrograde cholangiopancreatography (ERCP) and whether it affects the procedure's success, post-procedural adverse outcomes, and duration. A secondary analysis of the Pediatric ERCP Database Initiative, an international database, was performed. Consecutive ERCPs on children <19 years of age from 18 centers were entered prospectively into the database. In total 1124 ERCPs were entered into the database, of which 320 (28%) were performed by trainees. The results showed that the presence of trainees did not impact technical success ( P = 0.65) or adverse events rates ( P = 0.43). Rates of post-ERCP pancreatitis, pain, and bleeding were similar between groups ( P > 0.05). Fewer cases involving trainees were in the top quartile (>58 minutes) of procedural time (19% vs 26%; P = 0.02). Overall, our findings indicate trainee involvement in pediatric ERCP is safe.
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Affiliation(s)
- Rekha Gupta
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Racha T Khalaf
- the Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL
| | - John Morrison
- Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | | | - Wenly Ruan
- Baylor College of Medicine Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Bradley A Barth
- the UT Southwestern Medical Center; Children's Health, Children's Medical Center, Dallas, TX
| | - Quin Y Liu
- the Cedars-Sinai Medical Center, Los Angeles, CA
| | - Matthew Giefer
- The University of Queensland, AU-Oschsner Health, New Orleans, LA
| | - Kyung Mo Kim
- University of Ulsan College of Medicine; Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | - Mercedes Martinez
- Columbia University New York Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | | | | | | | | | - Sam Bitton
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Kulwinder Dua
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Steven Werlin
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Roberto Gugig
- Stanford Children's Health; Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | | | - Petar Mamula
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Yuhua Zheng
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Travis Piester
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Amit Grover
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Victor L Fox
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Michael Wilsey
- Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - David M Troendle
- the UT Southwestern Medical Center; Children's Health, Children's Medical Center, Dallas, TX
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Borrelli de Andreis F, Mascagni P, Schepis T, Attili F, Tringali A, Costamagna G, Boškoski I. Prevention of post-ERCP pancreatitis: current strategies and novel perspectives. Therap Adv Gastroenterol 2023; 16:17562848231155984. [PMID: 36895283 PMCID: PMC9989421 DOI: 10.1177/17562848231155984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/23/2023] [Indexed: 03/08/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.
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Affiliation(s)
- Federica Borrelli de Andreis
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, Pavia, Italy
- Gastroenterology Unit, Istituti Clinici Maugeri, University of Pavia, Pavia, Italy
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pietro Mascagni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Institute of Image-Guided Surgery, IHU-Strasbourg, France
| | - Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabia Attili
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, 00168, Italy
- IHU Strasbourg 1, Place de l’Hopital 67091 Strasbourg Cedex, France
- Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
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10
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Boškoski I, Pontecorvi V, Ibrahim M, Huberty V, Maselli R, Gölder SK, Kral J, Samanta J, Patai ÁV, Haidry R, Hollenbach M, Pérez-Cuadrado-Robles E, Silva M, Messmann H, Tham TC, Bisschops R. Curriculum for bariatric endoscopy and endoscopic treatment of the complications of bariatric surgery: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023; 55:276-293. [PMID: 36696907 DOI: 10.1055/a-2003-5818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Obesity is a chronic, relapsing, degenerative, multifactorial disease that is associated with many co-morbidities. The global increasing burden of obesity has led to calls for an urgent need for additional treatment options. Given the rapid expansion of bariatric endoscopy and bariatric surgery across Europe, the European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. This curriculum is set out in terms of the prerequisites prior to training, minimum number of procedures, the steps for training and quality of training, and how competence should be defined and evidenced before independent practice. 1: ESGE recommends that every endoscopist should have achieved competence in upper gastrointestinal endoscopy before commencing training in bariatric endoscopy and the endoscopic treatment of bariatric surgical adverse events. 2: Trainees in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery should have basic knowledge of the definition, classification, and social impact of obesity, its pathophysiology, and its related co-morbidities. The recognition and management of gastrointestinal diseases that are more common in patients with obesity, along with participation in multidisciplinary teams where obese patients are evaluated, are mandatory. 3 : ESGE recommends that competency in bariatric endoscopy and the endoscopic treatment of the complications of bariatric surgery can be learned by attending validated training courses on simulators initially, structured training courses, and then hands-on training in tertiary referral centers.
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Affiliation(s)
- Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Pontecorvi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Vincent Huberty
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Roberta Maselli
- Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Stefan K Gölder
- Department of Internal Medicine, Ostalb Klinikum Aalen, Aalen, Germany
| | - Jan Kral
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Árpád V Patai
- Division of Gastroenterology, Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Rehan Haidry
- Department of Gastroenterology, University College London Hospital, London, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | | | - Marco Silva
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, TARGID, KU Leuven, Leuven, Belgium
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11
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Choi JH, Cho IR, Lee SH, Kim JS, Park N, Lee MW, Jang DK, Paik WH, Ahn DW, Ryu JK, Kim YT, Kim E, Lee J. Efficacy and safety of novel hemostatic gel in endoscopic sphincterotomy or endoscopic papillectomy: A multicenter, randomized controlled clinical trial. Dig Liver Dis 2023; 55:527-533. [PMID: 36737314 DOI: 10.1016/j.dld.2023.01.157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/07/2022] [Accepted: 01/22/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Endoscopists often experience obstacles with traditional hemostasis using the side-viewing duodenoscope for bleeding after endoscopic sphincterotomy (EST) or endoscopic papillectomy (EP). AIMS In this randomized controlled trial, we evaluated the efficacy and safety of a novel hemostatic gel for post-EST or post-EP bleeding. METHODS A randomized trial was conducted from November 2020 to December 2021 at two tertiary centers in South Korea. Patients who experienced bleeding immediately after EST or EP were enrolled in the study, and primary hemostasis was achieved with either the novel hemostatic gel or epinephrine spray. RESULTS A total of 84 patients were enrolled in this study, and 41 patients were finally analyzed in each group. Hemostatic gel was significantly superior to epinephrine spray for successful primary hemostasis (100% vs. 85.4%; P = 0.026). ). In terms of delayed bleeding, no significant difference was observed between the hemostatic gel and epinephrine spray (2.4% vs. 7.3%; P = 0.329). The mean procedural time was significantly higher for the hemostatic gel than epinephrine spray (3.23 ± 1.94 vs. 1.76 ± 0.99 min; P < 0.001), and no differences were observed in the adverse events. CONCLUSIONS The novel hemostatic gel is expected to achieve satisfactory results with easier hemostasis for immediate bleeding after EST or EP. (Registered in Clinical Research Information Service: KCT0005607).
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - In Rae Cho
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
| | - Joo Seong Kim
- Department of Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Namyoung Park
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Min Woo Lee
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Dong Won Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Yong-Tae Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Eunji Kim
- CG Bio Co., Ltd., Seoul, Republic of Korea
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12
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Sabrie N, Khan R, Seleq S, Homsi H, Gimpaya N, Bansal R, Scaffidi MA, Lightfoot D, Grover SC. Global trends in training and credentialing guidelines for gastrointestinal endoscopy: a systematic review. Endosc Int Open 2023; 11:E193-E201. [PMID: 36845269 PMCID: PMC9949985 DOI: 10.1055/a-1981-3047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background and study aims Credentialing, the process through which an institution assesses and validates an endoscopist's qualifications to independently perform a procedure, can vary by region and country. Little is known about these inter-societal and geographic differences. We aimed to systematically characterize credentialing recommendations and requirements worldwide. Methods We conducted a systematic review of credentialing practices among gastrointestinal and endoscopy societies worldwide. An electronic search as well as hand-search of World Endoscopy Organization members' websites was performed for credentialing documents. Abstracts were screened in duplicate and independently. Data were collected on procedures included in each document (e. g. colonoscopy, ERCP) and types of credentialing statements (procedural volume, key performance indicators (KPIs), and competency assessments). The primary objective was to qualitatively describe and compare the available credentialing recommendations and requirements from the included studies. Descriptive statistics were used to summarize data when appropriate. Results We screened 653 records and included 20 credentialing documents from 12 societies. Guidelines most commonly included credentialing statements for colonoscopy, esophagogastroduodenoscopy (EGD), and ERCP. For colonoscopy, minimum procedural volumes ranged from 150 to 275 and adenoma detection rate (ADR) from 20 % to 30%. For EGD, minimum procedural volumes ranged from 130 to 1000, and duodenal intubation rate of 95 % to 100%. For ERCP, minimum procedural volumes ranged from 100 to 300 with selective duct cannulation success rate of 80 % to 90 %. Guidelines also reported on flexible sigmoidoscopy, capsule endoscopy, and endoscopic ultrasound. Conclusions While some metrics such as ADR were relatively consistent among societies, there was substantial variation among societies with respect to procedural volume and KPI statements.
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Affiliation(s)
| | - Rishad Khan
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
| | - Samir Seleq
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
| | - Hoomam Homsi
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
| | - Rishi Bansal
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
| | | | - David Lightfoot
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
| | - Samir C. Grover
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, Toronto, Canada
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13
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Tanisaka Y, Mizuide M, Fujita A, Jinushi R, Ogawa T, Katsuda H, Saito Y, Miyaguchi K, Mashimo Y, Ryozawa S. Competence development of trainees performing short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1316-1326. [PMID: 35594030 DOI: 10.1002/jhbp.1187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/01/2022] [Accepted: 04/17/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES This study aimed to evaluate the trainees' practice and learning curve in short-type single-balloon enteroscopy (short SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) for patients with surgically altered anatomy (SAA) and determine how to train these trainees. METHODS The data of short SBE-assisted ERCP procedures between September 2011 and June 2021 were analyzed. RESULTS Three trainees and 180 cases were included in the analysis. Each trainee performed 60 cases between April 2016 and June 2021. The trainees' completion rate was 73.9% (95% confidence interval [CI], 66.8-80.1%). Adverse events occurred in 5.0% of cases (95% CI, 2.3-9.3%). The trainee who experienced colonoscopy and ERCP the most achieved better outcomes of enteroscopy success (reaching the target site) and trainee's completion rates than those of the others (P = .03 and .02, respectively). The learning curve for trainee's completion showed a significant improvement after 60 cases (P = .001). Multiple logistic regression analysis indicated that Roux-en-Y reconstruction was the factor affecting trainees' completion failure. CONCLUSIONS Short SBE-assisted ERCP trainees has a substantial learning curve. If trainees do not have much experience with colonoscopy and ERCP procedures, it may be beneficial for them to start performing short SBE-assisted ERCP procedures on non-Roux-en-Y reconstruction cases.
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Affiliation(s)
- Yuki Tanisaka
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Masafumi Mizuide
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Akashi Fujita
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Ryuhei Jinushi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Tomoya Ogawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Hiromune Katsuda
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Yoichi Saito
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Kazuya Miyaguchi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Yumi Mashimo
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shomei Ryozawa
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
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14
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Khan U, Khan R, Benchimol E, Salim M, Telford J, Enns R, Mohamed R, Forbes N, Sandha G, Kohansal A, Mosko J, Chatterjee A, May G, Waschke K, Barkun A, James PD. Learning curves in ERCP during advanced endoscopy training: a Canadian multicenter prospective study. Endosc Int Open 2022; 10:E1174-E1180. [PMID: 36118648 PMCID: PMC9473840 DOI: 10.1055/a-1795-9037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/13/2021] [Indexed: 10/31/2022] Open
Abstract
Background and study aims Growing emphasis on quality and patient safety has supported the shift toward competency-based medical education for advanced endoscopy trainees (AETs). In this study, we aimed to examine Canadian AETs learning curves and achievement of competence using an ERCP assessment tool with strong evidence of validity. Methods This prospective study was conducted at five institutions across Canada from 2017-2018. Data on every fifth procedure performed by trainees were collected using the United Kingdom Joint Advisory Joint Advisory Group of Gastrointestinal Endoscopy (JAG) ERCP Direct Observation of Procedural Skills (DOPS) tool, which includes a four-point rating scale for 27 items. Cumulative sum (CUSUM) analysis was used to create learning curves for overall supervision ratings and ERCP DOPS items by plotting scores for procedures performed during training. Results Eleven trainees who were evaluated for 261 procedures comprised our sample. The median number of evaluations by site was 49 (Interquartile range (IQR) 31-76) and by trainee was 15 (IQR 11-45). The overall cannulation rate by trainees was 82 % (241/261), and the native papilla cannulation rate was 78 % (149/191). All trainees achieved competence in the "overall supervision" domain of the ERCP DOPS by the end of their fellowship. Trainees achieved competency in all individual domains, except for tissue sampling and sphincteroplasty. Conclusions Canadian AETs are graduating from fellowship programs with acceptable levels of competence for overall ERCP performance and for the most specific tasks. Learning curves may help identify areas of deficiency that may require supplementary training, such as tissue sampling.
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Affiliation(s)
- Usman Khan
- Division of General Surgery, Department of Surgery, University of Toronto
| | - Rishad Khan
- Department of Medicine, University of Toronto
| | - Eric Benchimol
- Division of Gastroenterology, Hepatology, and Nutrition, the Hospital for Sick Children, University of Toronto
| | - Misbah Salim
- Division of Gastroenterology, University Health Network, University of Toronto
| | - Jennifer Telford
- Division of Gastroenterology and Hepatology, Department of Medicine, University of British Columbia
| | - Robert Enns
- Division of Gastroenterology and Hepatology, Department of Medicine, University of British Columbia
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary
| | - Gurpal Sandha
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, University of Alberta
| | - Ali Kohansal
- Division of Digestive Care and Endoscopy, Department of Medicine, Dalhousie University
| | - Jeffrey Mosko
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto
| | - Avijit Chatterjee
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, University of Ottawa
| | - Gary May
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto
| | - Kevin Waschke
- Division of Gastroenterology, McGill University Health Centre, McGill University
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Centre, McGill University
| | - Paul D. James
- Division of Gastroenterology, University Health Network, University of Toronto
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15
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Deliwala SS, Chawla S. Ballooning Your Way in Altered Anatomy ERCP: Ready for Deductive Learning. Dig Dis Sci 2022; 67:2696-2698. [PMID: 35001243 DOI: 10.1007/s10620-021-07348-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Smit S Deliwala
- Department of Medicine, Michigan State University at Hurley Medical Center, Flint, MI, USA
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, 30322, USA.
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16
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CÁCERES-ESCOBAR D, MUÑOZ-VELANDIA OM, VARGAS-RUBIO R. FACTORS ASSOCIATED WITH DIFFICULT BILIARY CANNULATION IN A TRAINING CENTER FOR ENDOSCOPIC INTERVENTION OF THE BILIARY TRACT. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:29-34. [DOI: 10.1590/s0004-2803.202200001-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/03/2021] [Indexed: 11/21/2022]
Abstract
ABSTRACT Background This paper aims to determine factors associated with difficult biliary cannulation (DBC) that are identifiable before procedures. Methods This is a nested case-control study within a historical cohort in adult patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) from 2015-2019 in the Hospital Universitario San Ignacio, Colombia. This study assessed the associations among variables that could be identified before or at the beginning of procedures and the probability of DBC. These associations were evaluated through a bivariate and multivariate analysis. The study used criteria for DBC defined by the European Society of Gastrointestinal Endoscopy. Results A total of 498 ERCP performed in 376 patients were analyzed. Of all procedures, 144 (29%) fulfilled criteria for DBC. The multivariate analysis showed an association between DBC and the acute care hospital setting (OR:2.92; CI95% 1.70-5.01; P<0.001), redundant papilla (OR:7.26; CI95% 3.38-15.61; P<0.001), or peridiverticular papilla (OR:2.45; CI95% 1.38-4.36; P=0.002). No association was found between DBC and endoscopist’s experience, bilirubin levels, or dilation of the biliary tract. Conclusion The DBC is a frequent event. Alterations in the papilla and ERCP performed in the acute care hospital setting are the principal factors associated with DBC. This information might be useful to predict DBC and establish healthcare and administrative strategies to reduce its implications.
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17
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Learning Curve of Endoscopic Retrograde Cholangiopancreatography Using Single-Balloon Enteroscopy. Dig Dis Sci 2022; 67:2882-2890. [PMID: 34973148 PMCID: PMC9237007 DOI: 10.1007/s10620-021-07342-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/11/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically difficult. Extensive training is required to develop the ability to perform this procedure. AIMS To investigate the learning curve of single-balloon-assisted enteroscopy ERCP (SBE-ERCP). METHODS We conducted a retrospective, observational case series at a single center. We evaluated the SBE-ERCP procedures between April 2011 and February 2021. The main outcomes were the rate of reaching the target site and the success rate of the entire procedure. These parameters were additionally expressed as a learning curve. RESULTS A total of 687 SBE-ERCP procedures were analyzed. The learning curve was analyzed in blocks of 10 cases. In this study, seven endoscopists, experts in conventional ERCP, were included. The overall SBE-ERCP procedural success rate was 92.2% (634/687 cases). Combining all data from individual endoscopists' evaluation periods, the insertion and success rates of the SBE-ERCP procedures gradually increased with increased experience performing SBE-ERCP. The insertion success rates for the number of SBE-ERCP cases (< 20, 21-30, > 30) were 82.9%, 92.9%, and 94.3%, respectively; the procedure success rates were 74.3%, 81.4%, and 92.9%, respectively. The endoscopists who had performed > 30 SBE-ERCP cases had a success rate of ≥ 90%. CONCLUSIONS Our results suggest that performing > 30 cases is one of the targets for conventional ERCP experts to become competent in performing SBE-ERCP in patients with a surgically altered anatomy.
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18
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Siau K, Keane MG, Steed H, Caddy G, Church N, Martin H, McCrudden R, Neville P, Oppong K, Paranandi B, Rasheed A, Sturgess R, Hawkes ND, Webster G, Johnson G, on behalf of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) . UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography. Endosc Int Open 2022; 10:E37-E49. [PMID: 35047333 PMCID: PMC8759929 DOI: 10.1055/a-1629-7540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/24/2021] [Indexed: 12/25/2022] Open
Abstract
Background and study aims Despite the high-risk nature of endoscopic retrograde cholangiopancreatography (ERCP), a robust and standardized credentialing process to ensure competency before independent practice is lacking worldwide. On behalf of the Joint Advisory Group (JAG), we aimed to develop evidence-based recommendations to form the framework of ERCP training and certification in the UK. Methods Under the oversight of the JAG, a modified Delphi process was conducted with stakeholder representation from the British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on ERCP training and certification were formulated after formal literature review and appraised using the GRADE tool. These were subjected to electronic voting to achieve consensus. Accepted statements were peer-reviewed by JAG and relevant Specialist Advisory Committees before incorporation into the ERCP certification pathway. Results In total, 27 recommendation statements were generated for the following domains: definition of competence (9 statements), acquisition of competence (8 statements), assessment of competence (6 statements) and post-certification support (4 statements). The consensus process led to the following criteria for ERCP certification: 1) performing ≥ 300 hands-on procedures; 2) attending a JAG-accredited ERCP skills course; 3) in modified Schutz 1-2 procedures: achieving native papilla cannulation rate ≥80%, complete bile duct clearance ≥ 70 %, successful stenting of distal biliary strictures ≥ 75 %, physically unassisted in ≥ 80 % of cases; 4) 30-day post-ERCP pancreatitis rates ≤5 %; and 5) satisfactory performance in formative and summative direct observation of procedural skills (DOPS) assessments. Conclusions JAG certification in ERCP has been developed following evidence-based consensus to quality assure training and to ultimately improve future standards of ERCP practice.
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Affiliation(s)
- Keith Siau
- Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Helen Steed
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Grant Caddy
- Department of Gastroenterology, South Eastern Health and Social Care Trust, Northern Ireland, UK
| | - Nick Church
- Department of Gastroenterology, NHS Lothian, Edinburgh, Scotland
| | - Harry Martin
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Raymond McCrudden
- Department of Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Peter Neville
- Department of Gastroenterology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - Kofi Oppong
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ashraf Rasheed
- Department of Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - Richard Sturgess
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Neil D Hawkes
- Department of Gastroenterology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Gavin Johnson
- Department of Gastroenterology, University College London Hospitals, London, UK
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19
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The learning curve for transoral incisionless fundoplication. Endosc Int Open 2021; 9:E1785-E1791. [PMID: 34790546 PMCID: PMC8589558 DOI: 10.1055/a-1547-6599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/22/2021] [Indexed: 11/02/2022] Open
Abstract
Background and study aims Transoral incisionless fundoplication (TIF) is a safe and effective minimally invasive endoscopic technique for treating gastroesophageal reflux disease (GERD). The learning curve for this technique has not been reported. We studied the learning curve for TIF when performed by a gastroenterologist by identifying the threshold number of procedures needed to achieve consistent technical success or proficiency (consistent creation of TIF valve ≥ 270 degrees in circumference, ≥ 2 cm long) and efficiency after didactic, hands-on and case observation experience. Patients and methods We analyzed prospectively collected data from patients who had TIF performed by a single therapeutic endoscopist within 17 months after basic training. We determined thresholds for procedural learning using cumulative sum of means (CUSUM) analysis to detect changes in achievement rates over time. We used breakpoint analysis to calculate procedure metrics related to proficiency and efficiency. Results A total of 69 patients had 72 TIFs. The most common indications were refractory GERD (44.7 %) and proton pump inhbitor intolerance (23.6 %). Proficiency was achieved at the 18 th to 20 th procedure. The maximum efficiency for performing a plication was achieved after the 26 th procedure, when mean time per plication decreased to 2.7 from 5.1 minutes (P < 0.0001). TIF procedures time varied until the 44 th procedure, after which it decreased significantly from 53.7 minutes to 39.4 minutes (P < 0.0001). Conclusions TIF can be safely, successfully, and efficiently performed in the endoscopy suite by a therapeutic endoscopist. The TIF learning curve is steep but proficiency can be achieved after a basic training experience and 18 to 20 independently performed procedures.
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Johnson G, Webster G, Boškoski I, Campos S, Gölder SK, Schlag C, Anderloni A, Arnelo U, Badaoui A, Bekkali N, Christodoulou D, Czakó L, Fernandez Y Viesca M, Hritz I, Hucl T, Kalaitzakis E, Kylänpää L, Nedoluzhko I, Petrone MC, Poley JW, Seicean A, Vila J, Arvanitakis M, Dinis-Ribeiro M, Ponchon T, Bisschops R. Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2021; 53:1071-1087. [PMID: 34311472 DOI: 10.1055/a-1537-8999] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1: Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended. 2: Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee's procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice. 3: Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice). 4: The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies [FNA/FNBs]), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %. ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.
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Affiliation(s)
| | | | - Ivo Boškoski
- Gastroenterology and Digestive Endoscopy, Fondazione Policlinico Gemelli, Rome, Italy
| | - Sara Campos
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Stefan Karl Gölder
- Department of Internal Medicine III, University Hospital Augsburg, Augsburg, Germany
| | - Christoph Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Andrea Anderloni
- Division of Gastroenterology, Digestive Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy
| | - Urban Arnelo
- Department of Surgical and Perioperative Sciences/Surgery, Umeå University, Umeå, Sweden
| | - Abdenor Badaoui
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Noor Bekkali
- John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford, UK
| | - Dimitrios Christodoulou
- Department of Gastroenterology, Medical School and University Hospital of Ioannina, Ioannina, Greece
| | - László Czakó
- Department of Medicine, University of Szeged, Szeged, Hungary
| | - Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Istvan Hritz
- Centre for Therapeutic Endoscopy, 1st Department of Surgery and Interventional Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, IKEM, Prague, Czech Republic
| | - Evangelos Kalaitzakis
- Department of Gastroenterology, University Hospital of Heraklion, University of Crete, Heraklion, Greece
- Digestive Disease Center, University Hospital of Copenhagen/Herley, University of Copenhagen, Copenhagen, Denmark
| | - Leena Kylänpää
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Ivan Nedoluzhko
- Moscow Clinical Scientific Center n.a. A.S. Loginov, Moscow, Russia
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Jan-Werner Poley
- Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Juan Vila
- Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Instituto de Investigaciones Sanitarias de Navarra (IDISNA), Pamplona, Spain
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Thierry Ponchon
- Gastroenterology Division, Edouard Herriot Hospital, Lyon, France
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, and TARGID, KU Leuven, Leuven, Belgium
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21
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Gallo C, Boškoski I, Matteo MV, Orlandini B, Costamagna G. Training in endoscopic retrograde cholangio-pancreatography: a critical assessment of the broad scenario of training programs and models. Expert Rev Gastroenterol Hepatol 2021; 15:675-688. [PMID: 33599177 DOI: 10.1080/17474124.2021.1886078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) applications are rapidly evolving toward increasingly complex therapeutic approaches alongside with technological innovations. There are no globally agreed indications on the ERCP training path, which often requires too much time and does not always guarantee adequate skills.Areas covered: Frequency and difficulty of execution are the main objective criteria on which to draw up a training program: novel trainees should approach ERCP first through the simplest and most frequent procedures. An extensive use of training models would reduce the patient's performer-related risks. Amongst a wide variety of models, mechanical simulators have received large approval. In fact, they can be best-suited to each trainee's learning curve thanks to their precision and safety and by virtue of the unlimited repeatability of their use. However, more solid evidences are still needed.Expert opinion: Hands-on ERCP training should systematically employ mechanical simulators at least in the early stages of the learning process. An implementation of these models through sensors that objectively detect abnormalities in the movements would provide detailed feedbacks and deeper awareness. Simulators might also be useful for expert endoscopists to refine their skills. Rapid prototyping and 3D printing might be the way to create customized training models for successful training programs.
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Affiliation(s)
- Camilla Gallo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Maria Valeria Matteo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Beatrice Orlandini
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
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22
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Mutneja HR, Vohra I, Go A, Bhurwal A, Katiyar V, Palomera Tejeda E, Thapa Chhetri K, Baig MA, Arora S, Attar B. Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis. Endoscopy 2021; 53:357-366. [PMID: 32668463 DOI: 10.1055/a-1220-2242] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND : Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most common and most serious complication of ERCP. Our aim was to estimate the nationwide incidence, temporal trends, and mortality of PEP in the United States and to establish risk factors associated with PEP development. METHODS : This was a retrospective cohort study analyzing Nationwide Inpatient Sample data from 2011 to 2017 using International Classification of Diseases codes. The primary outcomes were trends in PEP incidence and predictors of PEP development. Secondary outcomes were in-hospital mortality, length of hospital stay, and admission to the intensive care unit. RESULTS : Of 1 222 467 adult patients who underwent inpatient ERCP during the study period, 55 225 (4.5 %) developed PEP. The hospital admission rate of PEP increased by 15.3 %, from 7735 in 2011 to 8920 in 2017 (odds ratio [OR] 1.23, 95 % confidence interval [CI] 1.04 - 1.46; P = 0.02). The overall rate of mortality increased from 2.8 % of PEP cases in 2011 to 4.4 % in 2017 (OR 1.62, 95 %CI 1.10 - 2.38; P = 0.01). Multiple patient-related (alcohol use, cocaine use, obesity, chronic kidney disease, heart failure), procedure-related (therapeutic ERCP, sphincterotomy, pancreatic duct stent placement, sphincter of Oddi dysfunction), and hospital-related (teaching hospitals, hospitals located in the West and Midwest) factors that impact the occurrence of PEP were identified. CONCLUSIONS : Our study showed rising hospital admission and mortality rates associated with PEP in the United States. This calls for a greater recognition of this life-threatening complication and amelioration of its risk factors, whenever possible.
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Affiliation(s)
- Hemant Raj Mutneja
- Gastroenterology, Cook County Health and Hospitals System, Chicago, Illinois, United States
| | - Ishaan Vohra
- Gastroenterology, Cook County Health and Hospitals System, Chicago, Illinois, United States
| | - Andrew Go
- Medicine, Loyola University Medical Center, Chicago, Illinois, United States
| | - Abhishek Bhurwal
- Gastroenterology, Robert Wood Johnson University Hospital, Chicago, Illinois, United States
| | - Vatsala Katiyar
- Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
| | | | - Kapil Thapa Chhetri
- Medicine, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
| | - Muhammad Arslan Baig
- Gastroenterology, University of Illinois College of Medicine, Peoria, Illinois, United States
| | - Shilpa Arora
- Medicine, Rush University Medical Center, Chicago, Illinois, United States
| | - Bashar Attar
- Gastroenterology and Hepatology, John H. Stroger Hospital of Cook County, Chicago, Illinois, United States
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23
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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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24
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van Riet PA, Quispel R, Cahen DL, Erler NS, Snijders-Kruisbergen MC, Van Loenen P, Poley JW, van Driel LMJW, Mulder SA, Veldt BJ, Leeuwenburgh I, Anten MPGF, Honkoop P, Thijssen AY, Hol L, Hadithi M, Fitzpatrick CE, Schot I, Bergmann JF, Bhalla A, Bruno MJ, Biermann K. Optimizing cytological specimens of EUS-FNA of solid pancreatic lesions: A pilot study to the effect of a smear preparation training for endoscopy personnel on sample quality and accuracy. Diagn Cytopathol 2020; 49:295-302. [PMID: 33098625 PMCID: PMC7820998 DOI: 10.1002/dc.24645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND In the absence of rapid on-side pathological evaluation, endoscopy staff generally "smears" endoscopic ultrasound guided fine needle aspiration (EUS-FNA) specimens on a glass slide. As this technique is vulnerable to preparation artifacts, we assessed if its quality could be improved through a smear-preparation-training for endoscopy staff. METHODS In this prospective pilot study, 10 endosonographers and 12 endoscopy nurses from seven regional EUS-centers in the Netherlands were invited to participate in a EUS-FNA smear-preparation-training. Subsequently, post training slides derived from solid pancreatic lesions were compared to pre-training "control" slides. Primary outcome was to assess if the training positively affects smear quality and, consequently, diagnostic accuracy of EUS-FNA of solid pancreatic lesions. RESULTS Participants collected and prepared 71 cases, mostly pancreatic head lesions (48%). Sixty-eight controls were selected from the pretraining period. The presence of artifacts was comparable for smears performed before and after training (76% vs 82%, P = .36). Likewise, smear cellularity (≥50% target cells) before and after training did not differ (44% (30/68) vs 49% (35/71), P = .48). Similar, no difference in diagnostic accuracy for malignancy was detected (P = .10). CONCLUSION In this pilot EUS-FNA smear-preparation-training for endoscopy personnel, smear quality and diagnostic accuracy were not improved after the training. Based on these results, we plan to further study other training programs and possibilities.
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Affiliation(s)
- Priscilla A van Riet
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rutger Quispel
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Djuna L Cahen
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Petri Van Loenen
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Lydi M J W van Driel
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Sanna A Mulder
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Bart J Veldt
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Ivonne Leeuwenburgh
- Department of Gastroenterology and Hepatology, Sint Franciscus Hospital, Rotterdam, The Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Hospital, Rotterdam, The Netherlands
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mohammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Claire E Fitzpatrick
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Rotterdam, The Netherlands
| | - Ingrid Schot
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Rotterdam, The Netherlands
| | - Jilling F Bergmann
- Department of Gastroenterology and Hepatology, HAGA, The Hague, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA, The Hague, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, the Netherlands and Institute for Pathology, Dueren, Germany
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25
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Maida M, Alrubaiy L, Bokun T, Bruns T, Castro V, China L, Conroy G, Trabulo D, Van Steenkiste C, Voermans RP, Burisch J, Ianiro G. Current challenges and future needs of clinical and endoscopic training in gastroenterology: a European survey. Endosc Int Open 2020; 8:E525-E533. [PMID: 32258375 PMCID: PMC7089798 DOI: 10.1055/a-1093-0877] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/04/2019] [Indexed: 12/19/2022] Open
Abstract
Background and study aims A universal European training program in gastroenterology and hepatology is currently not available. The European Board of Gastroenterology and Hepatology (EBGH) has produced guidance regarding expected competencies for European gastroenterology trainees but it is unclear whether these have been incorporated in national curricula. The aim of this study was to provide an in-depth assessment of training and research opportunities, professional activities and of socioeconomic aspects of gastroenterology training across Europe through a web-based 90-point questionnaire. Materials and methods Physicians in their last year or who had recently finished their training, from 16 European countries, were invited to answer the questionnaire. Results A total of 144 physicians answered the survey. A minimum number of procedures is required before completing training in nine of 16 countries (56 %). Overall, European trainees dedicate a median of 12 months (IQR 6-25) of their training period to endoscopy and a median of 3 months (IQR 0-6) to ultrasound. Training in interventional endoscopy was not always exhaustive, as about 50 % of participants performed fewer of several interventional procedures than was recommended by EBGH, most participants did not perform endoscopic hemostasis or endoscopic mucosal resection, and nearly a half of participants had no access to pancreatobiliary endoscopy training. Finally, up to 13 % of residents complete their training without the supervision of a mentor. Conclusion In this large European survey, deep gaps and considerable differences in several gastroenterology training activities were found both among and within 16 European countries. Homogenization of educational programs and training opportunities across Europe is therefore necessary.
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Affiliation(s)
- Marcello Maida
- Department of Gastroenterology, S.Elia - Raimondi Hospital, Caltanissetta, Italy
| | - Laith Alrubaiy
- Department of Gastroenterology, St Mark’s Hospital, London, UK
| | - Tomislav Bokun
- Department of Gastroenterology, Hepatology and clinical nutrition, University Hospital Dubrava, University of Zagreb, Zagreb, Yugoslavia
| | - Tony Bruns
- Department of Medicine III, University Hospital RWTH Aachen, Germany
| | - Valeria Castro
- Department of Internal Medicine, Gastroenterology and Hepatology Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Louise China
- Metabolism and Experimental Therapeutics, Division of Medicine, University College London, London, UK
| | - Guillaume Conroy
- Department of Hepatology and Gastroenterology, Mercy Hospital, Metz, France
| | - Daniel Trabulo
- Gastroenterology department, Hospital de Cascais, Hospital da Luz Setúbal, Portugal
| | | | - Rogier P. Voermans
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Johan Burisch
- Digestive Disease Centre, Medical Section, Herlev University Hospital, Copenhagen, Denmark
| | - Gianluca Ianiro
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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26
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Han SY, Kim DU, Lee MW, Park YJ, Baek DH, Kim GH, Song GA. Acute distal common bile duct angle is risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis in beginner endoscopist. World J Clin Cases 2020; 8:20-28. [PMID: 31970166 PMCID: PMC6962061 DOI: 10.12998/wjcc.v8.i1.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/04/2019] [Accepted: 12/13/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a critical and poorly managed complication of ERCP. Endoscopists need to understand the risk factors for PEP. However, the majority of studies investigating ERCP-related risk factors have included well-trained endoscopists, with the issue of endoscopist experience on PEP incidence not having been systematically evaluated. AIM To explore the risk factors for PEP in beginner endoscopists without supervision. METHODS We performed a retrospective analysis of 293 patients, with naïve papilla and no history of pancreatitis, treated using bile duct cannulation. Patients were classified according to the endoscopist's experience (beginner vs expert). The angle of the distal common bile duct (CBD) was measured as the angle between the lower wall of the bile duct and a vertical line extending to the lower wall of the bile duct on coronal view computed tomography. RESULTS After propensity matching, there were no differences between patients treated by the expert and beginner endoscopist with regard to age, sex, mean bile duct dilatation, and ratio of benign disease. The distal CBD angle was classified as acute (> 30º) or obtuse (≤ 30º), based on the mean angle of 29.9º for the group. An acute distal CBD angle was a significant risk factor for PEP for beginner (P = 0.049), but not expert. CONCLUSION For beginner endoscopists first performing unsupervised ERCP, cases with an obtuse distal CBD angle may be more appropriate to lower the risk of PEP.
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Affiliation(s)
- Sung Yong Han
- Division of Gastroenterology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Dong Uk Kim
- Division of Gastroenterology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Moon Won Lee
- Division of Gastroenterology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Young Joo Park
- Division of Gastroenterology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Dong Hoon Baek
- Division of Gastroenterology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Gwang Ha Kim
- Division of Gastroenterology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
| | - Geun Am Song
- Division of Gastroenterology, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
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Zheng L, Wang L, Ren G, Zhang R, Liang S, Wang B, Zhang L, Wang X, Luo B, Pan Y, Guo X. Patient-related factors associated with successful cannulation by trainees during hands-on endoscopic retrograde cholangiopancreatography training. Dig Endosc 2019; 31:558-565. [PMID: 30785645 DOI: 10.1111/den.13377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/14/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM Hands-on endoscopic retrograde cholangiopancreatography (ERCP) training is essential for trainees to grasp the technique. Cannulation success rate (CSR) is considered one of the main indicators of competency of trainees. We aimed to investigate whether patient-related factors had an impact on the CSR of trainees. METHODS A post hoc analysis of data from two multicenter studies (NCT02002650 and NCT03057769) was conducted. Patients aged 18-90 years with native papilla undergoing ERCP were eligible for this study. Only procedures involving trainees in centers strictly following "10-min criteria" for initial cannulation were enrolled. Primary outcome was CSR by trainees. RESULTS From December 2013 to October 2017, 20 trainees in four centers were involved in initial cannulation in 1044 patients with native papilla. Primary CSR by trainees was 61.0% (436/715), 31.5% (70/222) and 44.9% (48/107) in patients with common bile duct stone (CBDS), biliary stricture (BS) and other indications, respectively (P < 0.001). In multivariate analysis, indication of BS (OR, 0.31; 95% CI, 0.22-0.44; P < 0.001) and presence of type A diverticulum (OR, 1.69; 95% CI, 1.23-2.33; P = 0.001) were both independently associated with cannulation success of trainees. Biliary infection was significantly higher in the BS than in the CBDS group (3.6% vs 0.7%, P = 0.004), whereas other post-ERCP complications were comparable between the two groups. CONCLUSIONS Indication of BS and the presence of type A diverticulum were independently associated with the success of cannulation by trainees. These findings indicate that greater effort is needed for trainees to improve the ability of cannulation in BS.
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Affiliation(s)
- Liang Zheng
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Limei Wang
- Department of Gastroenterology, Shaanxi Second People's Hospital, Xi'an, Shaanxi, China
| | - Gui Ren
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Rongchun Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Biaoluo Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Linhui Zhang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiangping Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bing Luo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuegang Guo
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Boškoski I, Tringali A, Costamagna G. Teaching endoscopic retrograde cholangiopancreatography cannulation. Transl Gastroenterol Hepatol 2019; 4:30. [PMID: 31231697 DOI: 10.21037/tgh.2019.04.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/23/2019] [Indexed: 01/17/2023] Open
Abstract
In the last two decades, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic procedure to an almost exclusively therapeutic one. Contemporaneously, many different catheters have become available for cannulation and special techniques have also been developed for difficult cases. ERCP is a skill demanding procedure that can lead to severe complications and death. Teaching ERCP is the most difficult task in an endoscopic training program. Training programs in ERCP must be effective, standardized and structured. Furthermore, robust standards for certification and revalidation are required to ensure ERCP as effective and as safe as possible.
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Affiliation(s)
- Ivo Boškoski
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Università Cattolica Del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and training (CERTT), Rome, Italy
| | - Andrea Tringali
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Università Cattolica Del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and training (CERTT), Rome, Italy
| | - Guido Costamagna
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Università Cattolica Del Sacro Cuore di Roma, Center for Endoscopic Research Therapeutics and training (CERTT), Rome, Italy
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29
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ERCP practice beyond the training period - bridging the gap between guidelines and real-life practice: a single operator experience of 679 procedures. ACTA ACUST UNITED AC 2019; 57:151-158. [PMID: 30517080 DOI: 10.2478/rjim-2018-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography has evolved significantly in recent years. The increase in complexity and range of applications has not been adequately reflected in an improvement of training methods for ERCP, with many endoscopists failing to meet required performance standards during their training period and limited available data on their performance immediately after completing training. We aimed to analyze the performance of an independent operator from a developing country after the completion of formal training with regard to procedure and patient-related outcomes. METHODS We conducted an observational study of ERCPs performed by a young endoscopist from a referral center. Data about the procedure, cannulation technique (including use of precut), trainee involvement and procedure-related outcomes was retrieved and analyzed from a prospectively maintained database on quality in ERCP (the QUASIE initiative). RESULTS Data from 679 consecutive ERCPs conducted or supervised by one endoscopist with < 200 independent procedures prior to the study period were included in the final analysis. Cannulation rates significantly improved over time, from 90% to 96% (p = 0.016). Use of precut techniques changed significantly over time, with an initial increase followed by a subsequent decrease as overall cannulation rates improved. Trainee involvement was significantly associated with prolonged cannulation times (p = 0.003) and use of precut (p = 0.001), but did not impact on technical success or patient safety. CONCLUSIONS Independent practice of ERCP after the training period is characterized by ongoing changes in technique, especially with regard to cannulation and use of precut, showing significant improvements in performance over time.
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30
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Endoscopic Management of Acute Biliopancreatic Disorders. J Gastrointest Surg 2019; 23:1055-1068. [PMID: 30820794 DOI: 10.1007/s11605-019-04143-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 01/28/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders. METHODS Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders. RESULTS Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders. DISCUSSION Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.
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31
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Voiosu T, Bălănescu P, Voiosu A, Benguş A, Preda C, Umans DS, Bogdan Mateescu R, van Hooft JE. Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature. United European Gastroenterol J 2019; 7:239-249. [PMID: 31080609 PMCID: PMC6498806 DOI: 10.1177/2050640618817110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022] Open
Abstract
Background Current recommendations on training in endoscopic retrograde cholangiopancreatography are predicated on a performance-centred approach designed to ensure that trainees achieve appropriate skills. We aimed to analyse how competence in endoscopic retrograde cholangiopancreatography is defined in the literature and what proportion of trainees actually reach this threshold. Methods We conducted a systematic MEDLINE search for studies reporting on endoscopic retrograde cholangiopancreatography training programmes in a clinical setting. The main outcome measure was threshold for achieving competence in endoscopic retrograde cholangiopancreatography; the secondary outcome measure was assessment of trainee performance. Quality was assessed using the Cochrane Risk of Bias tool and the Methodological Index for Non-Randomized Studies criteria. Results Of 522 initially identified articles, 20 were included in the analysis; most studies showed a high risk of bias. Cannulation rate of the desired duct was the main marker of competence in all studies; however, only 8/20 studies reported on the performance of individual trainees, who achieved their respective standard of competence in only 25.6% of reported cases. Conclusions Current literature identifies cannulation rate of a native papilla to be the most appropriate measure of endoscopic retrograde cholangiopancreatography competence; however, most trainees do not reach predefined competence thresholds. Furthermore, due to the limitations of available studies, the most appropriate competence measure remains subject for debate.
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Affiliation(s)
- Theodor Voiosu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | | | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Andreea Benguş
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Carmen Preda
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Devica S Umans
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Radu Bogdan Mateescu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
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Rodrigues-Pinto E, Baron TH, Liberal R, Macedo G. Quality and competence in endoscopic retrograde cholangiopancreatography - Where are we 50 years later? Dig Liver Dis 2018; 50:750-756. [PMID: 29804924 DOI: 10.1016/j.dld.2018.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023]
Abstract
Training in endoscopic retrograde cholangiopancreatography (ERCP) requires the development of technical, cognitive, and integrative skills well beyond those needed for standard endoscopic procedures. So far, there are limited data regarding what constitutes competency in ERCP, including achievement and maintenance. Recent studies have highlighted overall procedural numbers are not enough to warrant competency, although more is better. We performed a comprehensive literature search until June 2017 using predetermined search terms to identify relevant articles and summarized their results as a narrative review. Selective native papilla deep cannulation should be used as a benchmark for assessing successful cannulation. Accurate and validated ERCP performance measures are needed to develop a curriculum that allows transition from numbers-based competency. However, available guidelines fail to state what degree of hands-on involvement is required by the trainee for the case to be counted in their overall procedural numbers. Qualitative assessment of competency should be done by trained raters using specially designed assessment tools. Competence continues to increase with practice following formal training in a fairly steady manner. The learning curve for overall common bile duct cannulation success may be a readily available surrogate for individual trainee progression and may correspond to learning curves for therapeutic interventions.
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Affiliation(s)
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
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Jovanovic I, Mönkemüller K. Quality in endoscopy training-the endoscopic retrograde cholangiopancreatography case. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:264. [PMID: 30094250 DOI: 10.21037/atm.2018.03.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most advanced therapeutic procedures in gastrointestinal endoscopy. It is highly operator-dependent procedure requiring specific, knowledge-based training in order to achieve competence. Strategies for assessing competency of trainees and those in practice include numbers of procedures performed, and subjective or objective assessment by a mentor or self-assessment by the trainee. However, it is still not clear how to measure the quality in (ERCP) training in an objective and reproducible way, so far. Thus, in this article, we will discuss issues related to training in ERCP and provide experience based discussion on how to best approach and master this complex and risky procedure.
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Affiliation(s)
- Ivan Jovanovic
- Clinic for Gastroenterology and Hepatology, University of Belgrade Medical School, Belgrade, Serbia.,Clinical Center of Serbia, University of Belgrade Medical School, Belgrade, Serbia
| | - Klaus Mönkemüller
- Division of Gastroenterology, Department of Visceral Surgery, Helios Frankenwaldklinik Kronach, Kronach, Germany
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34
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Borges AC, Almeida PCD, Furlani SMT, Cury MDS, Pleskow DK. ERCP PERFORMANCE IN A TERTIARY BRAZILIAN CENTER: FOCUS ON NEW RISK FACTORS, COMPLICATIONS AND QUALITY INDICATORS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2018; 31:e1348. [PMID: 29947682 PMCID: PMC6049994 DOI: 10.1590/0102-672020180001e1348] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/30/2018] [Indexed: 01/14/2023]
Abstract
Background: ERCP can lead to complications, which can be prevented by the recognition of risk factors. Aim: To identify these risk factors, with quality evaluation. Methods: Retrospective study in a Brazilian hospital in 194 patients, excluding surgically altered anatomy. Results: 211 ERCPs were performed: 97.6% were therapeutic, 83.4% were started by trainees, with deep cannulation rate of 89.6%. Precut was needed in 16.6% of the ERCPs and classic sphincterotomy in 67.3%, with 75.4% of ductal clearance at single session and 8.0% of technical failure. Inacessible papillas ocurred in 2.5% of cases. There were 2.5% of late complications and 16% of early complications. Multivariate analysis identified six predictors for early complications: fistulotomy precut (OR=3.4, p=0.010), difficult cannulation (OR=21.5, p=0.002), attending’s procedural time (OR=2.4, p=0.020), choledocholithiasis (adjusted OR=1.8, p=0.015), cannulation time (adjusted OR=3.2, p=0.018) and ERCP duration (adjusted OR=2.7, p=0.041). Conclusion: Six risk factors for post-ERCP complications were identified. ERCP duration and cannulation time are suggested as new potential quality indicators.
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Affiliation(s)
- Alana Costa Borges
- Zilda Arns Hospital and Maternity, Gastrointestinal Endoscopy, Fortaleza, CE, Brasil
| | | | | | - Marcelo de Sousa Cury
- SCOPE Gastrointestinal Endoscopy Unit, Gastrointestinal Endoscopy, Campo Grande, MS, Brasil
| | - Douglas K Pleskow
- Beth Israel Deaconess Medical Center, Center for Advanced Endoscopy, Boston, Massachusetts,USA
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35
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van der Wiel SE, Koch AD, Bruno MJ. Face and construct validity of a novel mechanical ERCP simulator. Endosc Int Open 2018; 6:E758-E765. [PMID: 29881768 PMCID: PMC5989785 DOI: 10.1055/s-0044-101754] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/27/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Simulation-based training has become an important pillar in competence-based medicine. However, limited data are available on use of simulators in training for endoscopic retrograde cholangiopancreatography (ERCP). We aimed to determine the face and construct validity of the Boškoski-Costamagna mechanical ERCP Trainer, and to assess its didactic value, as judged by experts. METHODS Participants were divided into four groups based on ERCP lifetime experience: novices, intermediate, experienced, and experts. Participants performed several standardized assignments on the simulator. Outcome parameters included times to complete the procedure, ability to cannulate both ducts, number of attempts to cannulate the common bile duct and pancreatic duct, number of inadvertent pancreatic duct cannulations, successful stent placement, and successful stone extraction. All experts filled out a questionnaire on the simulator's realism and didactic value. RESULTS Novices (n = 11) completed the total procedure in 21:09 (min:sec), intermediates (n = 5) in 10:58, experienced (n = 8) in 06:42 and experts (n = 22) in 06:05. Experts were significantly faster than novices (Kruskal-Wallis test P < 0.000). Experts rated the realism of the simulator 7.12 on a 10-point Likert scale. The simulator's potential as a tool for training novices was rated 3.91 on a four-point Likert scale, and there was a high agreement among experts to include the simulator in the training of novice endoscopists (3.86 on a four-point Likert scale). CONCLUSIONS The novel Boškoski-Costamagna ERCP simulator demonstrates good face and construct validity. ERCP experts highly agree on the didactic value and added value of this simulator in the training curriculum for novice endoscopists.
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Affiliation(s)
- Sophia E. van der Wiel
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical
Center Rotterdam, The Netherlands,Corresponding author Sophia E. van der Wiel, MD Erasmus MC University Medical Center Rotterdam, The NetherlandsDepartment of Gastroenterology and HepatologyPostbus 20403000 CA Rotterdam, The Netherlands+0031107030331
| | - Arjun D. Koch
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical
Center Rotterdam, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical
Center Rotterdam, The Netherlands
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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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37
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Iida T, Kaneto H, Wagatsuma K, Sasaki H, Naganawa Y, Nakagaki S, Satoh S, Shimizu H, Nakase H. Can Trainees Safely Perform Endoscopic Treatments for Common Bile Duct Stones? A Single-center Retrospective Study. Intern Med 2018; 57:923-928. [PMID: 29434158 PMCID: PMC5919847 DOI: 10.2169/internalmedicine.9737-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective There are no reports on whether or not trainees can safely carry out endoscopic procedures for the removal of common bile duct (CBD) stones. The aim of this study was to investigate the efficacy and safety of endoscopic treatments for CBD stones by trainees. Methods Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 1,016 consecutive patients at our institution during the 6-year study period. The endoscopically treated patients with CBD stones were included in this study. Physicians who had experienced ≥300 ERCP procedures were defined as experts, while those who had experienced <300 procedures were defined as trainees. The trainees were replaced by an expert when they could not achieve the established criteria. Patients were divided into the following three groups to retrospectively examine the patients' backgrounds, details of endoscopic treatments, and intra-/post-operative complications: Group A, completed by trainees under supervision of an expert; B, treated by an expert who switched in for a trainee in the middle of the procedure; and C, completed by an expert. Results A total of 325 patients with CBD stones underwent endoscopic treatments. The number included in Groups A, B, and C was 176, 102, and 47, respectively. The bile duct catheter insertion successes rates for Groups A, B, and C were 99.0%, 97.1%, and 100% (p=0.09), and the complete stone removal rates were 94.2%, 94.8%, and 100%, respectively (p=0.07), showing no significant difference among the three groups. Furthermore, the frequency of intra-/post-operative complications was not significantly different among the three groups (p=0.48, p=0.12, respectively). Conclusion This study showed that trainees could safely perform endoscopic procedures in accordance with our facility's criteria during ERCP.
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Affiliation(s)
- Tomoya Iida
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hiroyuki Kaneto
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Kohei Wagatsuma
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hajime Sasaki
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Yumiko Naganawa
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Suguru Nakagaki
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Shuji Satoh
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Haruo Shimizu
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
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Al-Mansour MR, Fung EC, Jones EL, Zayan NE, Wetzel TD, Martin Del Campo SE, Jalilvand AD, Suzo AJ, Dettorre RR, Fullerton JK, Meara MP, Mellinger JD, Narula VK, Hazey JW. Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers. Surg Endosc 2017; 32:2871-2876. [PMID: 29273876 DOI: 10.1007/s00464-017-5995-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.
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Affiliation(s)
- Mazen R Al-Mansour
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Eleanor C Fung
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Edward L Jones
- Department of Surgery, Denver Veterans Affairs Medical Center, University of Colorado, Denver, CO, USA
| | - Nichole E Zayan
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Timothy D Wetzel
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Sara E Martin Del Campo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Anahita D Jalilvand
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Andrew J Suzo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Rebecca R Dettorre
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - James K Fullerton
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Michael P Meara
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - John D Mellinger
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Vimal K Narula
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Jeffrey W Hazey
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.
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What Is the Value of the Learning Curve in Endoscopic Balloon Dilatation of the Major Papilla? Gastroenterol Res Pract 2017; 2017:6501485. [PMID: 29093736 PMCID: PMC5603744 DOI: 10.1155/2017/6501485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Endoscopic papillary large balloon dilatation (EPLBD) is an alternative for the treatment of common bile duct (CBD) stones. Existing evidence of factors associated with its outcomes is contradictory. Objective To identify predictors (including the experience of an endoscopist) of success and adverse events in EPLBD. Methods We reviewed the first 200 EPLBD with endoscopic sphincterotomy (EST) performed at our center. Demographic, clinical, and anatomic variables were studied, as well as the performance characteristics, correlating them with individual and group experience. Results Global success was obtained in 87% of cases, and adverse events occurred in 16% of cases. Success was associated with stone size, CBD diameter, and the need to perform mechanical lithotripsy (ML). Despite that adverse events were not univariately associated with any factor, severe adverse events were more likely to occur in stones > 13.5 mm. Multivariate analysis which disclosed success was higher when ML was not required and stones were < 13.5 mm. It also showed that no factor was associated with adverse events or their severity. No differences were found on success or adverse events that could be directly related to experience. Conclusions Success of EPLBD-EST is higher in stones < 13.5 mm and when ML is not required. Experience does not appear to play a major role.
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Moutinho-Ribeiro P, Peixoto A, Macedo G. Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound: To Be One Traveler in Converging Roads. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2017; 25:138-145. [PMID: 29761150 DOI: 10.1159/000481537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/14/2017] [Indexed: 12/28/2022]
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were initially introduced into the world of gastroenterology as purely diagnostic procedures. With progressive evolution of intervention, both these techniques conquered fields in the treatment of many conditions that had once been exclusively surgical domains. Nowadays, more and more clinical situations have an indication to perform both EUS and ERCP, and these two techniques are frequently required at the same time for the same patient. More than competitors, ERCP and EUS are truly complementary, with great ability for mutual aid. They share their main indications, equipment, accessories, and main technical gestures. Objectives and Methods We review the major indications to perform both techniques, sequentially or complementarily, describe the common things that these two techniques essentially share, and discuss the ERCP-EUS single session. Also, the issues of learning curves and education of upcoming biliopancreatic endoscopists are highlighted. Conclusion In recent years the complementation between ECRP and EUS has been growing both from a diagnostic and a therapeutic point of view, allowing optimization of the use of these techniques and the creation of a more systematized approach of patients with biliopancreatic pathology. Endoscopists with experience in both techniques will be increasingly important, suggesting a parallel formation in the training plans of future endoscopists with interest in the area.
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Affiliation(s)
- Pedro Moutinho-Ribeiro
- Gastroenterology Department, Centro Hospitalar São João, and Porto World Gastroenterology Organization Training Center, University of Porto Medical School, Porto, Portugal
| | - Armando Peixoto
- Gastroenterology Department, Centro Hospitalar São João, and Porto World Gastroenterology Organization Training Center, University of Porto Medical School, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, and Porto World Gastroenterology Organization Training Center, University of Porto Medical School, Porto, Portugal
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Rodrigues-Pinto E, Macedo G, Baron TH. ERCP competence assessment: Miles to go before standardization. Endosc Int Open 2017; 5:E718-E721. [PMID: 28791318 PMCID: PMC5546890 DOI: 10.1055/s-0043-107780] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA,Corresponding author Todd Huntley Baron, MD Division of Gastroenterology and HepatologyUniversity of North Carolina School of Medicine101 Manning DriveChapel Hill, NC 27514United States+1-984-9740132+1-984-9740744
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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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Number of Endoscopic Retrograde Cholangiopancreatography Procedures Required for Short Biliary Cannulation Time. Gastroenterol Res Pract 2017; 2017:1515260. [PMID: 28487727 PMCID: PMC5405567 DOI: 10.1155/2017/1515260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/15/2017] [Accepted: 03/23/2017] [Indexed: 02/04/2023] Open
Abstract
Background. Several previous studies assessed the competence in endoscopic retrograde cholangiopancreatography (ERCP) using the bile duct cannulation success rate. However, the cannulation time is also important, because a long cannulation time was reported to be a risk factor for post-ERCP pancreatitis. Aim. To determine the number of ERCP procedures required for short cannulation time of the bile duct. Methods. We retrospectively analyzed 605 ERCP procedures performed for bile duct cannulation in patients with native papilla at our institution between March 2012 and December 2015. The successful procedures were divided into 2 groups: group L and group S (cannulation time > 15 minutes and ≤15 minutes, resp.). An analysis of the relationship among the biliary cannulation time, ERCP experience, and other factors was then conducted. Results. Multivariate analysis showed that the ERCP experience of ≤300 procedures (odds ratio, 2.080; 95% confidence interval, 1.337–3.142; P = 0.001) and malignant biliary stricture due to pancreatic cancer (odds ratio, 1.912; 95% confidence interval, 1.072–3.412; P = 0.028) were found to be significantly associated with a cannulation time of >15 minutes. Conclusions. Our findings suggested that an ERCP experience of ≤300 procedures and malignant biliary stricture due to pancreatic cancer were associated with prolonged biliary cannulation time.
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Bekkali NLH, Johnson GJ. Training in ERCP and EUS in the UK anno 2017. Frontline Gastroenterol 2017; 8:124-128. [PMID: 28839896 PMCID: PMC5369444 DOI: 10.1136/flgastro-2016-100771] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/11/2016] [Indexed: 02/06/2023] Open
Abstract
In the last 20 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a diagnostic procedure to being almost exclusively therapeutic. Similarly, endoscopic ultrasound (EUS) is developing into ever-increasing therapeutic roles. Operator technique is central to diagnostic accuracy in EUS, as is effective and safer therapy for both ERCP and therapeutic EUS. Hence, effective training and robust standards for certification and revalidation are required to ensure ERCP and EUS in the UK are as effective and as safe as possible.
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Affiliation(s)
- Noor LH Bekkali
- GI Services, University College London Hospitals, London, UK,Pancreatobiliary Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Gavin J Johnson
- GI Services, University College London Hospitals, London, UK
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A Procedural and Educational Experience Following Creation of an Advanced Pediatric Endoscopy Service. J Pediatr Gastroenterol Nutr 2017; 64:e96-e99. [PMID: 27306104 PMCID: PMC5156590 DOI: 10.1097/mpg.0000000000001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Advanced endoscopic procedures occur infrequently enough in pediatric patients to preclude effective maintenance of competence among all pediatric gastroenterologists. A recent study suggests that fellows are largely unable to achieve the prescribed case volume recommended to achieve competence. We sought to describe the procedural and educational experience following the creation of an advanced pediatric endoscopy service in response to declining confidence among practice members regarding advanced procedures. We found most advanced endoscopy cases (90%) were accomplished during routine business hours with little seasonal variation. Esophageal dilations occurred far more than all other procedures provided by this service. Control of nonvariceal bleeding, feeding tube placement, enteroscopy, and needle knife therapy, among others, were performed exclusively but relatively infrequently by members of this advanced endoscopy service. Fellows were present for many cases, although they participated in relatively few. We conclude that the creation of an advanced endoscopy service permits distillation of rare but technically demanding cases to few providers, ensuring maintenance of skills, although the role of fellows remains in question.
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Li JW, Ang TL, Kam JW, Kwek ABE, Teo EK. The learning curve for needle knife precut sphincterotomy revisited. United European Gastroenterol J 2017; 5:1116-1122. [PMID: 29238590 DOI: 10.1177/2050640617701808] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/26/2017] [Indexed: 12/22/2022] Open
Abstract
Background There is no consensus on what constitutes adequate training for needle knife precut sphincterotomy. Objective The purpose of this study was to determine the number of procedures required before effective and safe precut sphincterotomy can be achieved. Methods This retrospective study examined the cumulative experience of a single endoscopist from January 2006-December 2015. Precut sphincterotomy success and complication rates were analyzed as a function of number of procedures performed. Acceptable success and complication rates were defined as 85% and 10% respectively. A one-sided binomial test was used to test success and complication rates of every 25 precut sphincterotomies performed. Results The index endoscopic retrograde cholangiopancreatography was successful in 141/158 (89.2%) patients who underwent precut sphincterotomy. This increased to 148/158 (93.7%) when endoscopic retrograde cholangiopancreatography was repeated on another day. Six precut sphincterotomies were required to achieve an 85% success probability. This was maintained consistently above 85% after 13 precuts, and was significantly higher (91.2%; p = 0.029) than 85% at the 125th precut. Bleeding and pancreatitis developed in 2/158 (1.3%) and 5/158 (3.2%). Probability of either complications remained below 5% after 50 precuts. No perforation occurred. Conclusion At least 13 precut sphincterotomies were required to achieve a sustained success rate greater than 85%. The probability of bleeding or pancreatitis was less than 5% after 50 precut sphincterotomies.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jia Wen Kam
- Clinical Trials and Research Unit, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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Faulx AL, Lightdale JR, Acosta RD, Agrawal D, Bruining DH, Chandrasekhara V, Eloubeidi MA, Gurudu SR, Kelsey L, Khashab MA, Kothari S, Muthusamy VR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85:273-281. [PMID: 28089029 DOI: 10.1016/j.gie.2016.10.036] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/08/2023]
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Gornals JB, Esteban JM, Guarner-Argente C, Marra-Lopez C, Repiso A, Sendino O, Loras C. Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined? GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:627-642. [PMID: 26920225 DOI: 10.1016/j.gastrohep.2015.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/01/2015] [Accepted: 12/04/2015] [Indexed: 02/07/2023]
Abstract
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.
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Affiliation(s)
- Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain.
| | - José Miguel Esteban
- Endoscopy Unit, Department of Digestive Diseases, Hospital Clinic San Carlos, Madrid, Spain
| | - Carlos Guarner-Argente
- Endoscopy Unit, Department of Digestive Diseases, Hospital Santa Creu i Sant Pau, Barcelona, Catalonia, Spain
| | - Carlos Marra-Lopez
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitario Araba sede Txagorritxu, Alava, Spain
| | - Alejandro Repiso
- Endoscopy Unit, Department of Digestive Diseases, Hospital Virgen de la Salud, Toledo, Spain
| | - Oriol Sendino
- Endoscopy Unit, Department of Digestive Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Carme Loras
- Endoscopy Unit, Department of Digestive Diseases, Hospital Mútua Terrassa, CIBEREHD, Terrassa, Catalonia, Spain
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James PD, Antonova L, Martel M, Barkun A. Measures of trainee performance in advanced endoscopy: A systematic review. Best Pract Res Clin Gastroenterol 2016; 30:421-52. [PMID: 27345650 DOI: 10.1016/j.bpg.2016.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/22/2016] [Accepted: 05/08/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The diversity, technical skills required, and risk inherent to advanced endoscopy techniques all contribute to complex training curricula and steep learning curves. Since trainees develop endoscopy skills at different rates, there has been a shift towards competency-based training and certification. Validated endoscopy performance measures for trainees are, therefore, necessary. The aim of this systematic review was to describe and critically assess the existing evidence regarding measures of performance for trainees in advanced endoscopy. METHODS A systematic review of the literature from January 1980 to January 2016 was carried out using the MEDLINE, EMBASE, CENTRAL, and ISI Web of knowledge databases. MeSH terms related to 'advanced endoscopy' and 'performance' were applied to a highly sensitive search strategy. The main outcomes were face, content, and construct validity, as well as reliability. RESULTS The literature search yielded 1,662 studies and 77 met the inclusion criteria after abstract and full-text review (endoscopic retrograde cholangiopancreatography (ERCP)=23, endoscopic ultrasound (EUS)=30, colonoscopic polypectomy (CP)=11, balloon-assisted enteroscopy (BAE)=7, luminal stenting=3, radiofrequency ablation (RFA)=2, and endoscopic muscosal resection (EMR)=1). Good validity and reliability were found for measurement tools of overall performance in ERCP, EUS and CP, with applications for both patient-based and simulator training models. A number of specific technical skills were also shown to be valid measures of performance. These include: selective biliary cannulation, sphincterotomy, biliary stent placement, stone extraction and procedure time for ERCP; pancreatic solid mass T-staging, EUS-guided fine needle aspiration (EUS-FNA) procedure time, number of EUS-FNA passes and puncture precision for EUS; procedure time and en bloc resection rate for CP; retrograde fluoroscopy time for BAE; and mean number of endoscopy sessions required to achieve complete eradication of intestinal metaplasia (CIEM) for RFA. The evidence for EMR and luminal stenting is of insufficient quality to make recommendations. CONCLUSIONS We have identified multiple valid and readily available performance measures for advanced endoscopy trainees for ERCP, EUS, CP, BAE and RFA procedures. These tools should be considered in advanced endoscopy training programs wishing to move away from apprenticeship-based training and towards competency-based learning with the help of patient-based and simulator tools.
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Affiliation(s)
- P D James
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - L Antonova
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - M Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - A Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada; Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, Montreal, Quebec, Canada
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Voiosu T, Bengus A, Voiosu A, Rimbas M, Zlate A, Haidar A, Baicus C, Mateescu B. Trainee caseload correlates with ERCP success rates but not with procedure-related complications: results from a prospective study (the QUASIE cohort). Endosc Int Open 2016; 4:E409-14. [PMID: 27092319 PMCID: PMC4831939 DOI: 10.1055/s-0042-102248] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIM Endoscopy society guidelines recommend a minimum of 200 cases for endoscopic retrograde cholangiopancreatography (ERCP) trainees in order to ensure competency and quality standards. However, there are few data regarding procedure-related complication rates and added risk for patients during this learning process. We aimed to evaluate the correlation between trainee caseload and procedure- and patient-related outcomes in an ERCP training program, and to assess the risk factors for ERCP failure and complications. PATIENTS AND METHODS We conducted a prospective study of all procedures performed in the ERCP training program at Colentina Clinical Hospital, Bucharest, Romania. Relevant data for each procedure (diagnosis, cannulation method, outcome, and complications during the following 30 days) as well as operator experience were documented. Univariable and multivariable analysis of the risk factors for ERCP failure and complications was done by analyzing the procedures completed by expert and trainee endoscopists during the study period. RESULTS The analysis included 534 ERCPs performed by 1 expert and 3 supervised trainees during a 12-month period. Technical success rates were comparable in the trainee and expert groups, and no statistically significant difference was found between the two groups with regard to procedure-related complications and mortality. The more experienced trainees had a better chance of successfully completing a procedure (odds ratio of 1.1 for each additional 10 ERCPs performed), but post-ERCP complications were unrelated to individual trainee caseloads on multivariable analysis. CONCLUSION The ERCP technical success rate increases with trainee experience, reflecting the learning curve of individual operators. However, the complication rates are similar across different levels of operator experience, indicating that ERCPs performed by supervised trainees imply no additional risk for patients.
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Affiliation(s)
- Theodor Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania,Corresponding author Theodor Voiosu, MD, PhD Gastroenterology DepartmentColentina Clinical Hospital19-21 Stefan cel Mare BoulevardBucharestRomania+40-21-3180604
| | - Andreea Bengus
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Mihai Rimbas
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Alina Zlate
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Andrei Haidar
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Cristian Baicus
- Internal Medicine Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
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