Response:

Abstract

I appreciate the comments from Dr García-Cano and laud him for submitting his individual learning curve for biliary cannulation success in patients with native papillary anatomy. It is interesting to note how his learning curve and mine are both similar yet different. Both of us clearly improved our cannulation success rates over time in a way that appears to correlate to procedural volume and accumulating experience. While my curve demonstrates a more gradual and linear improvement over time, Dr García-Cano experienced more significant fluctuations in his success rate, even toward the end of his training, although this may be explained by the fact that he measured success over shorter time intervals. It would have been interesting to see Dr García-Cano's post-training outcomes as well.The central focus of our manuscript was to promote the idea that successful, unassisted, deep biliary cannulation in patients with native papillary anatomy represents an objective, easily identifiable, and recordable benchmark of success, during both training and subsequent practice. In our manuscript, we were not in any way advocating the notion that a specific number of procedures was required to achieve a satisfactory success rate. Instead we suggest that it is the stable attainment of a specific success rate, as demonstrated by the type of learning curve we describe, that is of critical importance. Practitioners of ERCP recognize the comparative ease of biliary cannulation in patients who have undergone prior biliary sphincterotomy, or in cannulating the pancreatic duct, and these can no longer be used as benchmarks of success or competence, either during training or beyond. I appreciate the comments from Dr García-Cano and laud him for submitting his individual learning curve for biliary cannulation success in patients with native papillary anatomy. It is interesting to note how his learning curve and mine are both similar yet different. Both of us clearly improved our cannulation success rates over time in a way that appears to correlate to procedural volume and accumulating experience. While my curve demonstrates a more gradual and linear improvement over time, Dr García-Cano experienced more significant fluctuations in his success rate, even toward the end of his training, although this may be explained by the fact that he measured success over shorter time intervals. It would have been interesting to see Dr García-Cano's post-training outcomes as well. The central focus of our manuscript was to promote the idea that successful, unassisted, deep biliary cannulation in patients with native papillary anatomy represents an objective, easily identifiable, and recordable benchmark of success, during both training and subsequent practice. In our manuscript, we were not in any way advocating the notion that a specific number of procedures was required to achieve a satisfactory success rate. Instead we suggest that it is the stable attainment of a specific success rate, as demonstrated by the type of learning curve we describe, that is of critical importance. Practitioners of ERCP recognize the comparative ease of biliary cannulation in patients who have undergone prior biliary sphincterotomy, or in cannulating the pancreatic duct, and these can no longer be used as benchmarks of success or competence, either during training or beyond. ERCP training: every time more difficultGastrointestinal EndoscopyVol. 66Issue 4PreviewTo the Editor: Full-Text PDF