ERCP Training Research Articles

45 Status of ERCP Training in Advanced Endoscopy Training Programs (AETPs) in the U.S.: Results From a Prospective Multicenter Study Evaluating Competence Among Advanced Endoscopy Trainees (AETs)

45 Status of ERCP Training in Advanced Endoscopy Training Programs (AETPs) in the U.S.: Results From a Prospective Multicenter Study Evaluating Competence Among Advanced Endoscopy Trainees (AETs)

Gaining competence in needle-knife fistulotomy - can I begin on my own?

Background: While there are guidelines for appropriate training in ERCP, these are non-existent for needle-knife precut. The aim of this study was: (1) evaluate the experience curve of three endoscopists in needle-knife fistulotomy (NKF); (2) propose a minimum number of NKF procedures to attest proficiency. Methods: Between November 1997 and March 2011, the first 120 consecutive NKF performed by three endoscopists (A, B, and C) were selected (360 patients) from three centers. Each group of 120 patients was chronologically ordered into three subgroups of 40. The main outcomes were: NKF use, NKF success, and post-ERCP adverse events. Results: The need for NKF did not decrease over time. The NKF success rate in the first attempt for endoscopist A and C in each of the three subgroups was 85 %/85 %, 87.5 %/87.5 %, and 87.5 %/90 %, respectively. Furthermore, both demonstrated a high NKF success in their initial 20 NKFs (85 % and 80 %, respectively). Endoscopist B however presented a different pattern as the success rate initiated at 60 %, then rose to 82.5 % and 85 % for the last group (P = 0.03). Adverse events were mild (28 of the 32 occurrences) with no clear reduction with increased experience. Conclusions: A skillful endoscopist may expect to master NKF easily with few adverse events. While some endoscopists could begin on their own because of their innate skills, a minimal training is needed for all, as we cannot predict skills in advance. We propose a minimum of 20 NKF precuts to attest a trainee’s competence in this procedure.

Initial validation of a simple, nonbiological, mechanical ERCP training model for cannulation and stent placement.

Initial validation of a simple, nonbiological, mechanical ERCP training model for cannulation and stent placement.

Low ERCP Volume Is Associated with More Industry Representative Interactions but Similar Training of Nurses.

Data on ERCP nurses and associate (ERCP-NA) training and comfort are lacking. Healthcare industry representative (HCIR) influence may be greater in low-volume units (LVUs) due to decreased procedure and device familiarity. The aim of this study was to compare ERCP-NA training, safety, and HCIR relationships between LVU and high-volume unit (HVU) ERCP facilities. We conducted an electronic survey of all Society of Gastroenterology Nurses and Associates (SGNA) members assessing: (1) demographics and procedure volume, (2) ERCP training and radiation safety, and (3) HCIR interactions. Responses were stratified by ERCP volume. Among 832 SGNA member respondents (median age 55), 615 (74%) worked as an ERCP-NA; 41% derived from LVUs. The majority of ERCP-NAs, irrespective of unit volume, had observed <50 ERCPs before starting. Except for lead glasses, the majority (>80%) adhered to basic radiation safety, irrespective of unit volume. LVUs were more likely than HVU ERCP-NAs to agree that HCIRs were requested for intra-procedure assistance (24 vs. 19%, p = 0.008), asked for input on the next choice of device (22 vs. 15%, p = 0.01), and assist in device usage (27 vs. 22%, p = 0.04). Irrespective of volume, 30% agreed that they were more likely to utilize a company's devices if that HCIR was present. ERCP-NA training before independent participation in ERCP is suboptimal. HCIRs are frequently requested for assistance during ERCPs, especially in LVUs. HCIR impact on ERCP outcomes and device utilization and whether enhanced ERCP-NA training will impact the role of HCIR, require further study.

A Simple ex vivo, Biologic ERCP Training Model for Standard and Precut Biliary Sphincterotomy

A Simple ex vivo, Biologic ERCP Training Model for Standard and Precut Biliary Sphincterotomy

A simple ex vivo, biologic ERCP training model for sphincterotomy.

A simple ex vivo, biologic ERCP training model for sphincterotomy.

PTU-016 The lack of ercp training opportunities for surgical trainees

Introduction Endoscopic Retrograde Cholangio- Pancreatography (ERCP) training has been widely discussed in a number of reports and was deemed to be unsatisfactory by The UK ERCP Stakeholders Working Party in 2007. Their report was as a result of concerns regarding suboptimal standards of training and insufficient exposure to cases. The aim of this study was to determine the number of Hepato-Pancreato-Biliary (HPB) and Upper Gastrointestinal (UGI) surgical trainees receiving ERCP training and their satisfaction with training opportunities. Method An anonymous, online, non-incentivised questionnaire was distributed via National Research Collaborative leads to surgical trainees in England. The questionnaire assessed; their inclination to offer an ERCP service as a consultant; the degree of satisfaction with their ERCP training; and their attendance at a Joint Advisory Group (JAG) certified ERCP course. Results Only responses from surgical trainees with a declared interest in HPB and UGI were included in the analysis. 72 responses were received, 41 from HPB trainees and the remaining 31 from UGI trainees. 29 HPB and 16 UGI trainees intended to offer ERCP when appointed as a Consultant. 10 trainees (6 HPB, 4 UGI) felt they had adequate opportunities for ERCP training. Free text analysis revealed that respondents felt ERCP training was geared more towards gastroenterology trainees and regular sessions were difficult to come by. 12 respondents had attended a JAG certified ERCP course. Conclusion This survey demonstrates the difficulties faced by surgical trainees in obtaining ERCP training. The general consensus is that ERCP training is mainly organised for gastroenterology trainees. A level of frustration was noted at the lack of consistent, dedicated training opportunities which also formed one of the reasons as to why some trainees did not intend to offer this service once in a Consultant post. Disclosure of interest None Declared.

PWE-425 Does the presence of a trainee compromise biliary cannulation rates at ercp :results from a prospective audit

Introduction A trainee endoscopist on the ERCP list prolongs procedure time and may increase risk of technical failure or procedural complications. 1,2 Recent BSG guidance has identified a biliary cannulation rate of 90% as an ERCP performance indicator which may conflict with the need to train juniors. This prospective audit assessed the impact of an endoscopy trainee on the overall biliary cannulation rates. Method We prospectively audited sequential ERCPs done on a “virgin” ampulla (no previous ERCP). Procedures were supervised by 2 experienced trainers; trainees were present when possible (trainees were senior SpRs with limited ERCP experience). A short-wire system was used for biliary cannulation and standard techniques used. 1 The trainee would have 6 min to achieve biliary cannulation, failing which the trainer would take over. Predicted ERCP difficulty was graded using accepted criteria. 3 The primary outcome was the biliary cannulation rate. Results One hundred and eight sequential ERCPs were prospectively audited over a period of 6 months [July 2014–Dec 2014]. Difficulty was graded as 1 (n = 69] or 2 [n = 39]. One of two trainee endoscopists was present during 61[56%] ERCP cases; remaining cases were done by a consultant alone [n = 47, 44%]. Deep biliary cannulation was successful in 99 cases [91%]. The cannulation rate was 93% [57/61] with a trainee and 89% [42/47] without[p = 0.7229 Fishers exact test] Median cannulation time was 6.6 min (range 1–25). There was no significant difference in cannulation times when a trainee was present[T test, p = 0.890]. Where a trainee was involved, 20/61[32%] cannulations were achieved independently by the trainee. There were no major complications recorded in cases where a trainee was involved. Conclusion This audit suggested that acceptable biliary cannulation rates can be achieved on ERCP training lists, with involvement of experienced trainers and defined training parameters. Disclosure of interest None Declared. References Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al . Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996;335:909–18 Shekhar, Shetty, Fisher BSG 2014 (abstract) SchutzSM, AbbottRM. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc. 2000;51(5):535–9

716 Progression of Fellow's Competence in ERCP Training: the Proficient Study

716 Progression of Fellow's Competence in ERCP Training: the Proficient Study

Development of a novel and simple ex vivo biologic ERCP training model

Training and teaching of ERCP in biologic models has gained importance over the past decade. However, many existing models are expensive, are not widely available, or rely on live animals. We describe a novel and simple ex vivo, biologic model for hands-on teaching. Ex vivo porcine study. Experimental endoscopy unit. Experimental study using a custom-made ex vivo biologic ERCP simulation model. This model contains 2 new key concepts: (1) formation of a duodenal sweep by using the porcine stomach and (2) use of multiple neo-papillae for endoscopic sphincterotomy and biliary stent placement. The papilla was re-created with chicken heart, and the bile ducts were built from chicken trachea. Endoscopic sphincterotomy was performed by using a pull-type sphincterotome. Stenting was performed with Amsterdam-type plastic stents and guidewires. The following definitions were used to evaluate the model: successful implantation of the neo-papilla, stability of the neo-papilla to the neo-duodenum, successful removal of the neo-papilla, and damage to the model. The following endoscopic endpoints were evaluated: successful cannulation, cannulation time, difficulties in positioning the papilla, quality of the biliary sphincterotomy, and prosthesis placement. Procedure-related adverse events such as perforation were also assessed. Ten neo-papillae were consecutively used in 1 duodenalized stomach. The implantation and removal of the neo-papillae were easily and successfully accomplished in all 10 cases without any damage to the duodenalized stomach. The stability of the neo-papilla on the duodenal sweep was excellent in all cases. Cannulation, biliary sphincterotomy, and stent placement could be successfully performed in 100% of cases. There was no damage and were no technical problems with the model. There were no adverse events during endoscopy (ie, perforations, stent misplacement). Pilot study. Although further studies are necessary, this simple, novel ex vivo model appears useful for training in sphincterotomy and bile duct cannulation. Because the neo-papillae are interchangeable, repetitive sphincterotomies and other interventions can be performed using a single porcine model.

The Relationship of ERCP Facility Volume With Nurse/Associate Training and Functions of Health Care Industry Representatives (HCIR) During ERCP: A Survey of SGNA Members

Introduction: ERCP has become a predominantly therapeutic intervention and had an exponential increase in associated devices. HCIR are often present during ERCP, but their function has not been evaluated previously. Considering variable ERCP facility volume and training of ERCP Nurse/Associates (ERCP-NA), the primary aim was to measure the impact of onsite HCIR during ERCP. Methods: All members of the Society of Gastroenterology Nurses and Associates were asked to participate in an online survey evaluating: 1) respondent and facility characteristics, and 2) ERCP practice patterns and HCIR involvement. The analysis was stratified by ERCP facility volume, with moderate-high volume units (HVU) defined as 100+ ERCPs per year and low-volume units (LVU) as <100 ERCP per year. Results: Of 6,698 surveys distributed, there were 847 (13%) respondents; 726/847 (86%) participated in ERCP and reported their facility ERCP volume. Compared to LVU affiliates, ERCP-NAs at HVU were more likely to identify themselves as advanced endoscopy nurse/technicians (66% vs. 50%; p<0.001). Other respondent characteristics (mean age 52.7±8.6 years, 94% female) were similar, including ERCP training experience (Table). The majority (51%) shadowed an ERCP-NA for <25 cases prior to working independently. Self-reported interactions with HCIR were similar except providers at LVUs requested HCIR input during ERCPs more frequently (p=0.02; Figure). With increasing facility volume, we observed decreasing rates of requesting the presence of, and asking for hands-on assistance by, HCIR; these trends did not reach statistical significance. Irrespective of facility volume, 30% of respondents agreed/strongly agreed that they were more likely to utilize a company’s devices if that HCIR was present.Table 1Figure 1Conclusion: ERCP-NAs have limited training prior to their independent participation in ERCP. HCIR input is more frequently requested when ERCP is performed at LVUs, but the influence of HCIR on the intraprocedural choice of medical device(s) is similar irrespective of facility volume. The relationship between limited ERCP-NA training and on-site HCIR function requires further study. Disclosure - RNK - Consultant for Boston Scientific and Cook Medical. GAC - Consultant for Boston Scientific and Olympus.

PTH-002 Ercp: Balancing Demand, Training And Manpower In South East Region

IntroductionThe purpose of this survey is to assess trainees attitudes and exposure to ERCP training in the south east region of England and also to explore the demand for ERCP...

PTU-014 The Use Of Kinematic Analysis Of Bile Duct Cannulation As A Means Of Objectively Assessing Endoscopic Skill At Ercp

IntroductionTraining in ERCP has become more challenging due to a reduction in diagnostic cases following the introduction of MRCP. There is a need to explore options to assist with basic...

PTU-002 Ercp Cannulation; Evaluation Of A Wire-led Technique For Biliary Access In A Training Centre

IntroductionA range of techniques have been described to achieve successful cannulation at ERCP, and when training in ERCP it is often difficult to select the optimum approach.1 There are potential...

Su1696 The Effect of Endoscopist Control of Fluoroscopy on Cannulation Rate and Fluoroscopy Time During ERCP Training

Su1696 The Effect of Endoscopist Control of Fluoroscopy on Cannulation Rate and Fluoroscopy Time During ERCP Training

Do it yourself: building an ERCP training system within 30 minutes (with videos)

Ex vivo training of ERCP by using simulators is desirable before trainees perform endoscopy in patients. We aimed to construct a simple and inexpensive but realistic simulator for ERCP training. Construction and establishment of an ERCP simulator. Endoscopy suite. An ERCP simulator was assembled by using a polyvinylchloride hose, insulated wire end sleeves, a plastic board, and hose clamps. Application of the simulator for endoscopic training, with focus on endoscope maneuverability as well as on alignment and intubation of the papilla and assessment of simulator performance by a short questionnaire. Because of the sufficient diameter of the hose and varying orientations of the wire end sleeves, the system allows for realistic endoscope maneuvering and wire intubation of the "papillary orifices." Trainees feel better prepared and more confident in the technique before performing ERCP in patients for the first time. Extensive validation and statistical evaluation is lacking. The construction offers the opportunity to provide a readily available simulator for initial access to basic ERCP techniques.

Sa1517 Assessment of ERCP Performance in Novice Trainees

Measures for ERCP competence during training are poorly defined. Currently, various guidelines state to base competence on a minimum number ERCP procedures ranging between 100-150. This arbitrary number is lacking any scientific support and needs to be reconsidered. In this process, there is a general awareness that procedural competence certification should be based on objective performance criteria, rather than threshold numbers. Continuous self-assessment using a Rotterdam Assessment Form for ERCP (RAF-E) has shown to be useful in gaining insight in performance of trainees. The aim of this study was to express competence development as a learning curve for different types of procedures and to assess the performance of residents starting with ERCP training.

Quality matters: A protocol-based strategy in ERCP training

The medical literature has shed some light on these issues as they pertain to ERCP training. It has been noted that trainee involvement is associ-ated with increase in ERCP-related com-plications along with other factors such as sphincter of Oddi dysfunction (SOD), history of post-ERCP pancreatitis, age <60 years and multiple pancreatic duct injec-tions.

Principles of training in GI endoscopy

Principles of training in GI endoscopy

Advanced Endoscopy Fellowship Training: Where Do We Stand?

Purpose: The national gastrointestinal (GI) societies recognize that GI trainees should have a thorough knowledge of the endoscopic techniques used in the diagnosis and treatment of biliary tract and pancreatic diseases, including ERCP and EUS; however no standards for training have been established by the ACGME. In the absence of standardized guidelines, significant variability has developed among fellowship programs in regards to training in ERCP/EUS. Methods: We conducted a survey amongst GI fellows and program directors across the country to assess how many advanced procedures trainees were exposed to in their fellowship, how comfortable they were performing these procedures, how many felt a fourth year of fellowship was needed, and how many planned to perform advanced procedures such as ERCP and EUS once they graduated. Results: Of those who responded, 30% were program directors (PD), 64% were fellows, and 6% were fourth year advanced fellows (AF). 72% of respondents were from university programs and 86% of them had ERCP and EUS training available. Subgroup analysis showed that 47% of respondents were 2nd and 3rd year fellows, i.e., senior fellows (SF); and of these 71% were uncomfortable performing ERCP (67% performed <50 ERCPs), and 89% were uncomfortable performing EUS (84% performed <50 EUS). 79% of graduating fellows were planning to perform ERCP in their practice. It was noted that 59% of PD vs. 36% of fellows (17% 1st year fellows, 28% 2nd year fellows, 58% 3rd year fellows) and 100% of the AF felt that a fourth year of training is required for adequate training in ERCP and EUS. Conclusion: Our study shows that despite inadequate exposure to ERCP/EUS in standard 3-year fellowship programs, a majority of graduating fellows plan on performing ERCP in their practice. There also appears to be a great divide among PDs and fellows on whether a fourth year of fellowship is required for adequate training in ERCP and EUS. However, our data did show that as fellows progress in their training, there is a trend towards an increased belief that further training in ERCP/EUS is required. Given that a majority of fellows plan on performing these procedures without adequate training during their fellowship, standardized guidelines for training in ERCP and EUS should be developed by the ACGME in concordance with national gastrointestinal societies.