Mastery of the standard (forward-viewing) upper endoscope and colonoscope is a prerequisite before the trainee can begin passing the side-viewing duodenoscope. This requires skilled use of the endoscope dials, scope torque, and body movement. Importance of the endoscopic examination prior to reaching the bilioenteric orifice should be emphasized, and this is closely linked with the development of the proprioceptive skills to recognize a structural impediment to scope passage (such as cervical osteophyte or esophageal diverticulum) and subsequently make appropriate adjustments. Also, the trainee should become comfortable with passage of the duodenoscope in both the nonintubated and intubated patient in the prone, semiprone, or supine positions. Traversing the esophagus, stomach, pylorus, and proximal duodenum requires that the trainee learn a combination of landmarks and proprioceptive cues, while minimizing the introduction of air and endoscope loops. Once the bilioenteric orifice is reached, the trainee must master establishment of the “short” position and proper positioning for cannulation. Navigation of the subgroup of patients with surgically altered anatomy requires a higher level of expertise, particularly for patients with Roux-en-Y anatomy.

There are no published data regarding the number of ERCPs or type of training required to attain competency in duodenoscope passage.

Selective deep cannulation of the desired ductal system is a vital component to both the diagnostic and therapeutic application of ERCP. It requires coordinated manipulation of the scope and the catheter (with/without a guide wire). To obtain mastery of this cornerstone of ERCP, the trainee will need extensive one-on-one training , supplemented by review of literature and/or video media. A thorough understanding of the equipment is important, which includes the endoscope , catheters/sphincterotomes, guide wires, and supplementary tools. The trainee should understand the role of both the assistant and the operator in using this equipment . The trainee must know the periampullary, biliary, and pancreatic anatomy, such that the abnormal or variant anatomy is recognized and the accompanying adjustments can be made. Appropriate need for biopsy and further workup should be recognized as well.

Trainees should be prepared for dealing with difficulty cannulating the desired duct. Low-risk ancillary maneuvers such as contrast or wire assistance and dual-wire technique are options, as are advanced techniques, which require higher level expertise (described later in this chapter). In the event of cannulation failure, the trainee should be aware of when to plan for a repeat attempt and when to make a referral for alternative intervention that could be provided by an interventional radiologist or surgeon.

Given its central role in ERCP, attaining competence in achieving selective cannulation has been perhaps the most investigated aspect of ERCP training. In the 1996 seminal study by Jowell and colleagues, among a pool of 17 trainees, the probability of successfully deeply cannulating the common bile duct was just 0.65 [95 % confidence interval (CI) 0.53–0.78] after 180 ERCPs [10]. Another study published that same year by Watkins et al. assessed 21 trainee operators in selective cannulation of pancreatic/bile duct via any papilla, and the cannulation rate increased from 46 to 90 % with completion of 10 and then 90 ERCPs [21]. A more rigorous examination of cannulation skill acquisition (though with only one operator) was performed by Verma et al. in 2007; this study demonstrated that the success rate of bile duct cannulation via a native papilla increased from 43 % to over 80 % with caseload from 0 to 350–400 ERCPs, and then to over 96 % with caseload from 400 to 700 ERCPs [11].

Data from the 1990s indicates that successful selective cannulation rates of ≥ 95 % are consistently achieved by experienced endoscopists. Meanwhile, a selective biliary cannulation rate of ≥ 80 % has been widely accepted as a target for trainees [3, 13]. Data continues to emerge regarding the association of ERCP volume with cannulation ability; however, it is important to note that volume is only the most basic benchmark for training . Few data currently exist regarding the methodological or qualitative aspects of training leading to acquisition of this critical skill, an ongoing theme in the ERCP training literature [15, 22].

One area of particular concern in training programs remains the issue of inadvertent repeated non-selective ductal cannulation; that is, repeated cannulation of either the pancreatic duct instead of the desired bile duct, or vice versa, and subsequent possible complications. While numerous studies have described patient-related and procedure-related risk factors contributing to complications associated with ERCP, little is known about the risk attributable to trainee involvement. However, it is known, for example, that high numbers of cannulation attempts and/or pancreatic duct injections are risk factors for post-ERCP pancreatitis [23]. One study showed that trainee involvement was associated with increased risk [24]. A recent study by Kwek et al. demonstrated no difference between trainee-involved ERCPs and ERCPs solely by experienced operators when a protocol was followed in which the supervising endoscopist took over for the trainee if one of the following criteria were met: (1) failed cannulation after 5 attempts, (2) unsuccessful cannulation after 10 min, (3) edematous papilla, (4) pancreatic duct cannulation ≥ 2 times [25, 26].

Similar to EUS, ERCP places the endoscopist in the role as technician and radiologist. Thus, to become skilled in cholangiography and pancreatography, the trainee must become adept at two separate skill sets.

First, the trainee must understand the maneuvers necessary to acquire the best possible fluoroscopic image. This includes the following: positioning of the duodenoscope, patient, and fluoroscopy equipment ; volume and dilution of contrast, knowing to avoid overfilling; manipulation of radiation dose and degree of magnification; use of balloon occlusion (in the case of cholangiography).

Second, the trainee must become adept at interpreting the obtained still and dynamic images in real-time. This comes from thorough knowledge of both normal and variant pancreaticobiliary anatomy, as well as the changes associated with biliary disease (such as choledocholithiasis, benign/malignant strictures , primary sclerosing cholangitis, choledochal cysts, bile leaks) and pancreatic disease (pancreatic malignancy , chronic pancreatitis, intraductal papillary mucinous tumors, ductal disruptions leading to pseudocyst) . These more cognitive aspects of cholangiopancreatography are developed through one-on-one discussion between trainer and trainee following each ERCP, supplemented by case conferences and didactic sessions.

Third, the trainee must understand proper handling of fluoroscopy in order to minimize radiation exposure to the staff as well as the patient. This involves the use of appropriate protective lead shielding by the staff to the body, thyroid, eyes, and hands (when in the fluoroscopy field). The trainee must know the well-defined techniques to reduce fluoroscopy exposure including increasing distance from the radiation source, reducing total fluoroscopy time, collimation, placing the image receptor as close to the patient as possible, using magnification only as needed, and changing to a low dose rate setting, if possible [27]. In addition the need to monitor one’s own radiation exposure with the use of radiation-exposure dosimeters should be appreciated by the trainee.

There are no published data regarding the number of ERCPs or type of training required to attain competency in cholangiography/pancreatography.

Sampling of the ductal tissue is often performed during ERCP, typically upon recognition of strictures whether benign or malignant. Approaches include brushings for cytology , ductal fluid aspiration for cytology, and/or fluoroscopically guided biopsy. Trainees must know the indications , appropriate technique, and performance characteristics of each.

There are no published data regarding the number of ERCPs or type of training required to attain competency in tissue sampling.

Biliary sphincterotomy is utilized in ERCP to access the bile duct , remove bile duct stones, and/or facilitate introduction of accessories into the biliary system. Despite being an integral part of ERCP, sphincterotomy is also considered the most dangerous part of ERCP due to risks of bleeding , pancreatitis , and perforation . Thus, proper training in this technique is absolutely essential. This should be taught and performed by the trainee only after proficiency in basic ERCP techniques. Training in sphincterotomy then begins with gaining full understanding of the tools at one’s disposal, including sphincterotome devices, guide wires, and electrosurgical current generators (with cutting and/or blended current).

The specific technical aspects of performing biliary sphincterotomy are well-established and described in detail in the literature [28, 29]. Major points of emphasis should be establishing good endoscopic position, well-directed cutting, steady instrument control, and following anatomic landmarks. As the trainee masters sphincterotomy, s/he must also have complete understanding of the associated risks, factors influencing risk, and potential alternative therapies (such as sphincteroplasty or stent placement). An important part of this training is endoscopic management of complications as well, particularly bleeding.

Pancreatic sphincterotomy is a related technique, providing ductal decompression in a manner similar to its biliary counterpart; however, pancreatic sphincterotomy is accompanied by additional risk and can be technically more challenging. A subset of pancreatic sphincterotomy involves minor papillotomy and associated interventions in cases of pancreas divisum . Trainees need thorough understanding of the indications and contraindications to these pancreatic interventions, as well as special accessories to cannulate the minor papilla and proper use of pancreatic duct stenting . Like most pancreatic endotherapy, it should be undertaken only by experienced trainees well-versed in biliary interventions.

Data regarding training and skill acquisition of sphincterotomy is limited. The previously mentioned 1996 version of the ASGE Gastroenterology Core Curriculum put forth 100 ERCPs, including 20 sphincterotomies, as the threshold prior to evaluation of competency ; updated guidelines in 1999 stated 180 ERCPs as the threshold including 90 therapeutic cases, with the number of sphincterotomies unspecified [14]. In a review of training in sphincterotomy, Leung and Foster emphasize that so much of endoscopic technique remains difficult to measure—the training experience in ERCP varies from trainee to trainee, and the technical assessment of safe, effective sphincterotomy is difficult to quantitate and requires a measure of self-awareness. The young endoscopist, whether during training or after completion of it, must be mindful of his/her own skill level and improve upon it continually [28]. However, emerging data has begun to recognize that consistent consensus for quality sphincterotomy is being established, apart from complication rate. In a small prospective survey of biliary endoscopists, there was considerable agreement among the experts in scoring five recorded clinical papillotomies and in differentiating a good cut from a fair cut using a previously reported scoring scale [30]. Interest is growing in the use of ERCP simulator devices to facilitate acquisition of sphincterotomy skills, discussed later in this chapter.

Needle knife sphincterotomy (“pre-cut”) is an advanced therapeutic maneuver distinct from standard biliary or pancreatic sphincterotomy, as it is usually used to facilitate deep cannulation in cases when traditional deep cannulation fails. This technique requires a “free-hand” element, which demands the highest level of endoscopic control and proficiency, complete knowledge of ampullary anatomy, and full command of endoscopic maneuvers available to manage complications such as bleeding or perforation . It is known that the trainees’ exposure and experience with this technique varies widely, and as such, competency with the needle knife also presumably varies upon completion of training . Given the utility of this technique and its frequently essential role in completing difficult cannulations, appreciation of a need for standardized exposure and training in needle knife sphincterotomy is growing [31].

Strictures of the bile duct or pancreatic duct may be treated using dilation, whether via dilating catheters or hydrostatic balloons. Stricture management via dilation is a key skill for the trainee to master, which encompasses an understanding of its indications, technique , and complications . In certain cases, dilation can also be performed at the biliary or pancreatic sphincter using a balloon, usually to facilitate stone extraction, and the trainee should be aware of the associated indications , technique, and complications.

There are no published data regarding the number of ERCPs or type of training required to attain competency in dilation.

Biliary decompression is a common indication for ERCP. The trainee must become well-versed in the indications for stenting and selection of stent (type, size, and length). S/he must master the endoscopic techniques required for optimal stent placement and positioning. Nasobiliary drainage is currently used less frequently but is still included as a recommended part of ASGE training guidelines for ERCP as well.

The 1988 and 1996 ASGE guidelines put forth 5 stent placements (among the 20 therapeutic cases) as a threshold prior to assessing competency ; as mentioned, newer guidelines have increased this number of therapeutic cases [12, 14]. There is no rigorous data regarding the number of ERCPs or type of training required to attain competency in stent placement.

Pancreatic stent placement is a higher-risk endeavor which is usually reserved for experienced operators and advanced trainees. The trainee must learn proper technique and positioning, accompanied by an understanding of which clinical scenarios warrant this maneuver.

Removal of bile duct stones is a relatively common maneuver during ERCP that can be accomplished using balloons or baskets; there may also be a need for mechanical lithotripsy . The trainee must master these techniques, and higher level training is necessary for advanced lithotripsy (electrohydraulic and/or laser-assisted). Removal of pancreatic duct stones, also usually reserved for advanced trainees, is a higher-risk endeavor requiring additional expertise.

There are no published data regarding the number of ERCPs or type of training required to attain competency stone extraction.

These techniques complement routine ERCP and require a strong foundation in the broad basic skill set outlined thus far, with the addition of advanced training in a specialized referral center with experts. Such techniques include but are not limited to the following.

These techniques are very sophisticated, representing the cutting edge of endoscopic therapy, but they are also challenging and among the highest risk procedures that can be performed by a gastroenterologist. Advanced therapeutic procedures include but are not limited to complex stone extraction requiring electrohydraulic or laser lithotripsy , pancreatic stone/stricture management, pseudocyst drainage , necrosectomy , ampullectomy , photodynamic therapy, brachytherapy, minor papilla therapy, and rendezvous techniques. Generally, trainees will only receive sufficient instruction for competency in these procedures in the context of a dedicated advanced endoscopy fellowship of 12 months or more. Furthermore, training in the most complex of these therapeutic cases can potentially extend beyond fellowship and into full clinical practice, under the tutelage of a more experienced colleague in the endoscopy group.

Since the early 1990s, anesthetized pigs and dogs have been used for training in ERCP [34, 35]. Major advantages include natural tissue elasticity and sensation, as well as realistic tactile feedback. Disadvantages include cost, ethical and animal welfare concerns, hygiene issues, need for animal-specific endoscopes , and need for specialized animal facilities with veterinary anesthesia support [3]. Additional issues specific to pigs include the fact that there are two distinct papillae for the pancreatic duct and bile duct , the stomach remains full of food longer, and the distance to the pylorus is lengthened by the long snout [3].

These devices utilize the relevant organs for simulator purposes and are often referred to as “ex vivo” models. Advantages include more realism than mechanical models, lower cost and fewer regulatory issues than animal models. Disadvantages include lengthy and intensive setup and disposal procedures, as well as unfavorable tactile features compared with living tissue [36]. One of the early tissue models for ERCP was the CompactEASIE^TM (Erlangen Active Training Simulator Interventional Endoscopy) developed in 1998 as a modified and more lightweight version of the (EASIE). CompactEASIE^TM utilized a plastic platform and a specially prepared porcine upper gastrointestinal package (esophagus, stomach, duodenum) with the common bile duct, gallbladder, and liver. This allowed practice of biliary cannulation with discrete cannulation of left/right systems, sphincterotomy , needle knife, basic accessory use, stent placement, and stone extraction [37]. The ASGE has developed a simulator similar to the CompactEASIE^TM called the Endo X Trainer, also a plastic table-top platform with porcine organs [36]. Two more recent simulators have involved creation of a neo-papilla utilizing a chicken heart or simulating sphincter muscle using pig stomach and/or rectum (Fig. 1.1) [38, 39].

Mechanical models suffer from poor mimicry of actual tissue and do not have any inherent variety [36]. The earliest of these were used for general endoscopy rather than ERCP, but newer generations of these devices have addressed some of the shortcomings. The Boškoski-Costamagna ECRP Trainer was development in 2010 and replicates the duodenum and pancreaticobiliary system using plastic and light metals (Fig. 1.2). This model allows training in cannulation, stone extraction, stenting, balloon dilation , brushing, and biopsy (personal communication). Another relatively novel mechanical simulator , X-Vision ERCP Training System, is a simulated ERCP platform with simulated fluoroscopy.[40]