ERCP: see one, do one, teach a few? Not everybody needs to learn everything!

“Life has no limitations, except the ones you make!” Les Brown, 17/02/1945

Endoscopic retrograde cholangiopancreatography (ERCP) is by far the best example of a complex invasive endoscopic procedure. The procedure is life-saving and prevents significant surgery; on the other hand, it also entails a significant risk. The recent evolution where ERCP goes hand in hand with interventional endoscopic ultrasound (EUS) for third-space endoscopy makes proper skills acquisition even more challenging. It is therefore not surprising that, during the last decade, quality assurance in ERCP and, following that, training in ERCP have received increasing interest.

The European Society of Gastrointestinal Endoscopy (ESGE) instigated the quality improvement committee (QIC) in 2013 to develop quality metrics in all fields of endoscopy, including ERCP [1].

In this issue of Endoscopy, Theunissen et al. report on a Dutch quality improvement project. Since 2016, Dutch endoscopists have been required to register their ERCP outcomes [2]. The authors have now analyzed data from that registry and mirrored them against the ESGE performance measures. A total of 5671 procedures performed by 57 endoscopists in 11 centers were analyzed. They showed that three key performance measures were met, namely successful biliary cannulation, appropriate stent placement for biliary obstruction, and bile duct stone extraction, and that the overall success rate was high.

The authors and Dutch society need to be complemented for their effort in striving to obtain high quality in these invasive procedures. Overall, we can conclude that, as a whole, the quality of ERCP is high, which is reassuring for patient safety, and that the centralization of interventional high risk procedures such as these seems to work.

What can we learn from this and is this the end point?

“With a canulation rate showing failure in 1 in every 5 patients, endoscopists should look in the mirror and wonder if it is not time to throw in the towel and stop performing ERCP, or to acquire additional training.”

First, in addition to the overall national performance, a detailed analysis at the level of individual services and endoscopists is still necessary. The system that has been created in the Netherlands should certainly facilitate this. Indeed, the overall quality in the Dutch centers is high, but one should certainly have a look at their Table  1 s (available in online-only Supplementary material), which identifies a truth sometimes perceived as inconvenient and most applicable to complex procedures, such as ERCP: not all endoscopists are the same and quantity matters. The rates of overall procedural success and successful canulation of a virgin papilla were below the 90 % target for ERCP endoscopists performing less than 50 procedures per year. In particular, for those performing less than 25 procedures per year, the rate of appropriate stent placement after successful canulation was below 90 %. With regard to the lower canulation rate, one could argue that less experienced endoscopists wisely decide on a maximum number of cannulation attempts before referring the patient to a more experienced colleague. Unfortunately, we cannot deduce this from the registry data. Nonetheless, for the patient, it means that one has a higher likelihood of requiring a second attempt by a more experienced endoscopist. With a canulation rate showing failure in 1 in every 5 patients, endoscopists should look in the mirror and wonder if it is not time to throw the towel into the ring and abandon these procedures, or to acquire additional training.

Besides the risk of a second attempt that could have been avoided, a failed cannulation with (too) many attempts may entail an increased risk of pancreatitis. Unfortunately, this is not assessed in the database, although it may, from a patient, safety, and quality perspective, be one of the most important performance measures. It would therefore have been interesting to see in this registry whether the post-ERCP pancreatitis rate is also related to the case volume in daily practice.

The ESGE performance measures are not static or written in stone [3]. The QIC initiative was pioneering in developing metrics that allow for quality assessment in different fields of endoscopy; however, for many of the proposed performance measures, little evidence was available at the time of their development [1]. In particular, high quality reports of “real-life” data, such as the one from the Dutch registry, were often lacking. In their ambition, the respective working groups were maybe sometimes overenthusiastic in setting the targets. The Dutch registry for instance clearly shows that the target standard of a 95 % cannulation rate for virgin papillas in expert centers may be too high and not realistic [2]. Obviously, everything depends on how one defines a virgin papilla: if a patient is referred to an expert center because of difficult cannulation without sphincterotomy but after several probing attempts, it obviously constitutes a bias if a conscientious expert reports this as a virgin papilla. Therefore, the value of reports of high quality data collection, like this from Theunissen et al., is golden for the refinement of performance measures in the future. Indeed, the ESGE QIC is currently collecting all new evidence to check and revise the performance measures within the next 5 years [3].

With the matter of experience comes the paradox for training. With the centralization of care to high volume performers, the availability of training positions decreases. However, as also indicated in this report, new endoscopists will enter this field and this is of course necessary. The learning curve is however longer and comprises more complex procedures than simple stone extraction. Recently EGSE proposed an ERCP and EUS training curriculum [4]. Ideally, modern ERCP training should be combined with training in diagnostic and, eventually, interventional EUS. In addition, training should be gradual, with the introduction of more challenging cases once the basic ERCP skills have been mastered.

Because ERCP training positions are sparse and precious, it may be that simulator training could potentially be helpful in identifying suitable candidates for training without compromising patient safety, especially because the learning curve is highly dependent on the individual and given the fact that the ESGE recommends trainees will need at least 300 ERCPs to master the basics. A recent systematic review showed that trainees obtain a 76.5 % cannulation rate after 180 procedures and 81.8 % after 200 procedures [5]. This indicates that ERCP training cannot be obtained on the side, concurrently with another busy GI practice. It should instead be a focused and dedicated training program that should extend over at least a 1-year period. In addition, the ERCP curriculum indicates that “The attainment of competence in ERCP and EUS is not a single event, but a career-long process” and that “once competent, endoscopists should be supported to continue a period of mentored practice with an experienced colleague”. So, it is high time to spread the Dutch example of organizing centralized quality control [3].

With that in mind, the citation of the motivational speaker Les Brown should be interpreted inversely when it comes to ERCP practice. One should know one’s own technical limits before engaging in dedicated ERCP training and continue to monitor one’s ERCP performance to identify the need to accept limitations to one’s medical practice.

Publication History

Article published online:
28 October 2021

• References

• 1 Domagk D, Oppong KW, Aabakken L. et al. Performance measures for ERCP and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50: 1116-1127
• 2 Theunissen F, van der Wiel S, ter Borg PC. et al. Implementation of mandatory ERCP registration in The Netherlands and compliance with the ESGE performance measures: a multicenter endoscopy database study. Endoscopy 2022; 54: 262-267
• 3 Bisschops R, Rutter MD, Areia M. et al. Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement. Endoscopy 2021; 53: 196-202
• 4 Johnson G, Webster G, Boskoski I. et al. Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2021; DOI: 10.1055/a-1537-8999.
• 5 Fu W, Leung J, Wang Y. et al. What would be the appropriate number of clinical ERCP cases for trainees to acquire basic competence? A systematic review and meta-analysis. Turkish J Gastroenterol 2021; 32: 1-10