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Brodaric AM, Wong NLJ, Falon J, Wong J, Cheng K, Whereat S, Storey D. Anatomical endoscopic retrograde cholangiopancreatography simulator using moulded meshed silicone: A novel simulator pilot study. ANZ J Surg 2023; 93:1817-1824. [PMID: 37140189 DOI: 10.1111/ans.18495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangio-pancreatography (ERCP) has higher rates of morbidity and mortality compared to upper or lower gastrointestinal tract endoscopy. The availability of magnetic resonance cholangiopancreatography means ERCP is usually performed for therapeutic purposes. Simulation could provide an adjunct to patient-based training in ERCP however models to date have been unconvincing. METHODS This ERCP simulation model was constructed from moulded meshed silicone by co-designers: Jean Wong and Kai Cheng. The anatomical orientation was based on a combination of anatomical specimens, sectional atlases, and the clinical experience of expert endoscopists. RESULTS From March to October 2022, we recruited 5 surgeons/gastroenterologists to the expert group and 14 medical students, junior doctors, or surgical/gastroenterological trainees to the novice group. Most experts either agreed or strongly agreed that the simulation anatomy appearance (100%), anatomical orientation (83%), tactile feedback (66%), traversal actions (67%), cannula positioning (66%) and papilla cannulation (67%) resembled the procedure in humans. Experts statistically significantly outperformed novices in obtaining a cannulating position (80% vs. 14%, P = 0.006) and successful papilla cannulation (80% vs. 7%, P = 0.0015) on their first attempt. The novice group had statistically significant improvements in time to obtaining a cannulating position (3.53 vs. 11.5 min, P = 0.006) and passing the duodenoscope to the papilla (2.55 vs. 4 passes, P = 0.009). CONCLUSIONS The simulator showed statistically significant results in face, content, and construct validity. A follow-up validation study should recruit participants across multiple institutions. External validity could be assessed by comparing expert proceduralist simulator performance against clinical ERCP performance.
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Affiliation(s)
- Alen Maximillian Brodaric
- Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- RPA Institute of Academic Surgery, Sydney, Australia
| | - Ngar Lok Joshua Wong
- Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jessica Falon
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- RPA Institute of Academic Surgery, Sydney, Australia
| | - Jean Wong
- Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- RPA Institute of Academic Surgery, Sydney, Australia
| | - Kai Cheng
- RPA Institute of Academic Surgery, Sydney, Australia
| | - Sarah Whereat
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- RPA Institute of Academic Surgery, Sydney, Australia
- Sydney Education, Sydney Local Health District, Sydney, Australia
| | - David Storey
- Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- RPA Institute of Academic Surgery, Sydney, Australia
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Borrelli de Andreis F, Mascagni P, Schepis T, Attili F, Tringali A, Costamagna G, Boškoski I. Prevention of post-ERCP pancreatitis: current strategies and novel perspectives. Therap Adv Gastroenterol 2023; 16:17562848231155984. [PMID: 36895283 PMCID: PMC9989421 DOI: 10.1177/17562848231155984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/23/2023] [Indexed: 03/08/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.
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Affiliation(s)
- Federica Borrelli de Andreis
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, Pavia, Italy.,Gastroenterology Unit, Istituti Clinici Maugeri, University of Pavia, Pavia, Italy.,Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pietro Mascagni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Institute of Image-Guided Surgery, IHU-Strasbourg, France
| | - Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabia Attili
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, 00168, Italy.,IHU Strasbourg 1, Place de l'Hopital 67091 Strasbourg Cedex, France.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
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Siau K, Keane MG, Steed H, Caddy G, Church N, Martin H, McCrudden R, Neville P, Oppong K, Paranandi B, Rasheed A, Sturgess R, Hawkes ND, Webster G, Johnson G. UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography. Endosc Int Open 2022; 10:E37-E49. [PMID: 35047333 PMCID: PMC8759929 DOI: 10.1055/a-1629-7540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/24/2021] [Indexed: 12/25/2022] Open
Abstract
Background and study aims Despite the high-risk nature of endoscopic retrograde cholangiopancreatography (ERCP), a robust and standardized credentialing process to ensure competency before independent practice is lacking worldwide. On behalf of the Joint Advisory Group (JAG), we aimed to develop evidence-based recommendations to form the framework of ERCP training and certification in the UK. Methods Under the oversight of the JAG, a modified Delphi process was conducted with stakeholder representation from the British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on ERCP training and certification were formulated after formal literature review and appraised using the GRADE tool. These were subjected to electronic voting to achieve consensus. Accepted statements were peer-reviewed by JAG and relevant Specialist Advisory Committees before incorporation into the ERCP certification pathway. Results In total, 27 recommendation statements were generated for the following domains: definition of competence (9 statements), acquisition of competence (8 statements), assessment of competence (6 statements) and post-certification support (4 statements). The consensus process led to the following criteria for ERCP certification: 1) performing ≥ 300 hands-on procedures; 2) attending a JAG-accredited ERCP skills course; 3) in modified Schutz 1-2 procedures: achieving native papilla cannulation rate ≥80%, complete bile duct clearance ≥ 70 %, successful stenting of distal biliary strictures ≥ 75 %, physically unassisted in ≥ 80 % of cases; 4) 30-day post-ERCP pancreatitis rates ≤5 %; and 5) satisfactory performance in formative and summative direct observation of procedural skills (DOPS) assessments. Conclusions JAG certification in ERCP has been developed following evidence-based consensus to quality assure training and to ultimately improve future standards of ERCP practice.
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Affiliation(s)
- Keith Siau
- Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Margaret G Keane
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Helen Steed
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Grant Caddy
- Department of Gastroenterology, South Eastern Health and Social Care Trust, Northern Ireland, UK
| | - Nick Church
- Department of Gastroenterology, NHS Lothian, Edinburgh, Scotland
| | - Harry Martin
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Raymond McCrudden
- Department of Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Peter Neville
- Department of Gastroenterology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - Kofi Oppong
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Bharat Paranandi
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ashraf Rasheed
- Department of Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - Richard Sturgess
- Department of Gastroenterology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Neil D Hawkes
- Department of Gastroenterology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospitals, London, UK
| | - Gavin Johnson
- Department of Gastroenterology, University College London Hospitals, London, UK
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Gallo C, Boškoski I, Matteo MV, Orlandini B, Costamagna G. Training in endoscopic retrograde cholangio-pancreatography: a critical assessment of the broad scenario of training programs and models. Expert Rev Gastroenterol Hepatol 2021; 15:675-688. [PMID: 33599177 DOI: 10.1080/17474124.2021.1886078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) applications are rapidly evolving toward increasingly complex therapeutic approaches alongside with technological innovations. There are no globally agreed indications on the ERCP training path, which often requires too much time and does not always guarantee adequate skills.Areas covered: Frequency and difficulty of execution are the main objective criteria on which to draw up a training program: novel trainees should approach ERCP first through the simplest and most frequent procedures. An extensive use of training models would reduce the patient's performer-related risks. Amongst a wide variety of models, mechanical simulators have received large approval. In fact, they can be best-suited to each trainee's learning curve thanks to their precision and safety and by virtue of the unlimited repeatability of their use. However, more solid evidences are still needed.Expert opinion: Hands-on ERCP training should systematically employ mechanical simulators at least in the early stages of the learning process. An implementation of these models through sensors that objectively detect abnormalities in the movements would provide detailed feedbacks and deeper awareness. Simulators might also be useful for expert endoscopists to refine their skills. Rapid prototyping and 3D printing might be the way to create customized training models for successful training programs.
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Affiliation(s)
- Camilla Gallo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Maria Valeria Matteo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Beatrice Orlandini
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Catholic University of Rome, Italy
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Gender-Specific Factors Influencing Gastroenterologists to Pursue Careers in Advanced Endoscopy: Perceptions vs Reality. Am J Gastroenterol 2021; 116:539-550. [PMID: 33657041 DOI: 10.14309/ajg.0000000000001112] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/13/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION In 2020, only 19% of 63 matched advanced endoscopy (AE) fellows were women. This study evaluates the gender-specific factors that influence gastroenterologists to pursue careers in AE. METHODS An anonymous survey was distributed to gastroenterology fellows and attendings through various gastroenterology society online forums. Data were collected on demographics, training, mentorship, current practice, family planning, and career satisfaction. RESULTS Women comprised 71.1% of the 332 respondents. 24.7% of female fellows plan to pursue an AE career compared with 37.5% of male fellows (P = 0.195). The main motivating factor for both genders was interest in the subject area. Interest in another subspecialty was the main deterring factor for both genders. Women were more deterred by absence of same-sex mentors (P < 0.001), perception of gender-based bias in the workplace (P = 0.009), family planning (P = 0.018), fertility/pregnancy risks from radiation (P < 0.001), and lack of ergonomic equipment (P = 0.003). AE gastroenterologists of both genders were satisfied with their career decision and would recommend the field to any fellow. Most respondents (64%) believed that more female role models/mentors would improve representation of women in AE. DISCUSSION There are multiple gender-specific factors that deter women from pursuing AE. Increasing the number of female role models is strongly perceived to improve representation of women in AE. Most AE attendings are satisfied with their career and would recommend it to fellows of any gender. Thus, early targeted mentorship of female trainees has potential to improve recruitment of women to the field.
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Tan X, Li D, Jeong M, Yu T, Ma Z, Afat S, Grund KE, Qiu T. Soft Liver Phantom with a Hollow Biliary System. Ann Biomed Eng 2021; 49:2139-2149. [PMID: 33594636 PMCID: PMC8455397 DOI: 10.1007/s10439-021-02726-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023]
Abstract
Hepatobiliary interventions are regarded as difficult minimally-invasive procedures that require experience and skills of physicians. To facilitate the surgical training, we develop a soft, high-fidelity and durable liver phantom with detailed morphology. The phantom is anatomically accurate and feasible for the multi-modality medical imaging, including computer tomography (CT), ultrasound, and endoscopy. The CT results show that the phantom resembles the detailed anatomy of real livers including the biliary ducts, with a spatial root mean square error (RMSE) of 1.7 ± 0.7 mm and 0.9 ± 0.2 mm for the biliary duct and the liver outer shape, respectively. The sonographic signals and the endoscopic appearance highly mimic those of the real organ. An electric sensing system was developed for the real-time quantitative tracking of the transhepatic puncturing needle. The fabrication method herein is accurate and reproducible, and the needle tracking system offers a robust and general approach to evaluate the centesis outcome.
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Affiliation(s)
- Xiangzhou Tan
- Cyber Valley Research Group, Institute of Physical Chemistry, University of Stuttgart, Pfaffenwaldring 55, 70569, Stuttgart, Germany.,Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, 72072, Tuebingen, Germany.,Department of General Surgery, Xiangya Hospital Central South University, Changsha, 410008, China
| | - Dandan Li
- Cyber Valley Research Group, Institute of Physical Chemistry, University of Stuttgart, Pfaffenwaldring 55, 70569, Stuttgart, Germany.,Micro Nano and Molecular Systems Lab, Max Planck Institute for Intelligent Systems, Heisenbergstr. 3, 70569, Stuttgart, Germany
| | - Moonkwang Jeong
- Cyber Valley Research Group, Institute of Physical Chemistry, University of Stuttgart, Pfaffenwaldring 55, 70569, Stuttgart, Germany
| | - Tingting Yu
- Cyber Valley Research Group, Institute of Physical Chemistry, University of Stuttgart, Pfaffenwaldring 55, 70569, Stuttgart, Germany.,Micro Nano and Molecular Systems Lab, Max Planck Institute for Intelligent Systems, Heisenbergstr. 3, 70569, Stuttgart, Germany
| | - Zhichao Ma
- Micro Nano and Molecular Systems Lab, Max Planck Institute for Intelligent Systems, Heisenbergstr. 3, 70569, Stuttgart, Germany
| | - Saif Afat
- Department of Interventional and Diagnostic Radiology, University Hospital Tuebingen, 72072, Tuebingen, Germany
| | - Karl-Enrst Grund
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, 72072, Tuebingen, Germany
| | - Tian Qiu
- Cyber Valley Research Group, Institute of Physical Chemistry, University of Stuttgart, Pfaffenwaldring 55, 70569, Stuttgart, Germany. .,Micro Nano and Molecular Systems Lab, Max Planck Institute for Intelligent Systems, Heisenbergstr. 3, 70569, Stuttgart, Germany.
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Impact of mechanical simulator practice on clinical ERCP performance by novice surgical trainees: a randomized controlled trial. Endoscopy 2020; 52:1004-1013. [PMID: 32869230 DOI: 10.1055/a-1217-6727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Lack of forward-viewing endoscopy experience impairs training in endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the effect of ERCP mechanical simulator (EMS) practice on ERCP performance by surgical trainees. PATIENTS AND METHODS 12 surgical trainees without endoscopy experience were randomly allocated to non-EMS (n = 6) programs or to EMS (n = 6) programs with coaching and 20 hours of supervised EMS practice. All trainees then received supervised hands-on clinical ERCP training. Trainers provided verbal instructions and hands-on assistance, and took over if cannulation was not achieved by 20 minutes. Blinded trainers rated clinical performance. RESULTS Each group performed 150 clinical ERCPs. Biliary cannulation success was significantly higher in the EMS vs. the non-EMS group (P = 0.006), with shorter mean times (in minutes) for intubation, cannulation, and completion (all P < 0.001). EMS trainees showed a significantly better mean performance score (P = 0.006). In multivariate analysis, after adjusting for case sequence, CBD stone, complexity, and EMS training, the effect of EMS practice on odds for successful cannulation remained highly significant (odds ratio [OR] 2.10 [95 %CI 1.46 - 3.01]). At 6 months EMS trainees still had better cannulation success vs. non-EMS controls (P = 0.045); no difference was observed after 1 year. CONCLUSIONS EMS practice shortens the ERCP early learning curve of inexperienced surgical trainees, improves clinical success in selective biliary cannulation, and may reduce complications.
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Heinrich H, Arvanitakis M. Young GI Angle: How to manage complications in interventional endoscopy. United European Gastroenterol J 2020; 8:745-748. [PMID: 32628894 DOI: 10.1177/2050640620935028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Henriette Heinrich
- Stadtspital Waid und Triemli, University Hospital Zurich, Zurich, Switzerland
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Voiosu T, Voiosu A, Benguş A, Rimbaş M, Mateescu B. Trainee involvement increases precut rates and delays access to the common bile duct without an increase in procedure-related adverse events: a brave new world of ERCP training? ACTA ACUST UNITED AC 2019; 56:55-61. [PMID: 29080394 DOI: 10.1515/rjim-2017-0041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Selective cannulation of the desired duct is a key element in ERCP procedures and an important step in the training of fellows. However, there is limited data about technical success and patient safety for ERCPs conducted in a training setting.We aimed to evaluate the impact of trainee involvement on the cannulation technique and procedure related outcomes at ERCP. MATERIALS AND METHODS We conducted an observational study of all ERCP conducted in an endoscopy unit with an on-going training program. Patient related data and procedure-related data (method of cannulation, time to cannulation, degree of trainee involvement, technical success and procedure-related adverse events) were collected using a standard form. The method of cannulation, time to cannulation and procedure-related adverse events were compared between ERCPs with trainee involvement and those without. RESULTS 641 consecutive ERCPs were evaluated and 474 native papilla cases performed by 4 trainers and 3 trainees were included in the final analysis. Trainees were involved in 171 procedures (36.1%), achieving cannulation of the desired duct in 50.8% of the cases. Cannulation rates were similar in the trainee group compared to the control group (91.7% vs. 88.7%) and there was no increase in the rate of adverse events. However, cannulation time was significantly longer in the trainee group with a significant increase in the rate of precut use (32.1% vs. 23.4%, p < 0.001). CONCLUSIONS Trainee involvement resulted in longer cannulation times and increased use of precut sphincterotomy, but, was not associated with an increased risk of procedure related adverse events.
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Affiliation(s)
- Theodor Voiosu
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
| | - Andrei Voiosu
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
| | - Andreea Benguş
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
| | - Mihai Rimbaş
- UMF "Carol Davila" School of Medicine, Bucharest, Romania
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Cappell MS, Friedel DM. Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States. World J Gastroenterol 2019; 25:3468-3483. [PMID: 31367151 PMCID: PMC6658394 DOI: 10.3748/wjg.v25.i27.3468] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/16/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023] Open
Abstract
Endoscopic-retrograde-cholangiopancreatography (ERCP) is now a vital modality with primarily therapeutic and occasionally solely diagnostic utility for numerous biliary/pancreatic disorders. It has a significantly steeper learning curve than that for other standard gastrointestinal (GI) endoscopies, such as esophagogastroduodenoscopy or colonoscopy, due to greater technical difficulty and higher risk of complications. Yet, GI fellows have limited exposure to ERCP during standard-three-year-GI-fellowships because ERCP is much less frequently performed than esophagogastroduodenoscopy/colonoscopy. This led to adding an optional year of training in therapeutic endoscopy. Yet many graduates from standard three-year-fellowships without advanced training intensely pursue independent/unsupervised ERCP privileges despite inadequate numbers of performed ERCPs and unacceptably low rates of successful selective cannulation of desired (biliary or pancreatic) duct. Hospital credentialing committees have traditionally performed ERCP credentialing, but this practice has led to widespread flouting of recommended guidelines (e.g., planned privileging of applicant with 20% successful cannulation rate, or after performing only 7 ERCPs); and intense politicking of committee members by applicants, their practice groups, and potential competitors. Consequently, some gastroenterologists upon completing standard fellowships train and learn ERCP “on the job” during independent/unsupervised practice, which can result in bad outcomes: high rates of failed bile duct cannulation. This severe clinical problem is indicated by publication of ≥ 12 ERCP competency studies/guidelines during last 5 years. However, lack of mandatory, quantitative, ERCP credentialing criteria has permitted neglect of recommended guidelines. This work comprehensively reviews literature on ERCP credentialing; reviews rationales for proposed guidelines; reports problems with current system; and proposes novel criteria for competency. This work advocates for mandatory, national, written, minimum, quantitative, standards, including cognitive skills (possibly assessed by a nationwide examination), and technical skills, assessed by number performed (≥ 200-250 ERCPs), types of ERCPs, success rate (approximately ≥ 90% cannulation of desired duct), and letters of recommendation by program director/ERCP mentor. Mandatory criteria should ideally not be monitored by a hospital committee subjected to intense politicking by applicants, their employers, and sometimes even competitors, but an independent national entity, like the National Board of Medical Examiners/American Board of Internal Medicine.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
- Oakland University William Beaumont School of Medicine, William Beaumont Hospital, MI 48073, United States
| | - David M Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY 11501, United States
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11
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Voiosu T, Bălănescu P, Voiosu A, Benguş A, Preda C, Umans DS, Bogdan Mateescu R, van Hooft JE. Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature. United European Gastroenterol J 2019; 7:239-249. [PMID: 31080609 PMCID: PMC6498806 DOI: 10.1177/2050640618817110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022] Open
Abstract
Background Current recommendations on training in endoscopic retrograde cholangiopancreatography are predicated on a performance-centred approach designed to ensure that trainees achieve appropriate skills. We aimed to analyse how competence in endoscopic retrograde cholangiopancreatography is defined in the literature and what proportion of trainees actually reach this threshold. Methods We conducted a systematic MEDLINE search for studies reporting on endoscopic retrograde cholangiopancreatography training programmes in a clinical setting. The main outcome measure was threshold for achieving competence in endoscopic retrograde cholangiopancreatography; the secondary outcome measure was assessment of trainee performance. Quality was assessed using the Cochrane Risk of Bias tool and the Methodological Index for Non-Randomized Studies criteria. Results Of 522 initially identified articles, 20 were included in the analysis; most studies showed a high risk of bias. Cannulation rate of the desired duct was the main marker of competence in all studies; however, only 8/20 studies reported on the performance of individual trainees, who achieved their respective standard of competence in only 25.6% of reported cases. Conclusions Current literature identifies cannulation rate of a native papilla to be the most appropriate measure of endoscopic retrograde cholangiopancreatography competence; however, most trainees do not reach predefined competence thresholds. Furthermore, due to the limitations of available studies, the most appropriate competence measure remains subject for debate.
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Affiliation(s)
- Theodor Voiosu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | | | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Andreea Benguş
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Carmen Preda
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Devica S Umans
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Radu Bogdan Mateescu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
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Huang RJ, Barakat MT, Girotra M, Lee JS, Banerjee S. Unplanned Hospital Encounters After Endoscopic Retrograde Cholangiopancreatography in 3 Large North American States. Gastroenterology 2019; 156:119-129.e3. [PMID: 30243620 PMCID: PMC6309462 DOI: 10.1053/j.gastro.2018.09.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 09/07/2018] [Accepted: 09/14/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS We have few population-level data on the performance of endoscopic retrograde cholangiopancreatography (ERCP) in the United States. We investigated the numbers of unplanned hospital encounters (UHEs), patient and facility factors associated with UHEs, and variation in quality and outcomes in the performance of ERCP in 3 large American states. METHODS We collected data on 68,642 ERCPs, performed at 635 facilities in California, Florida, and New York from 2009 through 2014. The primary endpoint was number of UHEs with an ERCP-related event within 7 days of ERCP; secondary endpoints included number of UHEs within 30 days and mortality within 30 days. Each facility was assigned a risk-standardized cohort, and variations in number of UHEs were analyzed with multivariable analysis. RESULTS Among all ERCPs, 5.8% resulted in a UHE within 7 days and 10.2% within 30 days. Performance of sphincterotomy was significantly associated with a higher risk of UHE at 7 and 30 days (P < .001). Younger age, female sex, and more advanced comorbidity were associated with UHE. There was substantial heterogeneity in rates of UHE among facilities: 4.2% at facilities in the 5th percentile and 25.2% at facilities in the 95th percentile. Increasing facility volume and ability to perform endoscopic ultrasonography were associated inversely with risk. The median number of ERCPs performed each year was 68.7, but 69% of facilities performed 100 or fewer ERCPs per year. Risk for UHE after sphincterotomy decreased with increasing facility volume until an inflection point of 157 ERCPs per year was reached. CONCLUSIONS In an analysis of outcomes of 68,642 ERCPs performed in 3 states, we found a higher-than-expected number of UHEs. There is substantial unexplained variation in risk for adverse events after ERCPs among facilities, and volume is the strongest predictor of risk. Annual facility volumes above approximately 150 ERCPs per year may protect against UHE.
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Affiliation(s)
- Robert J. Huang
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA,Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Monique T. Barakat
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Mohit Girotra
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Jennifer S. Lee
- Department of Health Research and Policy, Stanford University, Stanford, CA,Department of Medicine, Stanford University, Stanford, CA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California.
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Rodrigues-Pinto E, Baron TH, Liberal R, Macedo G. Quality and competence in endoscopic retrograde cholangiopancreatography - Where are we 50 years later? Dig Liver Dis 2018; 50:750-756. [PMID: 29804924 DOI: 10.1016/j.dld.2018.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023]
Abstract
Training in endoscopic retrograde cholangiopancreatography (ERCP) requires the development of technical, cognitive, and integrative skills well beyond those needed for standard endoscopic procedures. So far, there are limited data regarding what constitutes competency in ERCP, including achievement and maintenance. Recent studies have highlighted overall procedural numbers are not enough to warrant competency, although more is better. We performed a comprehensive literature search until June 2017 using predetermined search terms to identify relevant articles and summarized their results as a narrative review. Selective native papilla deep cannulation should be used as a benchmark for assessing successful cannulation. Accurate and validated ERCP performance measures are needed to develop a curriculum that allows transition from numbers-based competency. However, available guidelines fail to state what degree of hands-on involvement is required by the trainee for the case to be counted in their overall procedural numbers. Qualitative assessment of competency should be done by trained raters using specially designed assessment tools. Competence continues to increase with practice following formal training in a fairly steady manner. The learning curve for overall common bile duct cannulation success may be a readily available surrogate for individual trainee progression and may correspond to learning curves for therapeutic interventions.
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Affiliation(s)
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
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Iida T, Kaneto H, Wagatsuma K, Sasaki H, Naganawa Y, Nakagaki S, Satoh S, Shimizu H, Nakase H. Can Trainees Safely Perform Endoscopic Treatments for Common Bile Duct Stones? A Single-center Retrospective Study. Intern Med 2018; 57:923-928. [PMID: 29434158 PMCID: PMC5919847 DOI: 10.2169/internalmedicine.9737-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective There are no reports on whether or not trainees can safely carry out endoscopic procedures for the removal of common bile duct (CBD) stones. The aim of this study was to investigate the efficacy and safety of endoscopic treatments for CBD stones by trainees. Methods Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 1,016 consecutive patients at our institution during the 6-year study period. The endoscopically treated patients with CBD stones were included in this study. Physicians who had experienced ≥300 ERCP procedures were defined as experts, while those who had experienced <300 procedures were defined as trainees. The trainees were replaced by an expert when they could not achieve the established criteria. Patients were divided into the following three groups to retrospectively examine the patients' backgrounds, details of endoscopic treatments, and intra-/post-operative complications: Group A, completed by trainees under supervision of an expert; B, treated by an expert who switched in for a trainee in the middle of the procedure; and C, completed by an expert. Results A total of 325 patients with CBD stones underwent endoscopic treatments. The number included in Groups A, B, and C was 176, 102, and 47, respectively. The bile duct catheter insertion successes rates for Groups A, B, and C were 99.0%, 97.1%, and 100% (p=0.09), and the complete stone removal rates were 94.2%, 94.8%, and 100%, respectively (p=0.07), showing no significant difference among the three groups. Furthermore, the frequency of intra-/post-operative complications was not significantly different among the three groups (p=0.48, p=0.12, respectively). Conclusion This study showed that trainees could safely perform endoscopic procedures in accordance with our facility's criteria during ERCP.
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Affiliation(s)
- Tomoya Iida
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hiroyuki Kaneto
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Kohei Wagatsuma
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hajime Sasaki
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Yumiko Naganawa
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Suguru Nakagaki
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Shuji Satoh
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Haruo Shimizu
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
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Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, Fujita N, Yasuda K, Tsuyuguchi T, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc 2018; 30:149-173. [PMID: 29247546 DOI: 10.1111/den.13001] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.
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Affiliation(s)
- Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironari Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Activities in a social networking-based discussion group by endoscopic retrograde cholangiopancreatography doctors. Eur J Gastroenterol Hepatol 2017; 29:1131-1135. [PMID: 28704223 DOI: 10.1097/meg.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Online social networking is increasingly being used among medical practitioners. However, few studies have evaluated its use in therapeutic endoscopy. Here, we aimed to analyze the shared topics and activities of a group of endoscopic retrograde cholangiopancreatography (ERCP) doctors in a social networking-based endoscopic retrograde cholangiopancreatography discussion group (EDG). MATERIALS AND METHODS Six ERCP trainers working in Xijing Hospital and 48 graduated endoscopists who had finished ERCP training in the same hospital were invited to join in EDG. All group members were informed not to divulge any private information of patients when using EDG. The activities of group members on EDG were retrospectively extracted. The individual data of the graduated endoscopists were collected by a questionnaire. RESULTS From June 2014 to May 2015, 6924 messages were posted on EDG, half of which were ERCP related. In total, 214 ERCP-related topics were shared, which could be categorized into three types: sharing experience/cases (52.3%), asking questions (38.3%), and sharing literatures/advances (9.3%). Among the 48 graduated endoscopists, 21 had a low case volume of less than 50 per year and 27 had a high volume case volume of 50 or more. High-volume graduated endoscopists posted more ERCP-related messages (P=0.008) and shared more discussion topics (P=0.003) compared with low-volume graduated endoscopists. A survey showed that EDG was useful for graduated endoscopists in ERCP performance and management of post-ERCP complications, etc. CONCLUSION A wide range of ERCP-related topics were shared on the social networking-based EDG. The ERCP-related behaviors on EDG were more active in graduated endoscopists with an ERCP case volume of more than 50 per year.
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Hwang JC, Yoo BM, Yang MJ, Lee YK, Lee JY, Lim K, Noh CK, Cho HJ, Kim SS, Kim JH. A prospective randomized study of loop-tip versus straight-tip guidewire in wire-guided biliary cannulation. Surg Endosc 2017; 32:1708-1713. [PMID: 28916891 DOI: 10.1007/s00464-017-5851-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Wire-guided cannulation has been widely accepted as a useful technique for achieving selective biliary access because it has significantly increased the success rate of biliary cannulation compared with conventional contrast-assisted cannulation. Unlike conventional guidewires with a straight tip, a loop-tip guidewire (LGW) has a closed distal loop that may facilitate less traumatic access through the epithelial folds of the intra-duodenal biliary segments. The aim of this study was to compare the performance of a LGW with a straight-tip guidewire (SGW) in achieving successful selective biliary cannulation. METHODS From December 2014 to December 2015, we performed 192 wire-guided biliary cannulations for a naïve papilla in a randomized controlled trial. Patients were randomly assigned to the LGW group (n = 96) or the SGW group (n = 96). Our study protocol did not include crossover to the other guidewire arm if randomized wire-guided cannulation proved unsuccessful within the first 10 min. RESULTS There was no significant difference in primary successful biliary cannulation between the two groups (LGW group: 86.5%; SGW group: 77.1%; p = 0.134). The rate and the mean number of unintentional pancreatic duct cannulations during wire-guided biliary cannulation were significantly lower in the LGW group than in the SGW group (LGW group: 14.6%; SGW group: 28.1%; p = 0.034; LGW group: 0.2 ± 0.5; SGW group: 0.6 ± 1.3; p = 0.007). Post-ERCP pancreatitis developed in 5.2% of patients in the LGW group and 8.3% of patients in the SGW group (p = 0.567). CONCLUSIONS The biliary cannulation rate of the LGW was not significantly different from those of conventional guidewires. Use of the LGW was associated with a lower rate of unintentional pancreatic duct cannulation during wire-guided biliary cannulation than use of the SGW.
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Affiliation(s)
- Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Byung Moo Yoo
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea.
| | - Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Yeon Kyung Lee
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Ju Young Lee
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Kihyun Lim
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Choong-Kyun Noh
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Hyo Jung Cho
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Soon Sun Kim
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yeongtong-gu, Suwon, 16499, Korea
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Rodrigues-Pinto E, Macedo G, Baron TH. Training pathways and competency assessment in endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Liao WC, Angsuwatcharakon P, Isayama H, Dhir V, Devereaux B, Khor CJL, Ponnudurai R, Lakhtakia S, Lee DK, Ratanachu-Ek T, Yasuda I, Dy FT, Ho SH, Makmun D, Liang HL, Draganov PV, Rerknimitr R, Wang HP. International consensus recommendations for difficult biliary access. Gastrointest Endosc 2017; 85:295-304. [PMID: 27720741 DOI: 10.1016/j.gie.2016.09.037] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/28/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Phonthep Angsuwatcharakon
- Department of Anatomy and Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Vinay Dhir
- Baldota Institute of Digestive Sciences, Global Hopsitals, Parel, Mumbai, India
| | - Benedict Devereaux
- University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christopher J L Khor
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Ryan Ponnudurai
- Division of Gastroenterology, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Dong-Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Thawee Ratanachu-Ek
- Department of Surgery, Rajavithi Hospital, Rangsit Medical College, Bangkok, Thailand
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
| | | | - Shiaw-Hooi Ho
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Dadang Makmun
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Huei-Lung Liang
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Peter V Draganov
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Faulx AL, Lightdale JR, Acosta RD, Agrawal D, Bruining DH, Chandrasekhara V, Eloubeidi MA, Gurudu SR, Kelsey L, Khashab MA, Kothari S, Muthusamy VR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85:273-281. [PMID: 28089029 DOI: 10.1016/j.gie.2016.10.036] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/08/2023]
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Can a Computerized Simulator Assess Skill Level and Improvement in Performance of ERCP? Dig Dis Sci 2016; 61:722-30. [PMID: 26572779 DOI: 10.1007/s10620-015-3939-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/22/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiography (ERCP) is a challenging procedure with considerable risk. Computerized simulators are valuable in training for flexible endoscopy, but little data exist for their use in ERCP training. AIM To determine a simulator's ability to assess the level of ERCP skill and its responsiveness over time to increasing trainee experience. MATERIALS AND METHODS In this prospective parallel-arm cohort study, six novice gastroenterology fellows and four gastroenterology faculty with expertise in ERCP completed four simulated baseline cases and the same four cases at a later date. This study took place at a surgical skills center at an academic tertiary referral center. The primary outcome was the total time to complete the ERCP procedure. RESULTS For the baseline session, experts had a shorter total procedure time than novices (444.0 vs. 616.9 s; least squares mean; p = 0.026). There was no significant difference between experts and novices in the difference of total procedure time between session 1 and session 2 (-200.3 vs. -164.4; least squares mean; p = 0.402). CONCLUSIONS The simulator was able to differentiate experts from novices for the primary outcome of total procedure time. The simulator was not responsive to an increase in trainee experience over time.
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Shahidi N, Ou G, Telford J, Enns R. When trainees reach competency in performing ERCP: a systematic review. Gastrointest Endosc 2016; 81:1337-42. [PMID: 25841579 DOI: 10.1016/j.gie.2014.12.054] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ERCP is an advanced endoscopic procedure that is technically more challenging and carries a higher risk of adverse events compared with standard endoscopy. A discrepancy currently exists among guidelines regarding the number of ERCPs that a trainee needs to complete before procedural competency should be assessed. Our aim was to assess the learning curve for performing ERCP. METHODS Two authors independently searched MEDLINE (1946 to November 25, 2014) along with the gray literature to identify relevant citations. To warrant inclusion, citations were required to report successful trainee cannulation rate. Successful cannulation rate, set at a value of 80% or higher, was used as our baseline reference for competency. RESULTS Nine studies, assessing 137 trainees and 17,100 ERCPs, were included in our analysis. Overall, competency was achieved among the included studies between 70 to 400 ERCPs. In the 2 studies that used pancreatic duct cannulation rate, competency was achieved by 70 to 160 ERCPs. Of the 5 studies that used selective duct cannulation rate, competency was achieved by 79 to 300 ERCPs. Finally, in the 4 studies that used common bile duct cannulation rate, 2 studies reached the reference competency threshold by 160 to 400 ERCPs. On further stratification, when assessing native papilla deep common bile duct cannulation, only 1 study reached the reference competency threshold by 350 to 400 ERCPs. CONCLUSIONS Our findings suggest that as ERCP has evolved from a predominantly diagnostic to therapeutic procedure, procedural thresholds have risen well above North American training guidelines. Therefore, advanced endoscopy training programs need to reassess their current structure to ensure that procedural competency is being reached.
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Affiliation(s)
- Neal Shahidi
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - George Ou
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Telford
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Robert Enns
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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Yang MJ, Hwang JC, Yoo BM, Kim JH, Ryu HK, Kim SS, Kang JK, Kim MK. Wire-guided cannulation over a pancreatic stent versus double guidewire technique in patients with difficult biliary cannulation. BMC Gastroenterol 2015; 15:150. [PMID: 26510825 PMCID: PMC4625430 DOI: 10.1186/s12876-015-0381-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 10/21/2015] [Indexed: 01/25/2023] Open
Abstract
Background In cases of difficult bile duct cannulation, the use of wire-guided cannulation over a pancreatic stent (WGC-PS) or the double guidewire technique (DGT) may facilitate biliary cannulation. The aim of this study was to compare the outcomes of WGC-PS and DGT in patients with difficult biliary cannulation. Methods We conducted a retrospective cohort study of all endoscopic retrograde cholangiopancreatographies (ERCPs) performed between July 2009 and November 2014 at a single tertiary referral center. WGC-PS or DGT was performed in patients for whom biliary cannulation was difficult and guidewire insertion into the pancreatic duct (PD) was inadvertently achieved while attempting the standard WGC technique. In those cases, we used the WGC-PS technique from July 2009 to January 2012 (WGC-PS group), and the DGT technique from February 2012 to November 2014 (DGT group). In the DGT group, WGC-PS was sequentially performed if successful biliary cannulation was not achieved during the DGT attempt. Consecutive patients who underwent DGT and/or WGC-PS with the aim of selective biliary cannulation were enrolled. The primary outcome parameter was the rate of initial successful biliary cannulation. Results During the study period 3270 ERCPs were performed and a total of 177 patients were enrolled. The rate of initial successful cannulation was 66.7 % (60/90) in the WGC-PS group and 70.1 % (61/87) in the DGT group (P = 0.632). In 26 cases of failed DGT, WGC-PS was sequentially performed in the DGT group, and cannulation was successful in 14 of these patients. The rate of successful cannulation without the needle-knife precut technique was significantly higher in the DGT group compared with the WGC-PS group (75/87, 86.2 % vs. 60/90, 66.7 %, P = 0.003). The incidence of post-ERCP pancreatitis was 3.3 % (3/90) in the WGC-PS group and 10.3 % (9/87) in the DGT group (P = 0.077). Conclusions In patients for whom biliary cannulation was difficult and PD access was inadvertently achieved while attempting the standard WGC technique, both WGC-PS and DGT were equally effective. Furthermore, the stepwise approach using DGT followed by WGC-PS as needed facilitated successful biliary cannulation and reduced the need for the needle-knife precut technique.
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Affiliation(s)
- Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
| | - Jae Chul Hwang
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
| | - Byung Moo Yoo
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
| | - Hyoung-Kyu Ryu
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
| | - Soon Sun Kim
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
| | - Joon Koo Kang
- Department of Gastroenterology, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
| | - Min Kyeong Kim
- Medical Information and Media Center, Ajou University School of Medicine, San-5, Woncheon-dong, Yongtong-gu, 443-721, , Suwon, South Korea.
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Cotton PB. ERCP (Ensuring Really Competent Practice): enough words-action please! Gastrointest Endosc 2015; 81:1343-5. [PMID: 25986111 DOI: 10.1016/j.gie.2015.02.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 02/13/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Peter B Cotton
- Digestive Disease Center, Medical University of South Carolina, Charleston, SC, USA
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Omuta S, Maetani I, Shigoka H, Gon K, Saito M, Tokuhisa J, Naruki M. Newly designed J-shaped tip guidewire: A preliminary feasibility study in wire-guided cannulation. World J Gastroenterol 2013; 19:4531-4536. [PMID: 23901229 PMCID: PMC3725378 DOI: 10.3748/wjg.v19.i28.4531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/19/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To perform wire-guided cannulation using a newly designed J-shaped tip guidewire, and to verify feasibility and safety for use.
METHODS: The study was conducted on endoscopic retrograde cholangiopancreatography (ERCP) patients with naïve papilla undergoing diagnosis and treatment of biliary diseases between September 2011 and July 2012. We performed ERCP in a succession of 50 cases with a J-shaped tip guidewire. The first insertion attempt began with a trainee who had 5 min to complete cannulation, followed if necessary by the trainer for another 5 min. We assessed the primary success rate of selective biliary cannulation within 10 min and adverse events such as post-ERCP pancreatitis (PEP), bleeding or perforation.
RESULTS: The primary success rate was 90% (45/50) within 10 min, the initial success rate within 5 min by trainee staff was 76% (38/50). The rate of PEP was 6% (3/50), but all 3 cases were mild pancreatitis. All patients were managed successfully with conservative treatment. There was no bleeding or perforation.
CONCLUSION: A newly designed J-shaped tip guide-wire has the possibility to facilitate selective biliary cannulation for ERCP and appears to be safe.
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Abstract
Endoscopic retrograde cholangiopancreatography allows intervention for a variety of diseases of the biliary tract. Cannulation of the bile duct is the prerequisite step for biliary intervention. Although obtaining biliary access is straightforward in many cases, it can occasionally be challenging. Multiple devices, all with additional wire-guided techniques, have been developed to aid cannulation. More advanced techniques have also been developed to aid biliary access if it is unsuccessful with standard devices. Multimodality techniques can be used if other approaches fail. This article provides an evidence-based discussion of these approaches, and provides insight into their appropriate application.
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Affiliation(s)
- Yan G Bakman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
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Leung C, De Cruz P, Jones A, Sliwka G, Bell SJ, Hebbard GS. Gastroenterology training in Australia: how much is enough? Intern Med J 2012; 43:381-5. [PMID: 22372490 DOI: 10.1111/j.1445-5994.2012.02757.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 02/13/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Advanced training in gastroenterology currently consists of 2 years of core training and 1 elective (non-core) year. We surveyed gastroenterologists 2-7 years following completion of training to determine the strengths and weaknesses of their training. METHODS All gastroenterologists were invited to participate in an anonymous online survey. RESULTS There was a 46% response rate (49/110). Eighty-one per cent were male with most aged 36-45. Respondents felt that the current training programme prepared them well for public practice and endoscopy but less well for private practice, ambulatory care, surgical aspects of gastroenterology and functional gastrointestinal disorders. Most had faced challenges transitioning to consultant practice. The majority (53%) spent more than the standard 3 years to complete training in gastroenterology. The top three subspecialty Fellowships were in endoscopy (45%), inflammatory bowel disease (29%) and hepatology (23%). In their elective year, 42% undertook a predominantly clinical year (registrar-type position in general or subspecialty gastroenterology), 28% engaged in research while 24% trained in another specialty. Seventy-eight per cent were in full-time work, and 36% were supervising trainees. Ninety-eight per cent felt that it was beneficial for trainees to move between hospitals during the core years of their advanced training. CONCLUSIONS The current Australian gastroenterology training programme is generally adequate in preparing trainees for consultant practice but could be improved by increased emphasis on areas such as private practice, ambulatory gastroenterology and functional gastrointestinal diseases. Exposure to a variety of experiences by training in several different hospitals during core training was universally viewed as being important.
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Affiliation(s)
- C Leung
- The Royal Australasian College of Physicians, Sydney, New South Wales, Australia.
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Cotton PB. Are low-volume ERCPists a problem in the United States? A plea to examine and improve ERCP practice-NOW. Gastrointest Endosc 2011; 74:161-6. [PMID: 21704815 DOI: 10.1016/j.gie.2011.03.1233] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 03/20/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Peter B Cotton
- Medical University of South Carolina, Charleston, SC, USA
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Training methods for endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Gastroenterology (GI) fellowship training slots are not expected to increase over the next 10 years despite a 9% estimated US population growth. There is also no expected increase in the number of hours worked per gastroenterologist; instead, this number will probably decrease slightly, as GI will have continued growth in the percentage of women and of men in dual career families. The current trend of "sub-specialization" within GI is likely to continue, although this will not be formally recognized by further extension of the length of training or by additional board requirements. Current sub-specialties include hepatology, inflammatory bowel disease, motility, small bowel imaging, and interventional endoscopy. Most "sub-specialty" GI training will be incorporated within the 3-year fellowship, with the probable exception of interventional endoscopy, which will likely take an additional training year. End points for training and criteria for credentialing in the future will focus more on quality measures in both procedural and cognitive aspects of GI. Hopefully, this move to "competency evaluation with quality measures" will eliminate undertrained endoscopists such as the non-gastroenterologist performing occasional colonoscopy or the gastroenterologist performing occasional ERCP. Post-graduate GI training is also undergoing transformation, partly due to a decrease in industry support of graduate medical education, which has previously been heavily relied upon. The expected wider use of web-based training by the technology-comfortable younger generation of physicians may partly fill this gap. Despite the challenges facing GI training at both the fellowship and post-graduate level, GI is expected to remain a popular specialty choice. It is likely that sub-specialization within GI will continue to grow in both academic and private practices due in part to an increasing focus on quality patient outcomes.
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Isaacs P. Endoscopic retrograde cholangiopancreatography training in the United Kingdom: A critical review. World J Gastrointest Endosc 2011; 3:30-3. [PMID: 21403814 PMCID: PMC3055941 DOI: 10.4253/wjge.v3.i2.30] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Revised: 12/31/2010] [Accepted: 01/07/2011] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography training used to be in virtually all district general hospitals, resulting in a large number of trainees with an inadequate case load and achieving poor levels of skill. Training is now restricted to a small number of trainees working in approved units. Continuous audit of outcomes and the appointment of a training lead in the unit are essential. Use of the global rating scale helps clinicians advise hospital administration on the priorities for a quality training program.
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Affiliation(s)
- Peter Isaacs
- Peter Isaacs, Gastroenterology Unit, Victoria Hospital, Blackpool, FY38NR, United Kingdom
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Lim BS, Leung JW, Lee J, Yen D, Beckett L, Tancredi D, Leung FW. Effect of ERCP mechanical simulator (EMS) practice on trainees' ERCP performance in the early learning period: US multicenter randomized controlled trial. Am J Gastroenterol 2011; 106:300-6. [PMID: 20978485 DOI: 10.1038/ajg.2010.411] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The impact of endoscopic retrograde cholangiopancreatography (ERCP) mechanical simulator (EMS) practice on trainee clinical performance is unknown. The hypothesis that trainees with EMS practice (study group (SG)) have improved clinical outcomes compared with those without such practice (control group (CG)) is tested. METHODS This was a randomized controlled trial involving six US academic centers. Sixteen trainees were randomized after ERCP didactic teaching. SG (n=8) participated in two sessions of EMS practice on selective cannulation; CG (n=8) did not undergo EMS practice. All participants' clinical performances were monitored in the subsequent 16 weeks. Intervention effects were assessed in multivariable regression models using generalizing estimating equations (GEE) to account for cluster randomization of trainees. The primary outcome was successful biliary cannulation, and secondary outcomes were cannulation time and competency score. RESULTS Cannulation success rate was 47.1% for CG and 69.6% for SG. SG had higher odds of successful cannulation (adjusted odds ratio=3.01, P=0.021). SG trainees achieved faster cannulation time (min) (4.7±4.2 vs. 10.3±14.1, P<0.001). Trainee competency scores given by supervising physicians were comparable confirming adequate blinding of the trainers. Limitations included short observation period, small number of ERCPs performed by individual trainees, and variation in the number of ERCPs between trainees. CONCLUSIONS In a prospective multicenter randomized controlled trial during early training, a significantly higher proportion of the biliary cannulations performed by trainees with EMS practice were successful and with faster cannulation time compared with those performed by trainees without such practice. The results provide objective evidence to support the continued evaluation of EMS practice to augment clinical training.
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Affiliation(s)
- Brian S Lim
- Department of Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, California 92505, USA
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Spier BJ, Durkin ET, Walker AJ, Foley E, Gaumnitz EA, Pfau PR. Surgical resident's training in colonoscopy: numbers, competency, and perceptions. Surg Endosc 2010; 24:2556-61. [PMID: 20339876 DOI: 10.1007/s00464-010-1002-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 01/29/2010] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is currently great discrepancy in the training requirements between medical societies regarding the recommended threshold number of colonoscopies needed to assess for technical competence. Our goal was to determine the number of colonoscopies performed by surgical residents, rate of cecal intubation, as well as trainee perceptions of colonoscopy training after completion of their training period. METHODS This study consisted of a 12-item electronic survey completed by 21 surgical residents after their 2-month endoscopy rotation at a tertiary care, urban referral center. This survey assessed numbers of colonoscopies performed, number successful to the cecum, and perceptions of training in colonoscopy. The cecal intubation rate was used as a surrogate marker of technical competence. RESULTS Twenty-one surgical residents performed a mean of 80 ± 35 total colonoscopies during the 2-month rotation. The average cecal intubation rate was 47% (range 9-78%). Resident comfort level for independently performing a total colonoscopy was scored a mean 3.6 on scale of 1-5 (5 = most comfortable), and 43% of the surgical residents planned on performing colonoscopy after residency training. CONCLUSIONS Surgical residents can obtain the recommended threshold for colonoscopy (N = 50) during a standard 2-month rotation. However, no resident was able to achieve technical competence in colonoscopy as defined by a 90% cecal intubation rate. These data suggest that the method of training of general surgery residents in colonoscopy may need reappraisal.
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Affiliation(s)
- Bret J Spier
- Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Medical School, H6/516 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792-5124, USA.
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A comparison of early learning curves for complex bimanual coordination with open, laparoscopic, and flexible endoscopic instrumentation. Surg Endosc 2010; 24:2145-55. [DOI: 10.1007/s00464-010-0913-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 10/07/2009] [Indexed: 10/19/2022]
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Bittner JG, Mellinger JD, Imam T, Schade RR, Macfadyen BV. Face and construct validity of a computer-based virtual reality simulator for ERCP. Gastrointest Endosc 2010; 71:357-64. [PMID: 19922914 DOI: 10.1016/j.gie.2009.08.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 08/28/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Currently, little evidence supports computer-based simulation for ERCP training. OBJECTIVE To determine face and construct validity of a computer-based simulator for ERCP and assess its perceived utility as a training tool. DESIGN Novice and expert endoscopists completed 2 simulated ERCP cases by using the GI Mentor II. SETTING Virtual Education and Surgical Simulation Laboratory, Medical College of Georgia. MAIN OUTCOME MEASUREMENTS Outcomes included times to complete the procedure, reach the papilla, and use fluoroscopy; attempts to cannulate the papilla, pancreatic duct, and common bile duct; and number of contrast injections and complications. Subjects assessed simulator graphics, procedural accuracy, difficulty, haptics, overall realism, and training potential. RESULTS Only when performance data from cases A and B were combined did the GI Mentor II differentiate novices and experts based on times to complete the procedure, reach the papilla, and use fluoroscopy. Across skill levels, overall opinions were similar regarding graphics (moderately realistic), accuracy (similar to clinical ERCP), difficulty (similar to clinical ERCP), overall realism (moderately realistic), and haptics. Most participants (92%) claimed that the simulator has definite training potential or should be required for training. LIMITATIONS Small sample size, single institution. CONCLUSIONS The GI Mentor II demonstrated construct validity for ERCP based on select metrics. Most subjects thought that the simulated graphics, procedural accuracy, and overall realism exhibit face validity. Subjects deemed it a useful training tool. Study repetition involving more participants and cases may help confirm results and establish the simulator's ability to differentiate skill levels based on ERCP-specific metrics.
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Affiliation(s)
- James G Bittner
- Department of Surgery, Medical College of Georgia School of Medicine, Augusta, Georgia, USA.
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Yoon KW, Park CH, Park SY, Cho SB, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS. Guidewire cannulation increases the success rate of needle-knife fistulotomy for difficult bile duct access. J Gastroenterol Hepatol 2010; 25:14-8. [PMID: 19780878 DOI: 10.1111/j.1440-1746.2009.05947.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Selective bile duct cannulation is a prerequisite for performing therapeutic endoscopic biliary intervention. This study aimed to evaluate if using a soft-tipped guidewire to cannulate the bile duct would increase the success rate of needle-knife fistulotomy for difficult bile duct access. METHODS We reviewed sixty 60 patients with difficult bile duct access who underwent conventional cannulation with radiocontrast dye (29) or guidewire cannulation (31) after needle-knife fistulotomy. RESULTS There were no significant differences in the demographic data between the two groups. The initial success rate of selective bile duct cannulation was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 79.3%, P = 0.009. The success rate of selective biliary cannulation in the patients with non-dilated common bile duct (< 8 mm) was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 68.4%, P = 0.003. The incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis was not significantly different between the two groups. No serious complications occurred in either group. CONCLUSIONS In this retrospective and small case series, guidewire cannulation after needle-knife fistulotomy increased the success rate of selective bile duct cannulation in patients with difficult bile duct access.
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Affiliation(s)
- Kyoung W Yoon
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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38
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von Delius S, Thies P, Meining A, Wagenpfeil S, Burian M, Huber W, Weidenbach H, Ebert MP, Neu B, Ludwig L, Almeida J, Prinz C, Schmid RM, Frimberger E. Validation of the X-Vision ERCP Training System and technical challenges during early training of sphincterotomy. Clin Gastroenterol Hepatol 2009; 7:389-96. [PMID: 19049832 DOI: 10.1016/j.cgh.2008.11.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2008] [Revised: 10/28/2008] [Accepted: 11/02/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A new fluoroscopy-free training system for endoscopic retrograde cholangiopancreatography (ERCP) with different model subtypes recently was developed. This study aimed to establish construct validity by investigating whether the X-Vision ERCP Training System could distinguish experienced endoscopists from beginners and to reveal characteristic mistakes during sphincterotomy. METHODS Six staff gastroenterologists that practice ERCP, 10 trainees that perform esophagogastroduodenoscopy and colonoscopy, and 12 residents without endoscopic experience each sequentially attempted 4 different models, simulating selective cannulation of the pancreatic or bile duct, intubation of differently arranged rubber papillas, stent placement, and sphincterotomy of a biopapilla. Performance parameters were recorded and participants' expectations were compared before and after training to determine whether the simulator was a credible tool for ERCP training. Staff gastroenterologists graded the realism and utility of the simulation. The quality of sphincterotomy was assessed by an expert endoscopist. RESULTS Participants with ERCP experience had significantly shorter procedure times compared with those with intermediate (P < .001) or no endoscopic experience (P < .001). Total and single credibility scores significantly increased after simulator practice. The faculty found the X-Vision ERCP Training System to be realistic and useful for training. In the less-experienced groups, common mistakes made during sphincterotomy included inadequate positioning of the duodenoscope, traumatic intubation of the papilla, and continued cutting despite insufficient endoscopic view. CONCLUSIONS The X-Vision ERCP Training System distinguished subjects with different levels of experience and was regarded as realistic and useful for ERCP training. Common mistakes during sphincterotomy could be assessed objectively.
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Affiliation(s)
- Stefan von Delius
- 2nd Medical Department, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
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Is a fourth year of training necessary to become competent in EUS and ERCP? Notes from the 2008 class of advanced endoscopy fellows. Gastrointest Endosc 2008; 68:1150-2. [PMID: 19028222 DOI: 10.1016/j.gie.2008.09.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 09/13/2008] [Indexed: 12/24/2022]
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Costamagna G, Familiari P, Marchese M, Tringali A. Endoscopic biliopancreatic investigations and therapy. Best Pract Res Clin Gastroenterol 2008; 22:865-81. [PMID: 18790436 DOI: 10.1016/j.bpg.2008.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The management of most biliopancreatic diseases benefits from endoscopic treatment. Forty years after the first endoscopic cannulation of the ampulla of Vater, the overall effectiveness and safety of endoscopic retrograde cholangiopancreatography (ERCP) can be evaluated using the quality assurance programs that have recently been developed for gastrointestinal endoscopy, including ERCP. Such evaluation does not mean simply reporting therapeutic success and complication rates; rather, it involves a complex analysis of the entire gastrointestinal unit, of the medical practises, and of patient satisfaction. The overall quality of ERCP has been analysed and many quality deficits identified, even in referral centres. Training for such a specialised procedure is difficult and expensive. Competence in ERCP requires as many as 200 ERCP procedures. Quality assurance programs can help to improve the overall quality of endoscopic practise, including training of young endoscopists.
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Affiliation(s)
- Guido Costamagna
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, A. Gemelli University Hospital, 8 Largo Gemelli, Rome, RM 00168, Italy.
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41
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Cohen DL, Naik JR, Tamariz LJ, Madanick RD. The perception of gastroenterology fellows towards the relationship between hand size and endoscopic training. Dig Dis Sci 2008; 53:1902-9. [PMID: 17990110 DOI: 10.1007/s10620-007-0069-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 10/14/2007] [Indexed: 12/09/2022]
Abstract
Some endoscopic trainees find it difficult to manipulate an endoscope's controls, possibly due to small hand size. To assess this, a survey was mailed to all gastroenterology fellows in the US. Two hundred twenty-seven of 1,295 (17.5%) fellows responded. Median surgical glove size was 7.5. Ninety-three respondents (41.0%) considered their hand too small for a standard endoscope's handle; 176 (78.2%) felt that hand size affects the ability to learn endoscopy. Seventy-seven (34.2%) would use smaller handled endoscopes if available. Of the 38 respondents with glove sizes < or =6.5, 37 (97.4%) were female. These respondents were more likely to consider their hand too small (P < 0.001), want to use smaller handled endoscopes (P < 0.001), and feel that training programs should offer them (P = 0.009). These results suggest that a significant number of trainees, especially women, perceive that their hands are too small for standard endoscopes and believe that hand size plays a role in learning and performing endoscopy.
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Affiliation(s)
- Daniel L Cohen
- Department of Medicine, Jackson Memorial Medical Center, Miami, FL, USA
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42
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Fukatsu H, Kawamoto H, Harada R, Tsutsumi K, Fujii M, Kato H, Hirao K, Nakanishi T, Mizuno O, Ogawa T, Ishida E, Okada H, Sakaguchi K. Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy. Surg Endosc 2008; 23:2066-72. [PMID: 18528622 DOI: 10.1007/s00464-008-9969-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2007] [Revised: 04/22/2008] [Accepted: 05/01/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although needle-knife precut papillotomy (NKPP) is considered a useful alternative for achieving selective biliary cannulation, controversy remains regarding the technical proficiency needed to perform the procedure and its safety. This study evaluated whether procedural experience with NKPP predicted either successful cannulation or the development of complications. METHODS This study retrospectively investigated 104 patients, out of 589 consecutive patients with native papillary, who underwent NKPP performed by a single endoscopist between October 2002 and July 2006. To demonstrate changes in NKPP, the 104 patients were divided chronologically into two groups according to periods: period A (October 2002 to September 2004) and period B (October 2004 to July 2006). RESULTS Of the 104 consecutive patients who underwent NKPP, 41 (41/267, 15%) were treated in period A and 63 (63/322, 20%) in period B. There was no significant difference in the overall success rate between periods A (90%) and B (98%) (p = 0.08). However, the initial success rate was higher in period B (95%) than in period A (80%) (p < 0.05). The complication rates were not significantly different between the two groups (10% vs 16%; p = 0.56). Although all complications involved pancreatitis, severe pancreatitis was not observed. CONCLUSION Whereas the initial success rate for NKPP can increase with procedural experience, the complication rate does not seem to decrease. Furthermore, the need for NKPP does not appear to decrease with increasing endoscopic retrograde cholangiopancreatography (ERCP) experience.
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Affiliation(s)
- Hirotoshi Fukatsu
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
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Abstract
The foundation of skills for the performance of natural orifice translumenal endoscopic surgery (NOTES) lies in the training for general surgery (especially laparoscopy) and flexible gastrointestinal endoscopy. Physicians wishing to practice NOTES need to acquire or have both skill sets, or need to partner together to blend complementary capabilities with colleagues. In the future, however, a new cadre of NOTES specialists may emerge who will have developed individual expertise in the full spectrum of NOTES knowledge base requirements. This article highlights a body of knowledge and skills needed to become a NOTES proceduralist and review the current training paradigms for gastrointestinal endoscopists and surgeons.
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Affiliation(s)
- L Campbell Levy
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
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44
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Lo SK. Intramural incision during ERCP: turning a complication into a positive experience? Gastrointest Endosc 2008; 67:634-5. [PMID: 18279863 DOI: 10.1016/j.gie.2007.08.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 08/27/2007] [Indexed: 02/08/2023]
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Tamada K, Wada S, Nakazawa K, Hatanaka H, Tomiyama T, Ohashi A, Sugano K, Ido K. TEACHING DEEP CANNULATION OF THE BILE DUCT DURING ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.2007.00754.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Leung JW, Lee JG, Rojany M, Wilson R, Leung FW. Development of a novel ERCP mechanical simulator. Gastrointest Endosc 2007; 65:1056-62. [PMID: 17531642 DOI: 10.1016/j.gie.2006.11.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Accepted: 11/05/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is a paucity of objective methods for evaluating trainee performance and comparing ERCP accessories. OBJECTIVE Use of a mechanical ERCP simulator to evaluate trainee performance and to compare ERCP accessories via procedure time. DESIGN Pilot study using a mechanical simulator. SETTING Hands-on ERCP practice workshops. SUBJECTS Endoscopists at various levels of ERCP experience. METHOD Validation studies are described to show that the simulator permits participants with varying ERCP experience to demonstrate their skill levels and offers novel training applications in ERCP courses. The time required for completing a simulated stent placement procedure, simulated fluoroscopy time, and participant expectations were recorded in different settings. Participants' expectations were compared before and after training to determine whether the simulator was a credible adjunct to ERCP training. RESULTS Significantly shorter procedure times were recorded for the same accessories used by participants with more ERCP experience than those with less experience and for the same group of participants when using accessories with 1 design compared with another. The mean total credibility score showed a significant increase after simulator practice. LIMITATIONS In vitro practice by using a mechanical simulator; results may not translate directly to the clinical setting. How the objective procedure times measured during practice can complement assessment of trainee competence or define usefulness of different accessories is unknown but deserves to be explored in future studies. CONCLUSIONS The procedure times can categorize participants according to their ERCP experience and separate accessories according to their ease of use. An increase in credibility score validates participants' endorsement of such practice as a credible adjunct to ERCP training.
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Affiliation(s)
- Joseph W Leung
- Section of Gastroenterology, Sacramento Veterans Affairs Medical Center, Veterans Affairs Northern California Healthcare System, Mather 95655, and Division of Gastroenterology, Davis Medical Center, University of California, Sacramento, USA
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García-Cano J. 200 supervised procedures: the minimum threshold number for competency in performing endoscopic retrograde cholangiopancreatography. Surg Endosc 2007; 21:1254-5. [PMID: 17484011 DOI: 10.1007/s00464-006-9013-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2006] [Accepted: 06/02/2006] [Indexed: 01/13/2023]
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Verma D, Gostout CJ, Petersen BT, Levy MJ, Baron TH, Adler DG. 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; 65:394-400. [PMID: 17321237 DOI: 10.1016/j.gie.2006.03.933] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2005] [Accepted: 03/31/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND Deep cannulation of the common bile duct (CBD) in patients with native papillary anatomy can be used as a marker of competence at ERCP. OBJECTIVE The primary aim of this study was to analyze a single-operator learning curve for supervised ERCPs in patients with native papillary anatomy and to assess the development of endoscopic competence, defined as the ability to deeply cannulate the CBD in the setting > or =80% of the time. Posttraining outcomes were evaluated as proof of training. DESIGN A retrospective review: 1097 ERCP procedures were analyzed, 697 were performed during ERCP training (July 2002-July 2003), 400 were performed after training as an independent operator, 499 and 303 procedures for training and posttraining periods, respectively, were performed with the intent of deep cannulation of CBD in patients with native papillary anatomy. Procedures were chronologically grouped into subsets. Success rates were plotted against time. SETTING Single center. MAIN OUTCOME MEASUREMENTS Rate of successful deep biliary cannulation. RESULTS The successful cannulation rate increased from 43% at the beginning of training to > or =80% after 350 to 400 supervised procedures. The success rate continued to improve posttraining with an aggregated success rate of >96% for the next 300 procedures performed as an independent operator. LIMITATIONS Single operator. CONCLUSIONS Achievement of a satisfactory success rate for deep biliary cannulation in patients with native papillary anatomy should be tracked by ERCP trainers and trainees. The consistent achievement of > or =80% success at deep biliary cannulation in such patients should become a standard for ERCP training programs to produce skilled and competent therapeutic biliary endoscopists.
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Affiliation(s)
- Dharmendra Verma
- Division of Gastroenterology, Department of Internal Medicine, University of Texas-Houston Medical School, 6431 Fannin, Houston, TX 77030, USA
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Abstract
BACKGROUND No published Papillotomy Performance Scoring Scale exists. AIMS To develop such a scale and to apply it to stratify the quality of performance of recorded papillotomies. METHODS Expert biliary endoscopists were polled regarding their opinion of a 'perfect' biliary papillotomy and experience with complications in relation to the cut axis. Based on these responses a scoring scale encompassing two components - wire alignment and cut orientation, was proposed. This scoring scale was presented to experienced and trainee endoscopists, who scored recording of five biliary papillotomies. The mean final combined score was used for stratification. RESULTS The experts' opinion of a 'perfect' biliary papillotomy is one cut along the axis of the distal bile duct and papilla. Their reported experience with complications occurring outside of the perfect axis validated their consensus. Application of the scoring scale stratified recorded papillotomies based on the mean final combined scores. CONCLUSIONS These pilot data support the hypothesis that a scoring scale focused on the cut axis can be constructed based on expert opinion, experience and consensus. The possibility of stratification of mean final combined scores that are significantly different validates application of the scoring scale for assessment of papillotomy performance.
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Affiliation(s)
- J W Leung
- Research and Medical Services, Sacramento Veterans Affairs Medical Center, Veterans Affairs Northern California Healthcare System, CA, USA.
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Tajiri H. HOW SHALL WE EFFECTIVELY TRAIN GASTROINTESTINAL FELLOWS IN THE NEAR FUTURE? Dig Endosc 2006. [DOI: 10.1111/j.1443-1661.2006.00648.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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