Trainee involvement in ERCP: safe under close surveillance

In their study, Voiosu et al. compared endoscopic retrograde cholangiopancreatographies (ERCPs) involving trainees with those performed exclusively by attending endoscopists [1]. No difference was detected in terms of technical success or adverse event rates. From a patient perspective, this finding is at least reassuring, but we would like to comment on the following points.

Firstly, technical failure was defined as “prolonged hospital stay for the purpose of an endoscopic reintervention or a different therapeutic approach.” In the trainee-involvement group, 41.6 % of ERCPs were taken over by an expert – obviously an ethical feature – who provided hands-on assistance or completed the examination. Therefore, the (acceptable) rate of technical failure in both groups (7.6 % vs. 6.3 %) may reflect the failure rate of the attending endoscopists and not a lack of difference between the groups.

Secondly, moderately severe and severe events occurred more often in the attending endoscopist group (3.4 % vs. 6.2 %). This difference is mainly driven by the unequal case distribution in terms of procedure difficulty. The attending endoscopist group consisted of significantly more grade 2 – 3 examinations (17.7 % vs. 25.1 %). These complex cases may be associated with a higher complication risk [2]. Overcoming the existing selection bias, we welcome the authors’ intention to offer their patients the best available treatment option for such difficult cases. A post hoc analysis excluding grade 2 – 3 cases could elucidate any potential difference.

Finally, lack of randomization and consequent intergroup and intercenter differences (procedure difficulty, percentage of procedures with trainee involvement, technical success rates) preclude these results being easily generalized.

In other endoscopy fields, trainees may actually improve the performance of attending physicians [3], but ERCP training is extremely laborious. Training in therapeutic endoscopy, based on national and international curricula, should provide not only important technical skills, but also adequate cognitive and nonendoscopic technical skills, like decision-making, judgement, and team communication, thereby offering our patients the highest quality of health services [4] [5].

Publication History

Article published online:
25 March 2020

• References

• 1 Voiosu T, Boskoski I, Voiosu AM. et al. Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial. Endoscopy 2019; DOI: 10.1055/a-1049-0359.
• 2 Sahar N, La Selva D, Gluck M. et al. The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital. Surg Endosc 2019; 33: 448-453
• 3 Tziatzios G, Gkolfakis P, Triantafyllou K. Effect of fellow involvement on colonoscopy outcomes: A systematic review and meta-analysis. Dig Liver Dis 2019; 51: 1079-1085
• 4 Siau K, Dunckley P, Feeney M. et al. ERCP assessment tool: evidence of validity and competency development during training. Endoscopy 2019; 51: 1017-1026
• 5 Jorgensen J, Kubiliun N, Law JK. et al. Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum. Gastrointest Endosc 2016; 83: 279-289