Trainee caseload correlates with ERCP success rates but not with procedure-related complications: results from a prospective study (the QUASIE cohort)

Endoscopic retrograde cholangiopancreatography training and education

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used to diagnose and treat biliary and pancreatic diseases. It is one of the most technically demanding endoscopic procedures. ERCP training programs must ensure trainees have adequate knowledge of the anatomy and physiology associated with biliopancreatic diseases. The variety of ERCP procedures included in training programs should provide sufficient basic training for novice trainees and advanced training for experienced endoscopists. The main endoscopic procedures should be trained in ascending order of difficulty. Incorporating models capable of simulating various clinical and anatomical conditions could provide an effective means of fulfilling training requirements, although they are not easily available due to expensive facilities and void of standard assessment. Competency assessment is crucial in ERCP training to ensure trainees can independently and safely perform ERCP. Because of the rapid advancement of diagnostic and therapeutic methods, postgraduate training is critical for ERCP practitioners. Once certificates are attained, practitioners are solely responsible for maintaining their competency, credentialing, and quality.

Endoscopic Retrograde Cholangiopancreatography Performed by Trainees Is Not Associated with Increased Immediate Adverse Events or Technical Failure Rates

BACKGROUND/AIM

Training endoscopists to perform endoscopic retrograde cholangiopancreatography (ERCP) is critical to address the increasing patient population with pancreatobiliary diseases. Concerns remain about ERCP safety and success involving trainees. We compared the technical success and immediate adverse events between ERCP with and without trainee involvement.

METHODS

Retrospective analysis of 28,271 ERCP procedures in a national sample of the United States over 12 years. Demographics, procedure and fluoroscopy time, visualization and cannulation of main structures, adverse events, and technical success rates were compared between ERCP with and without trainees. Categorical variables were compared using Pearson's chi-square test and continuous variables using a standard t-test. Univariate and multivariate regressions were performed adjusting for age, gender, ethnicity, US region, ASA class and clinical setting.

RESULTS

Approximately 49.5% of ERCPs had a trainee involved. The ampulla was visualized in 97.4% with trainee vs. 97.3% without trainee involvement (P = 0.858). The common bile duct was visualized and cannulated in 90.4% with trainees vs. 91.7% without trainees involved (P < 0.001). The ERCP was incomplete in 5.9% of cases with trainees vs. 6.4% without trainees involved (P = 0.207). Trainee participation added 8.7 min to average procedure time (aOR: 1.02, P < 0.001) and 2.0 min to fluoroscopy time (aOR: 1.00, P = 0.796). Adverse events (aOR: 0.89, P = 0.704) and technical success (aOR: 0.83, P = 0.571) were similar in both groups.

CONCLUSIONS

Trainee involvement leads to increased procedure duration but is not associated with increased immediate adverse events, or technical failure. Our study supports ERCP safety and success with trainee participation.

Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: Real life experience from a referral center

BACKGROUND

During ERCP for biliary indication, when a difficult bile duct (BD) cannulation occurs, with unintended access to the main pancreatic duct (PD), both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed. We aimed to compare the technical success and adverse events (AEs) rate of these techniques.

METHODS

A retrospective analysis of patients with naïve papillae referred to the Pancreas Institute of Verona from January 2016 and July 2021 to undergo ERCP for biliary indications was performed.

RESULTS

Overall, 202 patients (53.5% males, mean age 67.2 years) were evaluated (96 DGW, 106 TPBS). Malignant biliary stricture was the most common ERCP indication (78.2%). The rate of success in deep biliary cannulation was significantly higher in the DGW group (94.8%) compared to TPBS (79.2%) at the first attempt (p = 0.001). This result was also confirmed in the subgroup of patients with malignant distal stricture (72/77, 93.5% vs 63/80, 78.8%, p = 0.01). No significant difference in AEs rate, particularly in PEP incidence was found between the two groups.

CONCLUSIONS

DGW demonstrated a higher success rate and similar safety profile compared with TPBS in difficult biliary cannulation. Based on this retrospective study, DGW should be preferred over TPBS in case of unintended PD cannulation. Further prospective studies are needed to confirm our results.

Is Cholecystectomy a cause of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography?

BACKGROUND AND STUDY AIM

In European Society of Gastrointestinal Endoscopy guidelines, biliary cannulation of naive papillae is defined as difficult in the presence of more than 5 papilla contacts, more than 5min cannulation time or more than one unintended pancreatic duct cannulation or opacification. It is not known whether cholecystectomy is a cause of difficult biliary cannulation. This study aimed to investigate whether cholecystectomy (CCY) is a cause of difficult biliary cannulation in patients who have undergone Endoscopic Retrograde Cholangiopancreatography (ERCP) for choledocholithiasis.

PATIENTS AND METHODS

Adult patients with naive papillae and those who underwent ERCP for common bile duct stones and/or sludge were included in this retrospective study. Patient demographics, clinical presentation (acute cholangitis, biliary pancreatitis or biliary colic), periprocedural data including laboratory and radiological findings and ERCP results were compared between no-CCY and post-CCY groups.

RESULTS

438 patients were included in the present study and 347 of these patients were in the no-CCY group and 91 patients were in post-CCY group. A statistically significant difference was found in the number of patients with difficult cannulation in the post-CCY group (n=30, 33.0%) patients compared to the no- CCY group (n=67, 19.3%) (p=0.011). According the multivariate analyses results, presence of history of cholecystectomy was found an independent risk factor of difficult cannulation (Odds ratio: 2.014; 95 % Cl 1.205-3.366; p=0.008).

CONCLUSIONS

The results showed that biliary cannulation was significantly more difficult in patients with cholecystectomy who underwent ERCP for common bile duct stones.

Training in endoscopic retrograde cholangio-pancreatography: a critical assessment of the broad scenario of training programs and models

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.

Biliary Cannulation in Endoscopic Retrograde Cholangiography: How to Tackle the Difficult Papilla

BACKGROUND

In the setting of a naïve papilla, biliary cannulation is a key step in successfully performing endoscopic retrograde cholangiography. Difficult biliary cannulation (DBC) is associated with an increased risk of post-ERCP pancreatitis and failure of the whole procedure.

SUMMARY

Recommendations for biliary cannulation can be divided into (a) measures to reduce the likelihood of a difficult papilla situation a priori and (b) rescue techniques in case the endoscopist is actually facing DBC. (a) Careful inspection of the papillary anatomy and optimizing its accessibility by scope positioning is fundamental. A sphincterotome in combination with a soft-tip hydrophilic guidewire rather than a standard catheter with a standard guidewire should be used in most situations. (b) The most important rescue techniques are needle-knife precut, double-guidewire technique, and transpancreatic sphincterotomy. In few cases, anterograde cannulation techniques are needed. To this regard, the EUS-guided biliary drainage followed by rendezvous is increasingly used as an alternative to percutaneous transhepatic biliary drainage. Key Messages: Biliary cannulation can be accomplished with alternative retrograde or less frequently by salvage anterograde techniques, once conventional direct cannulation attempts have failed. Considering recent favorable data for the early use of transpancreatic sphincterotomy, an adopted version of the 2016 European Society for Gastrointestinal Endoscopy (ESGE) algorithm on biliary cannulation is proposed.

Intestinal perforations after endoscopic retrograde cholangiopancreatography in the USA: a 16-year study using the National Inpatient Sample

BACKGROUND

Intestinal perforation is a rare but feared complication of ERCP. In this study, we identify patient and hospital factors for ERCP related intestinal perforation using a large national database. We also examine the effects of intestinal perforations on hospital outcomes.

METHODS

Data were obtained from the National Inpatient Sample, the largest publicly available inpatient care database in the United States. ICD-9-CM procedure codes for all ERCP procedures conducted between 1998 and 2013. Our primary outcome of interest was the incidence of intestinal perforations after ERCP. Secondary outcomes of interest included hospital length of stay and inpatient mortality.

RESULTS

A total of 392,336 ERCP procedures were performed over the study period, met our inclusion criteria, and were analyzed. Mean age of sample was 59 years and just over 60% were females. Low volume hospitals accounted for over 85% of ERCPs. Intestinal perforations occurred at a rate of 1.2 per 1000 ERCP procedures. Patient's age was the only patient-related factor significantly associated with perforation. (OR: 1.016; 95% CI 1.009-1.025). For hospitals, teaching status was the only hospital related factor associated with intestinal perforation after ERCP (OR: 1.56; 95% CI 1.28-1.91). Length of stay was much longer in patients with ERCP related perforations and mortality risk was ten times higher in the same cohort.

CONCLUSIONS

Patients who have ERCP related perforations have longer hospital stays and have a higher mortality risk. Older patients and those who had ERCP in teaching hospitals are at a higher risk of perforation.

Potential Factors Affecting Results of Short-Type Double-Balloon Endoscope-Assisted Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Short-type double-balloon endoscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) has been developed as an alternative approach for cases with a surgically altered gastrointestinal anatomy. However, this technique is sometimes technically challenging and carries a risk of severe adverse events.

AIMS

To evaluate the factors affecting the technical success rate and adverse events of DBE-ERCP.

METHODS

A total of 319 patients (805 procedures) with a surgically altered gastrointestinal anatomy underwent short DBE-ERCP. The factors affecting the technical success rate and adverse events, and the learning curve of the trainees were retrospectively evaluated.

RESULTS

The technical success rate of all procedures was 90.7%. Adverse events occurred in 44 (5.5%) procedures. A multivariate analysis indicated that Roux-en-Y reconstruction and first-time short DBE-ERCP were factors affecting the technical failure and adverse event rates, while the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction was a non-risk factor for adverse events. The trainee caseload did not affect the technical success or adverse event rates significantly; however, trainees tended to perform cases involving the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction. The success rate of scope insertion increased according to experience; however, the overall success rate did not differ to a statistically significant extent.

CONCLUSION

Short DBE-ERCP was useful and safe for managing cases with a surgically altered anatomy; however, trainees should concentrate on accumulating experience with easy cases, such as those with the modified Child method after subtotal stomach-preserving pancreaticoduodenectomy reconstruction or a history of DBE-ERCP.

Risk factors for the development of post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with asymptomatic common bile duct stones

BACKGROUND

Previous studies have revealed that patients with asymptomatic common bile duct (CBD) stones are at a high risk of developing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, no studies to date have addressed the risk factors for PEP in patients with asymptomatic CBD stones.

AIM

To examine the risk factors for PEP in patients with asymptomatic CBD stones.

METHODS

Using medical records of three institutions in Japan for 6 years, we identified a total of 1135 patients with choledocholithiasis including 967 symptomatic patients and 168 asymptomatic patients with native papilla who underwent therapeutic ERCP. We performed univariate and multivariate analyses to examine the risk factors for PEP in the 168 patients with asymptomatic CBD stones.

RESULTS

The overall incidence rate of PEP in all the patients with during study period was 4.7% (53/1135). Of the 168 patients with asymptomatic CBD stones, 24 (14.3%) developed PEP. In univariate analysis, precut sphincterotomy (P = 0.009) and biliary balloon sphincter dilation (P = 0.043) were significant risk factors for PEP. In multivariate analysis, precut sphincterotomy (P = 0.002, 95%CI: 2.2-27.8, odds ratio = 7.7), biliary balloon sphincter dilation (P = 0.015, 95%CI: 1.4-17.3, odds ratio = 4.9), and trainee endoscopists (P = 0.048, 95%CI: 1.01-8.1, odds ratio = 2.9) were significant risk factors for PEP.

CONCLUSION

ERCP for asymptomatic CBD stones should be performed by experienced endoscopists. When performing precut sphincterotomy or biliary balloon sphincter dilation in patients with asymptomatic CBD stones, the placement of a prophylactic pancreatic stent is strongly recommended to prevent PEP.

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?

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.

Patient-related factors associated with successful cannulation by trainees during hands-on endoscopic retrograde cholangiopancreatography training

BACKGROUND AND AIM

Hands-on endoscopic retrograde cholangiopancreatography (ERCP) training is essential for trainees to grasp the technique. Cannulation success rate (CSR) is considered one of the main indicators of competency of trainees. We aimed to investigate whether patient-related factors had an impact on the CSR of trainees.

METHODS

A post hoc analysis of data from two multicenter studies (NCT02002650 and NCT03057769) was conducted. Patients aged 18-90 years with native papilla undergoing ERCP were eligible for this study. Only procedures involving trainees in centers strictly following "10-min criteria" for initial cannulation were enrolled. Primary outcome was CSR by trainees.

RESULTS

From December 2013 to October 2017, 20 trainees in four centers were involved in initial cannulation in 1044 patients with native papilla. Primary CSR by trainees was 61.0% (436/715), 31.5% (70/222) and 44.9% (48/107) in patients with common bile duct stone (CBDS), biliary stricture (BS) and other indications, respectively (P < 0.001). In multivariate analysis, indication of BS (OR, 0.31; 95% CI, 0.22-0.44; P < 0.001) and presence of type A diverticulum (OR, 1.69; 95% CI, 1.23-2.33; P = 0.001) were both independently associated with cannulation success of trainees. Biliary infection was significantly higher in the BS than in the CBDS group (3.6% vs 0.7%, P = 0.004), whereas other post-ERCP complications were comparable between the two groups.

CONCLUSIONS

Indication of BS and the presence of type A diverticulum were independently associated with the success of cannulation by trainees. These findings indicate that greater effort is needed for trainees to improve the ability of cannulation in BS.

ERCP practice beyond the training period - bridging the gap between guidelines and real-life practice: a single operator experience of 679 procedures

BACKGROUND

Endoscopic retrograde cholangiopancreatography has evolved significantly in recent years. The increase in complexity and range of applications has not been adequately reflected in an improvement of training methods for ERCP, with many endoscopists failing to meet required performance standards during their training period and limited available data on their performance immediately after completing training. We aimed to analyze the performance of an independent operator from a developing country after the completion of formal training with regard to procedure and patient-related outcomes.

METHODS

We conducted an observational study of ERCPs performed by a young endoscopist from a referral center. Data about the procedure, cannulation technique (including use of precut), trainee involvement and procedure-related outcomes was retrieved and analyzed from a prospectively maintained database on quality in ERCP (the QUASIE initiative).

RESULTS

Data from 679 consecutive ERCPs conducted or supervised by one endoscopist with < 200 independent procedures prior to the study period were included in the final analysis. Cannulation rates significantly improved over time, from 90% to 96% (p = 0.016). Use of precut techniques changed significantly over time, with an initial increase followed by a subsequent decrease as overall cannulation rates improved. Trainee involvement was significantly associated with prolonged cannulation times (p = 0.003) and use of precut (p = 0.001), but did not impact on technical success or patient safety.

CONCLUSIONS

Independent practice of ERCP after the training period is characterized by ongoing changes in technique, especially with regard to cannulation and use of precut, showing significant improvements in performance over time.

A Nationwide Assessment of the "July Effect" and Predictors of Post-Endoscopic Retrograde Cholangiopancreatography Sepsis at Urban Teaching Hospitals in the United States

Background/Aims

To analyze the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis in the early (July to September) and later (October to June) academic months to assess the “July effect”.

Methods

The National Inpatient Sample (2010–2014) was used to identify ERCP-related adult hospitalizations at urban teaching hospitals by applying relevant procedure codes from the International Classification of Diseases, 9th revision, Clinical Modification. Post-ERCP outcomes were compared between the early and later academic months. A multivariate analysis was performed to evaluate the odds of post-ERCP sepsis and its predictors.

Results

Of 481,193 ERCP procedures carried out at urban teaching hospitals, 124,934 were performed during the early academic months. The demographics were comparable for ERCP procedures performed during the early and later academic months. A higher incidence (9.4% vs. 8.8%, p<0.001) and odds (odds ratio [OR], 1.07) of post-ERCP sepsis were observed in ERCP performed during the early academic months. The in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of stay, and total hospital charges in patients with post-ERCP sepsis were also equivalent between the 2 time points. Pre-ERCP cholangitis (OR, 3.20) and post-ERCP complications such as cholangitis (OR, 6.27), perforation (OR, 3.93), and hemorrhage (OR, 1.42) were significant predictors of higher post-ERCP sepsis in procedures performed during the early academic months.

Conclusions

The July effect was present in the incidence of post-ERCP sepsis, and academic programs should take into consideration the predictors of post-ERCP sepsis to lower health-care burden.

Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature

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.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Quality and competence in endoscopic retrograde cholangiopancreatography - Where are we 50 years later?

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.

Can Trainees Safely Perform Endoscopic Treatments for Common Bile Duct Stones? A Single-center Retrospective Study

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.

When to let the fellow do the procedure

BACKGROUND AND AIMS

In complex endoscopies, the initial attempt is often associated with the highest success and subsequent attempts to achieve the same outcome have a higher failure rate. An attending physician needs to decide how the ultimate success may become compromised by letting a fellow start the procedure. A decision analysis is aimed to shed light on this issue.

METHODS

A formula is derived to calculate the point in time when to switch the instrument between an attending and fellow physician. This time point is determined by the ratio of benefit to the patient over benefit to the fellow, the difference in probability of achieving success by an attending versus a fellow, and the decline in probability of success during consecutive procedural attempts.

RESULTS

The attending should undertake the first attempts at doing the procedure, if the fellow is inexperienced and the difference in success rate between attending and fellow is still large, if the procedure is risky, and if the benefit of a successful outcome outweighs the benefit of a teaching experience to the fellow. Vice versa, fellows should take the lead, if they have become well trained and the difference in their procedural success rate compared with the attendings' has grown relatively small. The fellow should also be trusted to lead in all instances where the risk to the patient is small.

CONCLUSIONS

Such rules can serve as general guidance when to pass the endoscope to a fellow physician. Medical decision analysis is helpful to enlighten complex situations during training of fellows.

Quality measures in gastrointestinal endoscopy: the current state

PURPOSE OF REVIEW

The purpose of this review is to summarize the current state of endoscopic quality measurement and use of measures in enhancing the value of endoscopic services.

RECENT FINDINGS

Initially, quality measurement of endoscopic procedures was claims based or included small unit or practice-specific efforts. Now we have a mature national registry and large electronic medical or procedural records that are designed to yield valuable data relevant to quality measurement.

SUMMARY

With the advent of better measures, we are beginning to understand that initial process and surrogate outcome measures (adenoma detection rate) can be improved to provide a better reflection of endoscopic quality. Importantly, however, even measures currently in use relate to important patient outcomes such as missed colon cancers. At a federal level, older cumbersome pay-for-performance initiatives have been combined into a new overarching program named the quality payment program within the centers for medicare and medicaid services. This program is an additional step toward furthering the progress from volume-to-value-based reimbursement. The legislation mandating the movement toward outcomes-linked (value) reimbursement is the medicare access and children's health insurance program reauthorization act, which was passed with overwhelming bipartisan support and will not be walked back by alterations of the affordable care act. Increasing portions of medicare reimbursement (and likely commercial to follow) will be linked to quality metrics, so familiarity with the underlying process and rationale will be important for all proceduralists.

Does the presence of a trainee compromise success of biliary cannulation at ERCP?

BACKGROUND AND STUDY AIMS

 Findings in the literature are conflicting on whether trainee involvement in endoscopic retrograde cholangiopancreatography (ERCP) procedures is detrimental to cannulation success rates. We addressed this in a prospective study, where cannulation success with or without trainee presence was the primary outcome measure.

PATIENTS AND METHODS

 We prospectively recorded data on 2 senior endoscopists and their trainees over an 18-month period for ERCPs in patients with a virgin ampulla. Presence or absence of a trainee at ERCP procedures was pragmatic, reflecting their other service or training commitments or annual leave. For trainee presence, the training protocol allowed them 6 minutes of supervised time in which to achieve biliary cannulation after reaching the ampulla. Study outcome measures included cannulation success, time to cannulation, technique, whether this was achieved independently by the trainee, and complications.

RESULTS

 There were 219 procedures recorded and analyzed (134 with a trainee, 85 without). Three trainees were involved. Selective biliary cannulation was achieved in 201 (92 %) of cases. When a trainee was present, cannulation was successful in 122/134 procedures (91 %), compared to 79/85 (93 %) with a senior endoscopist alone ( P  = 0.8, Fisher's exact test). Mean time to biliary cannulation with a trainee present was 7 minutes, compared with 5 minutes with no trainee. Mean time for successful independent cannulation by the trainee was 4 minutes, and 9 minutes for a consultant following a trainee's attempt. There were no serious adverse events.

CONCLUSION

 Our study shows that with this training protocol, involvement of a trainee on a routine secondary care ERCP list does not impair biliary cannulation success, and does not prolong a subsequent attempt by the senior endoscopist if initially unsuccessful. These findings support the involvement of trainees in routine ERCP lists with this training protocol.