Making ERCP training safe: A protocol-based strategy to minimize complications during selective biliary cannulation

Trainee Involvement and ERCP Complications: A Systematic Review and Meta-Analysis

BACKGROUND

Therapeutic endoscopy and gastroenterology fellows often participate in endoscopic retrograde cholangiopancreatography (ERCP) during their training period. However, it is generally feared that trainee involvement may increase ERCP-related complications, mainly because of the side-viewing nature of the endoscope and the higher risk of pancreatic duct cannulation. There is no concrete evidence to support this notion. This systematic review and meta-analysis aims to investigate the resultsof trainee participation on adverse events related to ERCP.

METHODS

PubMed, EMBASE, Google Scholar, SCOPUS, and Web of Science databases were searched from inception to 31 May 2023 for studies evaluating the ERCP outcomes defined as success rates, procedure time, failed attempts, and adverse events with and without trainee participation. A random effect model was used to perform the meta-analysis, and heterogeneity was assessed using the I2 statistics.

RESULTS

Seven studies were included in the final analysis, including 17,088 ERCPs. The pooled odds ratio (pOR) of success rate, incomplete/failed attempts in the trainee and no trainee groups were 0.466 (95% CI 0.13 to 1.66, I2 = 97.8%, p = 0.239) and 3.2 (95% CI 0.70 to 14.55), I2 = 98.5%, p = 0.134), respectively. The pOR of post-ERCP pancreatitis and bleeding in the trainee vs. no trainee groups was 0.97 (95% CI 0.76 to 1.23, I2 = 0%, p = 0.78) and 1.3 (95% CI 0.59 to 2.83, I2 = 49%, p = 0.54). The pOR of all adverse events in both groups was 1.028 (95% CI 0.917 to 1.152, I2 = 0%, p = 0.636). Surprisingly, the pooled std mean difference for the procedure time was 0.217 (95% - 0.093 to 0.05, I2 = 98.5%, p = 0.17).

CONCLUSION

This meta-analysis comprising of 17,088 ERCPs in seven studies demonstrated comparable ERCP outcomes related to trainee participation regarding success rates, procedure time, and adverse events. Trainees' involvement in ERCP within a proper teaching setting appears safe and does not compromise the overall procedure's success.

Ketorolac Is Safe and Associated With Lower Rate of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in Children With Pancreatic Duct Manipulation

OBJECTIVES

Use of non-steroidal anti-inflammatory drugs (NSAIDs) for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) prevention in pediatrics is not well studied. Because of difficulty in accurately dosing indomethacin suppositories in pediatric patients, our center has used intravenous ketorolac for PEP prevention and present data on its safety and associated PEP rates.

METHODS

Prospective monitoring of PEP for all patients who underwent ERCP at a pediatric tertiary care center from July 2010 to June 2018. Retrospective review of patient and procedural factors and severity of PEP. Routine use of ketorolac for PEP prevention began in 2014.

RESULTS

Two hundred and ninety-eight ERCPs were analyzed. One hundred and sixty-six patients received intraprocedural ketorolac and 132 did not. One patient had post-ERCP bleeding and bleeding rates were not significantly different between ketorolac and non-ketorolac groups (0.6% vs 0%, P = 1). Overall rates of PEP were not significantly different between the ketorolac and no ketorolac group (9% vs 13%, P = 0.29); however, for high-risk pediatric patients with injection of contrast into and/or cannulation of the pancreatic duct, the rates of PEP were significantly lower for patients who received ketorolac (11% vs 25%, P = 0.035).

CONCLUSIONS

Pediatric patients undergoing ERCP with manipulation of the pancreatic duct are high risk for PEP, and ketorolac was associated with a lower rate of PEP in these patients. Ketorolac was well tolerated without a higher rate of bleeding after ERCP. These results are the first to provide evidence showing an association with intraprocedural NSAID use and lower rates of PEP in select pediatric patients.

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.

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.