Quality in endoscopy training-the endoscopic retrograde cholangiopancreatography case

Who will excel in advanced endoscopy? A study assessing the criteria and perceptions of experts with regard to selection of ERCP and EUS trainees

Background and study aims  Training program directors (TPDs) and experts play a crucial role in selecting ERCP/EUS trainees and determining the workforce in endoscopy. Additionally, prospective trainees should know what TPDs/experts expect from them. Nonetheless, the criteria and perceptions used in this selection have not been clarified. The aim of this study was to identify TPD/expert values/beliefs regarding personal attributes needed for selecting trainees that can excel and those which may lead to disqualification; compare perspectives between TPDs/experts and trainees regarding the selection process and critical trainee characteristics; and investigate the general approach and satisfaction regarding current application process for ERCP/EUS training.

Methods  We conducted a web-based survey to collect general opinion and data regarding the application process and trainee selection and disqualification from training. European TPDs/experts and trainees were invited to participate.

Results  Thirty-six TPDs/experts and 25 trainees from 18 countries responded. The application process is mainly driven by individual request (86.1 %). Almost half of TPDs/experts felt only moderately (38.9 %) to slightly (8.3 %) satisfied with the current application process. TPDs/experts value a diversity of trainee characteristics, but mainly traits such as “honesty,” “being a team player,” and “self-awareness” (72.2 % each). Technical skills ranked seventh as considered “extremely important.” “Disregard for patient welfare” and “lack of work ethic” were the most common reasons for disqualification. TPDs/experts and trainees agreed in most questions.

Conclusions  This survey outlines trainee selection criteria for ERCP/EUS training. Non-technical skills are the most valued by TPDs/experts. While knowledge and technical expertise are clearly important, understanding that professional attitudes are highly regarded may help direct the application process more effectively.

A prospective study on quality in endoscopic retrograde cholangiopancreatography (ERCP): trend in Italy from the REQUEST study

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure with a relatively high rate of adverse events. Data on training of operators and fulfillment of quality indicators in Italy are scarce. The goal of this study was to assess the overall quality of ERCP in Italy compared to international standards. Patients and methods  This was a prospective, observational study from different Italian centers performing ERCP. Operators answered a questionnaire, then recorded data on ERCPs over a 1-to 3-month period. Results  Nineteen Italian centers participated in the study. The most common concern of operators about training was the lack of structured programs. Seven/19 centers routinely used conscious sedation for ERCP. Forty-one experienced operators and 21 trainees performed 766 ERCPs: a successful deep biliary cannulation in native-papilla patients was achieved in 95.1 % of cases; the post-ERCP pancreatitis (PEP) rate was 5.4 % in native-papilla patients; cholangitis rate was 1.0 %; bleeding and perforation occurred in 2.7 % and 0.4 % of the patients, respectively. Conclusions  This study revealed that, overall, ERCP is performed in the participating Italian centers meeting good quality standards, but structured training and sedation practice are still subpar. The bleeding and perforation rate slightly exceeded the American Society of Gastrointestinal Endoscopy indicator targets but they are comparable to the reported rates from other international surveys.

Improving the Standard of Care for All-A Practical Guide to Developing a Center of Excellence

Pancreatic surgery is one of the more challenging procedures performed by surgeons. The operations are technically complex and have historically been accompanied by a substantial risk for mortality and postoperative complications. Other pancreatic pathologies require advanced therapeutic procedures that are highly endoscopist-dependent, requiring specific, knowledge-based training for optimal outcomes. An increase in diagnosed pancreatic pathologies every year reinforces a critical need for experienced surgeons, gastroenterologists/endoscopists, hospitals, and support personnel in the management of complex pancreatic cases and thus, well-designed Centers of Excellence (CoE). In this paper, we outline the framework for a Pancreas CoE across three developmental domains: (1) establishing the foundation; (2) formalizing the program; (3) solidifying the CoE status. This framework can likely be translated to any disease or procedure-specific service-line and facilitate the development of a successful CoE.

Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP

BACKGROUND AND AIMS

Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation.

METHODS

Patients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages.

RESULTS

A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P < .001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P < .0001), even though they were replaced by a senior endoscopist after 5 minutes.

CONCLUSIONS

The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.