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ERCP training and experience

2002; Elsevier BV; Volume: 56; Issue: 4 Linguagem: Inglês

10.1016/s0016-5107(02)70463-x

1097-6779

Jerome D. Waye, Philippus C. Bornman, N Chopita, Guido Costamagna, Arnaldo José Ganc, Tony Speer,

Radiology practices and education

This Perspectives article on ERCP Training is a compilation of the responses to a questionnaire sent to select members of the International Editorial Board who perform ERCP procedures. Most started their ERCP training in their own institutions but traveled to experts in various countries to further develop their skills. Dr. Bornman: Four endoscopes: Olympus Optical Co., Ltd. (Tokyo, Japan) TJF200, TJF240, and JF200. Dr. Chopita: Six instruments: Olympus TJF, JFV, and JF100. Dr. Costamagna: Eight duodenoscopes: TJF140, TJF100, JF130, and Pentax (Tokyo, Japan) ED3430. Dr. Ganc: Four endoscopes: TJF130, JFV100, JF1T20, and a “mother baby scope.” Dr. Speer: The larger teaching hospitals have 3 to 4 duodenoscopes each, with a mixture of old and new, Olympus and Pentax. My preference is the wide-channel Olympus TJF160R. Dr. Bornman: Six physicians in my referral area perform ERCPs. In my unit, 600 are performed annually with about two thirds of them being interventional. Dr. Chopita: Ten physicians perform ERCPs in my area. About 500 are performed per year in my unit. Dr. Costamagna: In Rome there are many hospitals and many physicians performing ERCPs per year. In my unit, 1200 cases are performed annually, and more than 90% of them are therapeutic. Dr. Ganc: In the São Paulo area there are 90 ERCP endoscopists. In my strictly private hospital, about 200 ERCP examinations are performed a year. Dr. Speer: In Australia, 176 endoscopists have registered as being trained for ERCP. I personally perform about 600 ERCPs a year, with more than 70% of them being therapeutic. Most of the respondents train between 1 and 3 persons annually in techniques of ERCP. Dr. Bornman: About 50. Dr. Chopita: About 150. Drs. Costamagna and Ganc: About 100. Dr. Speer: The Australian conjoint committee for recognition of training in GI endoscopy specifies that any trainee should complete a total of at least 200 ERCPs, with a minimum of 80 sphincterotomies, and the placement of either 60 stents or nasobiliary drains. Details of each case are submitted for review, including the indications, complications, degree of success, and the time taken for the examination. Dr. Bornman: MRCP is not available onsite. Dr. Chopita: Although MRCP is available, it has not made a change in our ERCP volume. Diagnostic ERCP is still performed, but less often than before. In general, MRCP has replaced diagnostic ERCP; it is especially used when there is doubt about the pathology in the biliary or pancreatic duct. Dr. Costamagna: In our practice, MRCP has mainly replaced diagnostic ERCP. Dynamic secretin-enhanced MRCP (S-MRCP) is also used when there is suspected pancreatic pathology. However, this policy has not affected the ERCP volume. MRCP is ordered mainly in the following cases: when there is (1) suspicion of pancreatic disease (S-MRCP); (2) suspicion of hilar stricture; or (3) low risk of stones before laparoscopic cholecystectomy. Dr. Ganc: MRCP has practically abolished diagnostic ERCP in our hospital, but some diagnostic ERCP is performed, especially after complications of biliopancreatic surgery including liver transplantation. Dr. Speer: MRCP is becoming widely available in Australia, and ERCP volume has decreased. MRCP is especially valuable in assessing hilar strictures and in those patients in whom there is a low index of suspicion to exclude pathology in the bile duct. Dr. Speer: Training in ERCP has evolved over the last 15 years. Initially competence was defined as the ability to achieve deep cannulation of both ducts and to safely perform a sphincterotomy. Now competence includes the ability to perform a number of therapeutic procedures of variable difficulty. These include stent placement of low biliary strictures, stent placement of hilar strictures, and pancreatic interventions. Stent placement in low strictures is a little more difficult than sphincterotomy, but hilar strictures and pancreatic intervention are an order of magnitude more difficult again. A well-trained practitioner of ERCP should be competent in these areas. Training in all these procedures can be divided into 3 broad overlapping areas: clinical decision making, imaging interpretation (particularly fluoroscopy), and technical skills. Considering hilar strictures for instance, the clinical decision-making skills include deciding whether the stricture is resectable, whether the risks of palliation outweigh the benefits, and determining which segment/segments should receive stent placement. Imaging skills include deciding which segment the guidewire has entered and how to best maneuver the guidewire into the desired segment. Placing the catheter deep into the bile duct and then maneuvering the guidewire and stent into the desired segment are technical skills. In my experience, most trainees achieve competence in the technical skills first, then they develop skills in interpreting imaging and finally achieve the most difficult skill of all, developing a mature clinical judgement that carefully considers all the information available and balances the risks and benefits for that patient. Dr. Waye: It is evident that ERCP is a heavily used procedure among these members of the International Editorial Board. The estimate of the number of ERCPs that need to be performed to achieve competency varies greatly, but Dr. Speer has thoughtfully addressed competency that goes beyond the ability to cannulate successfully or to place a stent. The highest level of expertise is achieved by experience in these decision-making areas in which nothing is black or white, and the right course must be decided on in the best interest of the patient.