How Often Should I Perform Endoscopic Retrograde Cholangiopancreatography in Order to Retain an Adequate Level of Skill?
The use of endoscopic retrograde cholangiopancreatography (ERCP) today has moved from diagnostic and therapeutic to predominantly therapeutic with the advent of magnetic resonance cholangiopancreatography (MRCP). To perform basic therapeutic ERCP expertly, one must possess proficiency in performing sphincterotomy and stent placement of the common bile duct and pancreatic duct, stone removal using a variety of balloons and baskets, balloon dilatation of strictures, and tissue sampling using brushes and biopsy forceps. Advanced endoscopists also command knowledge of complicated bile duct stone management such as mechanical, electrohydraulic, laser, extracorporeal, and shock wave lithotripsy; pancreatic duct stone and stricture management; pseudocyst drainage; ampullectomy; and other miscellaneous procedures such as photodynamic therapy, brachytherapy, minor papillary therapy, needle-knife sphincterotomy, and rendezvous techniques. These endoscopists must be able to recognize and deal with the potential complications of such procedures: pancreatitis, bleeding, cholangitis, and perforation and should be familiar with and able to perform diagnostic techniques such as sphincter of Oddi manometry, cholangioscopy, pancreatoscopy, and interductal ultrasound.
To date, there is no definitive evidence-based criteria for ascertaining when clinical competence is achieved for ERCP. Although there are guidelines for determining the number of procedures required for credentialing, this does not necessarily indicate competency, especially since this may vary depending on the technicality of the procedure and the experience of the endoscopist.
Guidelines from Gastroenterology Core Curriculum 1996 indicate that a minimum number of procedures to be completed for competency include 100 ERCPs including 25 therapeutic cases (20 sphincterotomies and 5 stent placements), along with other earlier studies proposing the same number of procedures needed.1 As the techniques advance, some published studies have suggested that increased numbers are required. Jowell et al2 assessed procedural competence by evaluating the number of supervised ERCPs that physicians need to perform to achieve competence (0.8 probability of successfully completing specific technical components of ERCP). By grading 17 gastroenterology fellows performing consecutive 1796 ERCPs, they determined that at least 180 ERCPs were required to be considered competent that would enable them to practice in an unsupervised setting and that they needed to perform 50 or more per year in order to maintain technical expertise and competence. Since then other studies suggest a minimum of 200 procedures is sufficient to achieve competency3 and now, American Society for Gastrointestinal Endoscopy (ASGE) guidelines for ERCP Core Curriculum mentions that seldom can trainees achieve adequate selection cannulation rates even after 200 procedures have been performed and proposes that a grading system be applied according to the degree of difficulty to gauge competency (Table 46-1). Verma et al4 uses deep cannulation of the common bile duct as a measure of competence. They showed that successful cannulation rate increased from 43% in the beginning of training to 80% or greater after 350 to 400 supervised procedures. The success rate continued to improve post-training with an aggregated success rate of greater than 96% for the next 300 procedures performed as an independent operator.
ASGE guidelines for methods of granting hospital privileges to perform gastrointestinal endoscopy indicates that the published numbers are not adequate to achieve competency and emphasizes the need to use objective criteria of skill, rather than an arbitrary number or procedures performed when granting privileges for endoscopic procedures. Subsequent studies have shown that maintenance of ERCP competence and technical expertise is directly related to volume of patients seen.5,6
Regardless of the number of procedures needed, ASGE clearly outlines in its guidelines for renewal of endoscopic privileges that maintaining competence is important since procedural dexterity optimizes patient safety and comfort and that performing a procedure infrequently may lead to missed or inappropriate diagnosis. In addition, they propose that changes in equipment through upgrade necessitate familiarity, the endoscopic recognition of lesions may improve over time, and endoscopic therapy continues to undergo evaluation and evolution, and these should be re-evaluated and monitored on a constant basis.
The bottom line is that although performing a minimum number of 180 to 200 ERCPs appears reasonable to learn the technique, the art of the skill can only be developed as per the endoscopist’s discretion who should be the ultimate judge in determining if he or she can expertly diagnose and treat biliary disease via ERCP with minimal complications and to the patient’s overall benefit.
1. Garcıá Lizcano J, González Martın JA. Training in cannulation of bile duct using endoscopic retrograde cholangiopancreatography. Gastrointest Endosc. 2000;58:345-349.
2. Jowell PS, Baillie J, Branch MS, et al. Quantitative assessment of procedural competence: a prospective study of training in endoscopic retrograde cholangiopancreatography. Ann Intern Med. 1996;983-989.
3. Garcia-Cano J. 200 supervised procedures: the minimum threshold number for competency in performing endoscopic retrograde cholangiopancreatography. Surg Endosc. 2007;21(7):1254-1255.
4. Verma D, Gostot CT, Petersen B, Levy M, Baron T, Adler D. Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointest Endosc. 2007;65(3):394-400.
5. Kowalski T, Kanchana T, Pungpapong S. Perceptions of gastroenterology fellows regarding ERCP competency and training. Gastrointest Endosc. 2003;58(3):345-349.
6. Sedlack R, Petersen B, Binmoeller K, et al. A direct comparison of ERCP teaching models. Gastrointest Endosc. 2003;57(7):886-890.