Chapter 8 ERCP Training

Juergen Hochberger, Juergen Maiss, Todd H. Baron

Proficiency in all aspects of endoscopic retrograde cholangiopancreatography (ERCP) requires several years of practical training and continuous refinement of knowledge. Historically, endoscopic training consisted primarily of “learning by doing” under the supervision of an experienced endoscopist.¹ With the advent of noninvasive tests such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS), ERCP has become primarily a therapeutic procedure. This creates a new challenge for ERCP training, since ERCPs are becoming more concentrated in large or mid-volume endoscopy centers and the number of ERCPs performed in smaller hospitals is decreasing.² These smaller hospitals are often located in rural areas and provide limited ERCP services such as sphincterotomy, stone extraction, and stent implantation. ERCP volume plays a role in adverse event rates. In some studies a minimum of 40 to 50 endoscopic sphincterotomies (ES) per endoscopist annually is associated with a lower adverse event rate compared to endoscopists who perform fewer procedures.³ Both the number of ERCPs and ESs performed in the past and the number of ERCPs currently performed by the endoscopist seem to influence success and adverse event rates. Similarly, experience plays a role in radiation exposure.⁴ Finally, objective outcomes and medicolegal concerns play an increasing role in daily gastrointestinal (GI) practice⁵ (also see Chapter 12). In light of all of these issues, this chapter will cover the training options for the beginner as well as for the practicing gastroenterologist to acquire or maintain ERCP skills.

Clinical Training in ERCP

Prior to acquiring the skills necessary for the safe and effective performance of ERCP, the trainee must first understand the procedural indications, risks, and limitations (see Chapter 6). Training and proficiency in manual and technical skills are other aspects of a competent endoscopist. ERCP training is expected to follow experience in less complex and technically demanding examinations.⁶ A core curriculum for training in ERCP by the American Society for Gastrointestinal Endoscopy (ASGE) has become the standard in the United States.⁷

Fellows begin their ERCP training by observing the procedure and assisting the primary endoscopist. In Europe this initial experience may involve maneuvering x-ray equipment during the procedure or in some institutions the trainee may perform the duties of the assisting endoscopy nurse in order to learn how to properly handle catheters, guidewires, and other accessories. Accompanying learning aids include the review of video material, ERCP atlases, and interactive computer programs. In most cases the first practical steps to learning ERCP involve understanding how to maneuver a side-viewing endoscope by passing the endoscope during the early stages of the procedure. This involves incrementally learning how to intubate the esophagus, maneuver along the greater curvature of the stomach, appreciate the “setting sun phenomenon” at the passage of the pylorus, maneuver around the superior duodenal angle, and finally bring the endoscope to an appropriate “short” position in front of the papilla. It is often easier for the trainee to begin this process by placing the patient in the left lateral decubitus position with the patient’s left arm behind his or her back instead of starting in a prone or supine position.

Now that most ERCPs are performed almost exclusively for therapeutic purposes, it is controversial whether cannulation is the most appropriate step for the trainee to learn after he or she is able to competently maneuver the duodenoscope to the papilla. For example, it is well known that routine stent exchange in the setting of a prior sphincterotomy requires a lower number of procedures (60) to obtain competence than cannulation of a native papilla (180 to 200), and is associated with a lower risk profile.^8,⁹ Patients with benign biliary strictures, chronic obstructive pancreatitis, and recurrent bile duct stones in the setting of prior sphincterotomy are safer cases for the trainee in the early stages of his or her ERCP experience.

An ERCP grading scale based on procedural difficulty has been developed.⁷ In more difficult grade procedures the fellow may not have much hands-on involvement. Absolute numbers of these “partially performed procedures” may not realistically contribute to or reflect competency. Where possible, trainee logbook records should specify particular skills completed by the fellow (cannulation, sphincterotomy, stent placement, tissue sampling) as well as indicate cases that the trainee completed without assistance.

ASGE guidelines for advanced endoscopic training state that most fellows require at least 200 cases to achieve competency, with at least half of these cases being therapeutic. Per the American Gastroenterological Association (AGA) Gastroenterology Core Curriculum, the threshold number of ERCPs that should be performed by trainees before competency can be assessed is 200.¹⁰ It must be emphasized that this number does not indicate that the trainee is competent. Also, this is the minimum number and “it is understood that most trainees will require more (never less) than the stated number.”¹⁰ In addition, per the 2006 ASGE guidelines: “Competence of graduates of advanced training programs in ERCP may be assessed by the demonstrated ability (at least an 80% success rate) to obtain access to (selectively and freely cannulate) the desired duct reliably without assistance in normal anatomy cases. Cases that are used to assess competency for ERCP should exclude those procedures in which the native anatomy of the patient has been surgically or otherwise altered (e.g., gastric outlet obstruction, Billroth II anastomosis), where prior sphincterotomy has been performed, or where a routine stent exchange is being performed.”⁷

Data that led to these recommendations were in part derived from Jowell et al., who found that the minimum number of ERCPs needed to be performed before a trainee could be considered competent for nonsupervised ERCP was 180 to 200.⁹ However, these data are now approximately 20 years old. More recent data based on one trainee’s experience suggests that successful deep cannulation of a native papilla is consistently achieved after 350 cases.^11,¹²

It must be emphasized that performance of a threshold number of procedures does not automatically bestow competency, rather that competency can be assessed after this number of procedures has been performed. Though nearly all GI training programs offer some exposure to ERCP, not all of the trainees perform ERCP after the completion of their training. Indeed, a recent ASGE training guideline states that “providing brief exposure to an advanced procedure such as ERCP during standard fellowship with the expectation that the trainee will subsequently complete training in practice is no longer appropriate.”¹³ However, all fellows should at least develop an understanding of the diagnostic and therapeutic indications for ERCP, including indications, contraindications, and adverse events. This exposure is generally accomplished within the context of a 3-year gastroenterology fellowship training program. The decision by a program director to train one or more fellows per year to achieve competency in ERCP depends in some measure on the volume of ERCPs performed at the institution and the availability of experts in ERCP to supervise the training of fellows. Based on data that suggest that well over 200 cases are required for most trainees to consistently cannulate the desired duct, programs with a limited case volume will have to weigh their training objectives against what is feasible. For example, with an annual ERCP case volume of 400 and three potential trainees, it would be reasonable to have one trainee perform 300 or more cases and provide the other two trainees with exposure to ERCP, rather than have all three individuals share cases equally, as there is a low likelihood that any of the three would otherwise reach competency by the end of the fellowship.

Trainees who elect to pursue additional training in ERCP in order to attain procedural competence should have completed at least 18 months of a standard gastroenterology training program per the Gastroenterology Core Curriculum.¹⁰ The minimum duration of training required to achieve advanced technical and cognitive skills is usually 12 months. This period of advanced training may be incorporated into the standard 3-year fellowship program or may be completed during an additional year dedicated to advanced endoscopic procedures.⁷

Other Guidelines

There are no uniform guidelines for training in ERCP.

The Canadian guidelines for credentialing in ERCP are similar to those of the ASGE.¹²

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has also published guidelines on training in diagnostic and therapeutic ERCP.¹⁴ The guidelines state that “training for ERCP may be obtained during surgical residency, gastroenterology fellowships, advanced surgical endoscopy fellowships, hepatopancreaticobiliary fellowships, or during other advanced surgery fellowships and preceptorships dedicated to providing a rich educational experience in diagnostic and therapeutic ERCP.” The SAGES guidelines do not provide threshold numbers to assess competency and maintain proficiency but state that “completion of a significant volume of both diagnostic and therapeutic ERCPs under the supervision of a qualified endoscopic instructor is necessary to achieve acceptable rates of selective cannulation.” Per the SAGES guidelines, proficiency (competence) in diagnostic and therapeutic ERCP is defined as the ability to (1) reliably achieve selective cannulation of the desired duct, (2) perform a controlled sphincterotomy, (3) achieve biliary and/or pancreatic decompression, (4) gather sufficient endoscopic, radiographic, and pathologic material to formulate an accurate diagnosis and efficient treatment plan, and (5) achieve mastery of commonly related therapeutic maneuvers such as stone clearance, stent placement, and management of sphincterotomy-related hemorrhage; proficiency in other advanced therapeutic skills should be based on an appropriate individual experience. Finally, the SAGES guidelines state that additional training may be necessary to master these and other advanced skills. General statements are provided regarding granting privileges and maintenance of skill levels.¹⁴

In the United Kingdom standards for training and service quality are set by the Royal Colleges Joint Advisory Group (JAG).² The recommendation for advanced training after routine gastroenterologic training is an additional 6 to 12 months of 7 or 8 sessions of highly specialized endoscopies per week.² A specified minimum number of ERCPs was previously recommended but in 2010 the JAG requirement became achievement of competence rather than the number of procedures. Assessment of competence is recorded by completing directly observed procedural skills (DOPS) evaluation forms during training. The DOPS form has four headings: consent, safety and sedation, insertion, and diagnostic and therapeutic ability. At the end of training, a summary DOPS must be performed by two ERCP trainers who are not the trainee’s usual trainers and who certify competence in basic ERCP. The trainee must produce a record certified by the supervisor that should show an adverse event rate less than 5%, satisfactory completion of intended therapeutic procedure of >80%, and more than 75 procedures performed in the previous 12 months.²

Recently, an ERCP Working Group was set up under the auspices of the Academy of Medicine, Singapore to examine training, credentialing, and quality control in ERCP in Singapore.¹⁵ The Working Group endorsed the 200 cases threshold for assessment of trainee competence and quality measures for achievement of competency at an 85% successful cannulation rate for native papilla as proposed in a multisociety U.S. document.¹⁶

The World Gastroenterology Organization (WGO) describes an interventional program in which the final year of fellowship involves performing at least 250 ERCP and 250 EUS procedures per year, as well as a minimum of 5000 endoscopies per year.¹⁷ The WGO has organized training centers around the world that not only teach trainees to perform endoscopy, including ERCP, but also offer courses in how to “train the trainer.”

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