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Thomson BNJ. ERCP remains a critical skill for HPB, Upper GI & General Surgeons. ANZ J Surg 2023; 93:1738-1739. [PMID: 37565640 DOI: 10.1111/ans.18599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Benjamin N J Thomson
- Surgical Services, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- University of Melbourne Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Victorian Department of Health, Collaborations & Systems Improvement, Melbourne, Victoria, Australia
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Sabat N, McSweeney W, Konno T, Gilberd MA, Molloy C, Pretorius C. Advanced skills for general surgeons and carving out a niche: Endoscopic retrograde cholangiopancreatography in regional Australia. ANZ J Surg 2023; 93:1768-1772. [PMID: 37150893 DOI: 10.1111/ans.18506] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND The provision of high-quality healthcare in rural Australian hospitals has necessitated general surgeons to take up the challenge and expand their expertise to advanced endoscopy techniques including endoscopic retrograde cholangiopancreatography (ERCP). This study examines the utility of ERCP in a regional setting especially in decreasing patient transfers and associated costs while achieving exceptional safety by measuring key indicators of safety and efficacy. METHODS A single-centre retrospective cross-sectional cohort review in a rural Queensland hospital of patients who underwent ERCP (emergent and elective) from January 2019 until July 2022. Standardized international ERCP performance indicators were collected and compared to benchmark literature values including the rate of cannulation, stone extraction, successful stent placement, and post-ERCP pancreatitis. RESULTS The majority of the ERCP performance indicator benchmarks were met. 100% of patients had an appropriate indication for the procedure and consent. 98.95% successful CBD cannulation with only 14.14% requiring multiple attempts. 92.22% successful stone retrieval with 100% stent placement, well above guideline targets. The post-procedural complication rate was 6.81% (2.09% pancreatitis; 1.05% pancreatitis; 1.05% duodenal perforation). Antibiotic prophylaxis adherence was identified to require improvement (12.57%). CONCLUSION High-quality ERCP procedures can be performed in a regional hospital by general surgeons in a safe and cost-effective manner, significantly decreasing the costs associated with patient transfer. This study reflects strong evidence for consistently achieving international ERCP performance benchmarks and the provision of high-quality healthcare by a regional hospital and provides a strong argument for increasing access to ERCP in rural and remote hospitals.
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Affiliation(s)
- Nestor Sabat
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
| | - William McSweeney
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
| | - Takuma Konno
- James Cook University, Townsville, Queensland, Australia
| | | | - Charles Molloy
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
| | - Casper Pretorius
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
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Borrelli de Andreis F, Mascagni P, Schepis T, Attili F, Tringali A, Costamagna G, Boškoski I. Prevention of post-ERCP pancreatitis: current strategies and novel perspectives. Therap Adv Gastroenterol 2023; 16:17562848231155984. [PMID: 36895283 PMCID: PMC9989421 DOI: 10.1177/17562848231155984] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/23/2023] [Indexed: 03/08/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that might lead to severe adverse events. Post-ERCP pancreatitis (PEP) is the most common post-procedural complication, which is related to significant mortality and increasing healthcare costs. Up to now, the prevalent approach to prevent PEP consisted of employing pharmacological and technical expedients that have been shown to improve post-ERCP outcomes, such as the administration of rectal nonsteroidal anti-inflammatory drugs, aggressive intravenous hydration, and the placement of a pancreatic stent. However, it has been reported that PEP originates from a more complex interaction of procedural and patient-related factors. Appropriate ERCP training has a pivotal role in PEP prevention strategy, and it is not a chance that a low PEP rate is universally considered one of the most relevant indicators of proficiency in ERCP. Scant data on the acquisition of skills during the ERCP training are currently available, although some efforts have been recently done to shorten the learning curve by way of simulation-based training and demonstrate competency by meeting technical requirements as well as adopting skill evaluation scales. Besides, the identification of adequate indications for ERCP and accurate pre-procedural risk stratification of patients might help to reduce PEP occurrence regardless of the endoscopist's technical abilities, and generally preserve safety in ERCP. This review aims at delineating current preventive strategies and highlighting novel perspectives for a safer ERCP focusing on the prevention of PEP.
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Affiliation(s)
- Federica Borrelli de Andreis
- First Department of Internal Medicine, Fondazione IRCCS San Matteo Hospital, University of Pavia, Pavia, Italy.,Gastroenterology Unit, Istituti Clinici Maugeri, University of Pavia, Pavia, Italy.,Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pietro Mascagni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Institute of Image-Guided Surgery, IHU-Strasbourg, France
| | - Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabia Attili
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli, Rome, 00168, Italy.,IHU Strasbourg 1, Place de l'Hopital 67091 Strasbourg Cedex, France.,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Roma, Italy
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Seo HS, Kim SJ, Jeon CH, Song KY, Lee HH. The First Systematic Gastroscopy Training Program for Surgeons in Korea. J Korean Med Sci 2022; 37:e295. [PMID: 36254531 PMCID: PMC9577353 DOI: 10.3346/jkms.2022.37.e295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 08/23/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Endoscopic evaluation of the stomach is essential for preoperative planning and post-surgical surveillance for various diseases of the stomach, including malignancy. The gastroscopy education program for surgeons is currently in its infancy and is not systematically organized in Korea. This study aimed to introduce the first systematic gastroscopy education program for surgeons in Korea. METHODS The gastroscopy education program entitled "Gastroscopy School for Surgeons (GSS)" comprised of theoretical education, dry lab hands-on training, and clinical practice. All participants were beginners without any gastroscopy experience. Clinical practice started after the completion of the theoretical and dry lab training. The gastroscopy practices utilized simple luminal observation, biopsy, localization using clips or dye injection, and limited therapeutic gastroscopy. The educational performances and surveys from 33 participants were analyzed. RESULTS The participants consisted of surgical residents, general surgeons, gastrointestinal-specialized surgeons, and physicians. Participants performed a total of 2,272 gastroscopies, 2,008 of which were post-gastrectomy cases. Currently, of the 33 participants, 7 (21.2%) of the participants performed gastroscopy regularly, and 7 (21.2%) occasionally. According to the self-reported survey, one participant assessed their current gastroscopic technique to be at the expert level, and 25 (75.8%) at a proficient level. All participants considered gastroscopy education for surgeons to be necessary, and 28 (84.8%) stated that systematic education is not currently provided in Korea. CONCLUSION We introduced the first systematic gastroscopy education program for surgeons in Korea, namely the GSS, which is practical and meets clinical needs. More training centers are needed to expand gastroscopy training among Korean surgeons.
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Affiliation(s)
- Ho Seok Seo
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - So Jung Kim
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Hyo Jeon
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Han Hong Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Yılmaz* S. ERCP licence in the context of medical practices, legal regulations, medical ethics and patient’s rights in our country. Turk J Surg 2022; 38:1-4. [DOI: 10.47717/turkjsurg.2022.5555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/21/2022] [Indexed: 01/18/2023]
Abstract
Endoscopic Retrograde Cholangiopancreatography (ERCP) is an invasive endoscopic procedure mainly used for hepatobiliary and pancreatic disorders. Although it was first developed by a surgeon, McCune, there is still debate on who can perform this procedure. This problem, which actually needs to be solved within medical ethics, has been brought to the courts, and lawsuits have been filed against general surgeons to prevent them from performing ERCP. The current situation in our country demonstrates that 50-70% of ERCP procedures are performed by general surgeons. In regions where there are not enough gastroenterology specialists, only general surgeons perform this procedure. Today, general surgeons have hundreds of articles on ERCP procedures and studies accepted as international guideline. ERCP procedure -which is in fact a surgical procedure- is included in hepatobiliary surgical procedures in the general surgery core training schedule. General surgeons receive ERCP education in a 6-month challenging program at centers accredited by the Turkish Surgical Society. The problem of ERCP license cannot be solved by legal authorities but by medical, ethical and deontological discussions. Our recommendation here is that the Ministry of Health should associate this procedure with a specific legislation, just like in endoscopy, and establish a specific ERCP training program accepted for license. In this article, the problem of who should perform ERCP was discussed within the framework of legal legislation, medical doctrine and realities of our country.
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Morton A, Cralley A, Brooke-Sanchez M, Pieracci FM. Laparoscopic common bile duct exploration by acute care surgeons saves time and money compared to ERCP. Am J Surg 2022; 224:116-119. [DOI: 10.1016/j.amjsurg.2022.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/03/2022] [Accepted: 03/22/2022] [Indexed: 12/01/2022]
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Chen JH, Chung CH, Li CH, Chien WC, Chang CF. Epidemiological Survey of Different Treatments for Choledocholithiasis in Taiwan: A Nationwide, Population-Based Cohort Analysis. J Clin Med 2022; 11:jcm11040970. [PMID: 35207241 PMCID: PMC8876383 DOI: 10.3390/jcm11040970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/28/2022] [Accepted: 02/10/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: Open, laparoscopic, and endoscopic choledocholithotomy (OC, LC, and EC, respectively) are accepted choledocholithiasis treatment modalities. However, an assessment of the nationwide trends in their outcomes is lacking. This nationwide population-based analysis evaluated treatment outcomes of choledocholithiasis in Taiwan; (2) Methods: A total of 13,139,306 individuals were randomly enrolled from the Longitudinal Health Insurance Database (LHID) between 2000 to 2013 for cohort analysis. All patients with newly diagnosed choledocholithiasis aged 18 years or older who were treated during the study period were enrolled and allocated to the OC, LC, EC, or combined endoscopy and open choledocholithotomy (CEOC) groups. Age, readmission, retained stone, comorbidities, hospital stay, medical cost, complications, mortality were analyzed; (3) Results: A total of 58,064 individuals met the inclusion criteria, including 46.54%, 1.10%, 47.52%, and 4.85% who underwent OC, LC, EC, and CEOC, respectively. The endpoint characteristics showed that the LC group had higher readmission, longer hospital stay, and higher medical cost. Cox regression analysis showed that the adjusted hazard ratio (HR) of complications for EC was 1.259 times higher than that for OC. The adjusted HRs of readmission within 90 days for LC, EC, and CEOC were higher than that of OC. The adjusted HR of retreatment with surgery was higher in LC. The adjusted HR of retreatment with endoscopy was higher in CEOC. The adjusted HR of mortality in EC was 1.603 times that of OC; (4) Conclusions: Different choledocholithiasis treatments lead to different outcomes. However, further studies on other large or national data sets are required to support these findings.
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Affiliation(s)
- Jia-Hui Chen
- Division of General Surgery, Department of Surgery, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, New Taipei City 231, Taiwan;
- School of Medicine, Buddhist Tzu Chi University, Hualien 970, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei City 114, Taiwan;
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei City 114, Taiwan
| | - Chung-Hsien Li
- Division of Gastroenterology, Department of Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, New Taipei City 231, Taiwan;
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei City 114, Taiwan;
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei City 114, Taiwan
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei City 114, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei City 114, Taiwan
- Correspondence: (W.-C.C.); (C.-F.C.); Tel.: +886-2-87923100 (ext. 18130) (W.-C.C.); Fax: +886-2-87923147 (W.-C.C.)
| | - Chao-Feng Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 114, Taiwan
- Correspondence: (W.-C.C.); (C.-F.C.); Tel.: +886-2-87923100 (ext. 18130) (W.-C.C.); Fax: +886-2-87923147 (W.-C.C.)
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Voiosu T, Voiosu A, Benguş A, Mateescu B. ERCP practice beyond the training period - bridging the gap between guidelines and real-life practice: a single operator experience of 679 procedures. ACTA ACUST UNITED AC 2019; 57:151-8. [PMID: 30517080 DOI: 10.2478/rjim-2018-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Indexed: 11/21/2022]
Abstract
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.
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Voiosu T, Bălănescu P, Voiosu A, Benguş A, Preda C, Umans DS, Bogdan Mateescu R, van Hooft JE. Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature. United European Gastroenterol J 2019; 7:239-249. [PMID: 31080609 PMCID: PMC6498806 DOI: 10.1177/2050640618817110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Theodor Voiosu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | | | - Andrei Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Andreea Benguş
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Carmen Preda
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Fundeni Clinical Institute, Bucharest, Romania
| | - Devica S Umans
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Radu Bogdan Mateescu
- Carol Davila School of Medicine, Bucharest, Romania
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, the Netherlands
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Rodrigues-Pinto E, Baron TH, Liberal R, Macedo G. Quality and competence in endoscopic retrograde cholangiopancreatography - Where are we 50 years later? Dig Liver Dis 2018; 50:750-756. [PMID: 29804924 DOI: 10.1016/j.dld.2018.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
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Guan G, Sun C, Ren Y, Zhao Z, Ning S. Comparing a single-staged laparoscopic cholecystectomy with common bile duct exploration versus a two-staged endoscopic sphincterotomy followed by laparoscopic cholecystectomy. Surgery 2018; 164:1030-4. [PMID: 30054013 DOI: 10.1016/j.surg.2018.05.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/09/2018] [Accepted: 05/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND With the advent of minimally invasive surgery, the limits of surgery have been stretched by questioning the more usual, established 2-stage approach for choledocholithiasis with an initial endoscopic retrograde cholangiography and endoscopic biliary sphincterotomy followed by laparoscopic cholecystectomy in favor of the single-stage laparoscopic common bile duct exploration with laparoscopic cholecystectomy. The aim of this study was to compare the related benefits, difficulties, and outcomes of these 2 methods at a single institution. METHODS A retrospective analysis of 128 patients satisfying the inclusion criteria was divided into 2 groups (n = 68 for the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy and n = 60 for the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy) between 2014 and 2017. Patient data including age, sex, duration of the operation, intraoperative and postoperative complications, and duration of hospital stay were reviewed. RESULTS The group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy had 24 men and 44 women (mean age 52 years), and the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy had 16 men and 44 women (mean age 47 years). Statistically significant results were found in the clearance range (100% in the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy versus 75% in the group with endoscopic retrograde cholangiography/laparoscopic cholecystectomy), a shorter total duration of hospitalization for the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy (4.1 days vs 8.4 days) (P < .05), but a great incidence of biliary leakage in the group with laparoscopic common bile duct exploration with laparoscopic cholecystectomy. Duration of surgery was not different between the 2 groups. CONCLUSION Laparoscopic common bile duct exploration with laparoscopic cholecystectomy is a single-stage procedure that has many advantages over endoscopic retrograde cholangiography/laparoscopic cholecystectomy if appropriate experience and when expertise is available.
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Wani S, Keswani RN, Petersen B, Edmundowicz SA, Walsh CM, Huang C, Cohen J, Cote G. Training in EUS and ERCP: standardizing methods to assess competence. Gastrointest Endosc 2018; 87:1371-82. [PMID: 29709305 DOI: 10.1016/j.gie.2018.02.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 02/08/2023]
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Iida T, Kaneto H, Wagatsuma K, Sasaki H, Naganawa Y, Nakagaki S, Satoh S, Shimizu H, Nakase H. Can Trainees Safely Perform Endoscopic Treatments for Common Bile Duct Stones? A Single-center Retrospective Study. Intern Med 2018; 57:923-928. [PMID: 29434158 PMCID: PMC5919847 DOI: 10.2169/internalmedicine.9737-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Tomoya Iida
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hiroyuki Kaneto
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Kohei Wagatsuma
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hajime Sasaki
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Yumiko Naganawa
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Suguru Nakagaki
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Shuji Satoh
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Haruo Shimizu
- Department of Gastroenterology, Muroran City General Hospital, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Japan
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Al-Mansour MR, Fung EC, Jones EL, Zayan NE, Wetzel TD, Martin Del Campo SE, Jalilvand AD, Suzo AJ, Dettorre RR, Fullerton JK, Meara MP, Mellinger JD, Narula VK, Hazey JW. Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers. Surg Endosc 2017; 32:2871-2876. [PMID: 29273876 DOI: 10.1007/s00464-017-5995-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.
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Affiliation(s)
- Mazen R Al-Mansour
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Eleanor C Fung
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Edward L Jones
- Department of Surgery, Denver Veterans Affairs Medical Center, University of Colorado, Denver, CO, USA
| | - Nichole E Zayan
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Timothy D Wetzel
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Sara E Martin Del Campo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Anahita D Jalilvand
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Andrew J Suzo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Rebecca R Dettorre
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - James K Fullerton
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Michael P Meara
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - John D Mellinger
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Vimal K Narula
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Jeffrey W Hazey
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.
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Rodrigues-Pinto E, Macedo G, Baron TH. Training pathways and competency assessment in endoscopic retrograde cholangiopancreatography. Techniques in Gastrointestinal Endoscopy 2017. [DOI: 10.1016/j.tgie.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Cooper J, Desai S, Scaife S, Gonczy C, Mellinger J. Volume, specialty background, practice pattern, and outcomes in endoscopic retrograde cholangiopancreatography: An analysis of the national inpatient sample. Surg Endosc. 2017;31:2953-2958. [PMID: 27815746 DOI: 10.1007/s00464-016-5312-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/25/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic procedure performed by both gastroenterologists and surgeons. There has been recent controversy regarding training paradigms for gastrointestinal endoscopy. No prior studies have evaluated comparative outcomes for ERCP in relation to specialty training background. This study utilized the National Inpatient Sample (NIS) to assess ERCP outcomes as a function of training background, practice pattern, and individual provider volume. METHODS NIS data was queried from 2007 to 2009. Gastroenterologists and surgeons were identified by procedural profiles and unique physician identifiers. Comorbidity was assessed via Charlson Score. Outcomes including cost, length of stay (LOS), and mortality were analyzed, with and without propensity score matching (PSM). Analysis of outcomes as a function of provider procedural volume was also performed. Comparison for statistical significance was accomplished via t test. RESULTS A total of 110,811 ERCP's were identified, of which 42,025 (37.9%) were performed by surgeons. Surgeons exhibited longer LOS (8.7 vs. 7.2 days), overall cost ($24,739 vs. $16,960), and mortality (3.9 vs. 1.2%, odds ratio 3.3), with p < 0.001 for all measures. 71.6% of surgical patients, versus 19.6% of gastroenterologic, underwent subsequent inpatient laparoscopic cholecystectomy or laparotomy. Outcome differences persisted when PSM included performance of subsequent laparoscopic cholecystectomy. Evaluation of minimum performance standards revealed up to a fivefold increased mortality for providers who performed less than 5 ERCP's/year, irrespective of specialty background. CONCLUSIONS Gastroenterologists demonstrate favorable gross outcomes compared to surgeons performing ERCP. Differences may correlate in part with more frequent subsequent surgical management of comorbid conditions by surgical providers. Lower volume providers achieve inferior outcomes regardless of specialty background. Analyses of this type may help inform discussions on optimal training and proficiency paradigms, including maintenance of proficiency, for therapeutic endoscopic procedures.
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Tierney J, Baucom RB, Holzman MD, Poulose BK, Pierce RA. Current trends in the practice of endoscopy among surgeons in the USA. Surg Endosc 2017; 31:1675-9. [DOI: 10.1007/s00464-016-5157-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
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James PD, Antonova L, Martel M, Barkun A. Measures of trainee performance in advanced endoscopy: A systematic review. Best Pract Res Clin Gastroenterol 2016; 30:421-52. [PMID: 27345650 DOI: 10.1016/j.bpg.2016.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 04/22/2016] [Accepted: 05/08/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The diversity, technical skills required, and risk inherent to advanced endoscopy techniques all contribute to complex training curricula and steep learning curves. Since trainees develop endoscopy skills at different rates, there has been a shift towards competency-based training and certification. Validated endoscopy performance measures for trainees are, therefore, necessary. The aim of this systematic review was to describe and critically assess the existing evidence regarding measures of performance for trainees in advanced endoscopy. METHODS A systematic review of the literature from January 1980 to January 2016 was carried out using the MEDLINE, EMBASE, CENTRAL, and ISI Web of knowledge databases. MeSH terms related to 'advanced endoscopy' and 'performance' were applied to a highly sensitive search strategy. The main outcomes were face, content, and construct validity, as well as reliability. RESULTS The literature search yielded 1,662 studies and 77 met the inclusion criteria after abstract and full-text review (endoscopic retrograde cholangiopancreatography (ERCP)=23, endoscopic ultrasound (EUS)=30, colonoscopic polypectomy (CP)=11, balloon-assisted enteroscopy (BAE)=7, luminal stenting=3, radiofrequency ablation (RFA)=2, and endoscopic muscosal resection (EMR)=1). Good validity and reliability were found for measurement tools of overall performance in ERCP, EUS and CP, with applications for both patient-based and simulator training models. A number of specific technical skills were also shown to be valid measures of performance. These include: selective biliary cannulation, sphincterotomy, biliary stent placement, stone extraction and procedure time for ERCP; pancreatic solid mass T-staging, EUS-guided fine needle aspiration (EUS-FNA) procedure time, number of EUS-FNA passes and puncture precision for EUS; procedure time and en bloc resection rate for CP; retrograde fluoroscopy time for BAE; and mean number of endoscopy sessions required to achieve complete eradication of intestinal metaplasia (CIEM) for RFA. The evidence for EMR and luminal stenting is of insufficient quality to make recommendations. CONCLUSIONS We have identified multiple valid and readily available performance measures for advanced endoscopy trainees for ERCP, EUS, CP, BAE and RFA procedures. These tools should be considered in advanced endoscopy training programs wishing to move away from apprenticeship-based training and towards competency-based learning with the help of patient-based and simulator tools.
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Affiliation(s)
- P D James
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - L Antonova
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - M Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - A Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada; Epidemiology and Biostatistics and Occupational Health, McGill University Health Center, McGill University, Montreal, Quebec, Canada
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Kadam R, Saxena D, Singh Rana A, Chhabra S, Ahmed Z, Vij V, Kankaria J, Kamal Jenaw R. Laparoscopic common bile duct exploration versus ERCP/stenting and cholecystectomy: Is a single staged procedure better? Int J Hepatobiliary Pancreat Dis 2016. [DOI: 10.5348/ijhpd-2016-55-oa-11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Aims: Choledocholithiasis is most common cause of obstructive jaundice. Laparoscopic choledocholithotomy has evolved as an alternative procedure to ERCP/ stenting in the management of choledocholithiasis. This study was aimed to compare the outcomes of laparoscopic CBD exploration with cholecystectomy (group 1) as compared to the conventional two staged procedure involving ERCP/ stenting (group 2).
Methods: 60 patients admitted to our department (mean age = 45.52, SD = 17.71, 15 males, 45 females) for the management of choledocholithiasis from April 2014 to October 2015 were included in the study. We reviewed retrospectively the patients' data including age, sex, duration of the surgery, intra-operative and postoperative complications, duration of hospital stay, mortality and condition on follow-up.
Results: Group 1 included 30 patients (mean age 50.76, 21 females, 9 males). The average operative time in this group was 110 minutes (96–145), stone clearance rate was 100%, and average hospital stay was 3.2 days (2–9). Group 2 also included 30 patients (mean age 44.36, 24 females, 6 males) with stone clearance rate of 70% (21 out of 30), average operative time 120.7 minutes (90–167), average hospital stay 9.1 (3–30) days and an average of 2.3 procedures per patient.
Conclusion: In our study mean operative time, stone clearance rate, average hospital stay and average number of procedures per patient were found to be significantly lower in laparoscopic CBD exploration group. It can be concluded that laparoscopic CBD exploration with cholecystectomy is much safer and cost effective than the conventional two staged procedure involving ERCP/ stenting.
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Affiliation(s)
- Raju Kadam
- MBBS, MS (Std.), PG Resident, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Dhananjay Saxena
- MBBS, MS, Senior Resident, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Arun Singh Rana
- MBBS, MS (Std.), PG Resident, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Sanjeev Chhabra
- MBBS, MS (Std.), PG Resident, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Zeeshan Ahmed
- MBBS, MS (Std.), PG Resident, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Vikesh Vij
- MBBS, MS (Std.), PG Resident, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Jeevan Kankaria
- MBBS, MS, Associate Professor, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
| | - Raj Kamal Jenaw
- MBBS, MS, Senior Professor and Head of the Department, Department of General Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
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Abstract
INTRODUCTION Training procedural skills in GI endoscopy once focused on threshold numbers. As threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training programme. AIMS The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Second, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Third, we aimed to propose a structured training curriculum based on the presented evidence. METHODS A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round. RESULTS The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programmes for GI endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 randomised control trials. Increased performance on a virtual reality (VR) simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Current simulators lack the discriminative power to determine competence levels in patient-based endoscopy. Eight out of 14 studies on colonoscopy, endoscopic retrograde cholangiopancreatography and endosonography reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for GI endoscopy provided insight into the performance of endoscopists. Five out of seven studies proved that intense training programmes result in good performance. CONCLUSIONS The use of validated VR simulators in the early training setting accelerates the learning of practical skills. Learning curves are valuable for the continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in GI endoscopy. A complete curriculum with the assessment of competence throughout training needs to be developed for all GI endoscopy procedures.
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Affiliation(s)
| | - Arjun D Koch
- Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Robert A de Man
- Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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Shahidi N, Ou G, Telford J, Enns R. When trainees reach competency in performing ERCP: a systematic review. Gastrointest Endosc 2016; 81:1337-42. [PMID: 25841579 DOI: 10.1016/j.gie.2014.12.054] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ERCP is an advanced endoscopic procedure that is technically more challenging and carries a higher risk of adverse events compared with standard endoscopy. A discrepancy currently exists among guidelines regarding the number of ERCPs that a trainee needs to complete before procedural competency should be assessed. Our aim was to assess the learning curve for performing ERCP. METHODS Two authors independently searched MEDLINE (1946 to November 25, 2014) along with the gray literature to identify relevant citations. To warrant inclusion, citations were required to report successful trainee cannulation rate. Successful cannulation rate, set at a value of 80% or higher, was used as our baseline reference for competency. RESULTS Nine studies, assessing 137 trainees and 17,100 ERCPs, were included in our analysis. Overall, competency was achieved among the included studies between 70 to 400 ERCPs. In the 2 studies that used pancreatic duct cannulation rate, competency was achieved by 70 to 160 ERCPs. Of the 5 studies that used selective duct cannulation rate, competency was achieved by 79 to 300 ERCPs. Finally, in the 4 studies that used common bile duct cannulation rate, 2 studies reached the reference competency threshold by 160 to 400 ERCPs. On further stratification, when assessing native papilla deep common bile duct cannulation, only 1 study reached the reference competency threshold by 350 to 400 ERCPs. CONCLUSIONS Our findings suggest that as ERCP has evolved from a predominantly diagnostic to therapeutic procedure, procedural thresholds have risen well above North American training guidelines. Therefore, advanced endoscopy training programs need to reassess their current structure to ensure that procedural competency is being reached.
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Affiliation(s)
- Neal Shahidi
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - George Ou
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Telford
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Robert Enns
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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Boehler ML, Roberts N, Sanfey H, Mellinger J. Do Surgeons and Gastroenterologists Describe Endoscopic Retrograde Cholangiopancreatography Differently? A Qualitative Study. J Surg Educ 2016; 73:66-72. [PMID: 26342954 DOI: 10.1016/j.jsurg.2015.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/30/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging procedure performed by both surgeons and gastroenterologists. There is controversy in the field regarding the training necessary to perform ERCP. Widely disparate requisite volumes of experience to achieve proficiency have been published by representatives of each specialty. The basis for these differences has not been fully explored, with particular reference to the cognitive mindset of the different specialties. METHODS Structured cognitive task analytic interviews were conducted with 7 expert gastroenterologists and 4 expert surgeons from 4 institutions, each of whom performs ERCP as a common procedure in their clinical practice. A qualitative analysis and grounded theory approach was used, focusing specifically on duct cannulation as a critical procedural element. Transcripts were analyzed using Atlas.ti software. RESULTS The qualitative analysis of 11 transcripts identified 173 unique codes from a total of 653 quotes. In all, 5 themes were found to describe the codes: judgment, teaching, techniques, principles, and equipment. Significant differences were noted between gastroenterologists and surgeons across these themes. Gastroenterologists placed emphasis on issues of judgment including rationale, and emphasized explanation and clarification in teaching. Surgeons placed more emphasis on use of visual cues, and emphasized technique and equipment nuances. CONCLUSION The data suggest that gastroenterologists deconstruct ERCP competence based on application of rules and rationale through reflection. Surgeons focus more on visual and tactile cues in task deconstruction, and may be more likely to measure proficiency based on technical response to such cues. Based on this study, it is proposed that both specialties might have complementary roles in training therapeutic endoscopists.
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Affiliation(s)
- Margaret L Boehler
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Nicole Roberts
- Medical Education and Academic Affairs Office, Sophie Davis School of Biomedical Education, City College of New York, New York, New York
| | - Hilary Sanfey
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - John Mellinger
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois.
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Canopy E, Evans M, Boehler M, Roberts N, Sanfey H, Mellinger J. Interdisciplinary cognitive task analysis: a strategy to develop a comprehensive endoscopic retrograde cholangiopancreatography protocol for use in fellowship training. Am J Surg 2015; 210:710-4. [DOI: 10.1016/j.amjsurg.2015.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/08/2015] [Accepted: 05/29/2015] [Indexed: 12/31/2022]
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Palma GDD. Minimally invasive treatment of cholecysto-choledocal lithiasis: The point of view of the surgical endoscopist. World J Gastrointest Surg 2013; 5:161-166. [PMID: 23977417 PMCID: PMC3750126 DOI: 10.4240/wjgs.v5.i6.161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 05/19/2013] [Indexed: 02/06/2023] Open
Abstract
The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%, depending on the patient’s age. Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones. At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include: single-stage laparoscopic treatment, perioperative endoscopic treatment and endoscopic treatment alone. Published data evidence that, associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay. However, current data does not suggest clear superiority of any one approach with regard to success, mortality, morbidity and cost-effectiveness. Considering the variety of therapeutic options available for management, a critical appraisal and decision-making is required. Endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis, i.e., in patients with acute obstructive suppurative cholangitis, severe biliary pancreatitis, ampullary stone impaction or severe comorbidity. In a setting where all facilities are available, decision in the selection of the therapeutic option depends on the patients, the number and size of choledocholithiasis stones, the anatomy of the cystic duct and common bile duct, the surgical history of patients and local expertise.
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Sachdeva AK, Buyske J, Dunnington GL, Sanfey HA, Mellinger JD, Scott DJ, Satava R, Fried GM, Jacobs LM, Burns KJ. A new paradigm for surgical procedural training. Curr Probl Surg 2011; 48:854-968. [PMID: 22078788 DOI: 10.1067/j.cpsurg.2011.08.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Ajit K Sachdeva
- Division of Education, American College of Surgeons, Chicago, Illinois, USA
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Spaun GO, Zheng B, Martinec DV, Arnold BN, Swanström LL. A comparison of early learning curves for complex bimanual coordination with open, laparoscopic, and flexible endoscopic instrumentation. Surg Endosc 2010; 24:2145-55. [DOI: 10.1007/s00464-010-0913-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 10/07/2009] [Indexed: 10/19/2022]
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Waller HM, Connor SJ. Cumulative sum (Cusum) analysis provides an objective measure of competency during training in endoscopic retrograde cholangio-pancreatography (ERCP). HPB (Oxford) 2009; 11:565-9. [PMID: 20495708 PMCID: PMC2785951 DOI: 10.1111/j.1477-2574.2009.00091.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 05/28/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangio-pancreatography (ERCP) is a complex and technically challenging procedure with a risk of significant complications. Although recommendations exist as to how many ERCPs should be performed before a trainee is deemed competent they lack objective measures of outcome. Cumulative sum (Cusum) analysis allows continuous monitoring of a proceduralist's performance to ensure acceptable outcomes are being achieved. The aim of the present study was to assess a trainee's progress with ERCP using Cusum analysis. METHOD A single trainee performed one supervised ERCP list per week between June 2005 and May 2008. Prospective data were collected and analysed by intention to treat using Cumulative failure charting and Cusum analysis. The binary outcome measure was successful cannulation in patients with a native sphincter. Acceptable and unacceptable cannulation failure rates were set at 20% and 35% respectively, with Type I and II error rates set at 0.10. RESULTS A total of 290 ERCPs were performed. Successful cannulation was achieved in 168 of 238 (70.6%) patients with intact biliary sphincters. Although cumulative failure charting suggested the trainee had not yet achieved satisfactory performance, Cusum analysis with sequential probability ratio testing indicated that an acceptable outcome had been achieved for the last 179 consecutive ERCPs. CONCLUSION Cusum analysis enables sensitive and continuous monitoring of a trainee's performance to objectively determine competency. Wider and systematic use may enable appropriate benchmarks to be identified and more objective assessment of a trainee's experience.
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Affiliation(s)
- Hayley M Waller
- Department of Surgery, Christchurch Hospital Christchurch, New Zealand
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Abstract
Although surgeons can safely perform endoscopic retrograde cholangiopancreatography (ERCP), it has fallen within the domain of gastroenterologists. We sought to quantify the role of ERCP in a tertiary-care surgery department. The hospital discharge database was queried for all ERCPs performed from January 2007 to December 2007. Gastroenterologists performed all ERCPs in our query. Surgical patients were admitted and/or under the care of a surgeon; whereas nonsurgical patients had no surgeon involvement. Patient characteristics and diagnoses were compared between groups. ERCP procedural details were recorded. Surgical patients comprised 48 per cent (n = 151) of the total 311 ERCPs performed. The mean time interval from a surgeon's request for ERCP to actual procedure was 2.43 days (standard deviation [SD] 2.55; range, 0-13 days). The surgical group had significantly different diagnoses and underwent less diagnostic (22% vs 56%) and more therapeutic ERCPs (72% vs 38%). Surgical patients were more likely inpatients (82.1% vs 16.8%) with a longer length of stay (6.7 vs 3.9 days; P = 0.0029) compared with nonsurgical patients. We found surgical patients requiring ERCP differ significantly from nonsurgical patients, with a significant number of technical interventions being outsourced. Given the benefits of a surgical ERCP program and the potential volume of these unique patients, this procedure should be performed by appropriately trained surgeons.
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Affiliation(s)
- Wesley B. Jones
- From the Division of Minimal Access and Bariatric Surgery, Department of Academic Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Richard H. Roettger
- From the Division of Minimal Access and Bariatric Surgery, Department of Academic Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - William S. Cobb
- From the Division of Minimal Access and Bariatric Surgery, Department of Academic Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Alfredo M. Carbonell
- From the Division of Minimal Access and Bariatric Surgery, Department of Academic Surgery, Greenville Hospital System University Medical Center, Greenville, South Carolina
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Springer J, Enns R, Romagnuolo J, Ponich T, Barkun AN, Armstrong D. Canadian credentialing guidelines for endoscopic retrograde cholangiopancreatography. Can J Gastroenterol 2008; 22:547-51. [PMID: 18560632 DOI: 10.1155/2008/582787] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
The foundation of skills for the performance of natural orifice translumenal endoscopic surgery (NOTES) lies in the training for general surgery (especially laparoscopy) and flexible gastrointestinal endoscopy. Physicians wishing to practice NOTES need to acquire or have both skill sets, or need to partner together to blend complementary capabilities with colleagues. In the future, however, a new cadre of NOTES specialists may emerge who will have developed individual expertise in the full spectrum of NOTES knowledge base requirements. This article highlights a body of knowledge and skills needed to become a NOTES proceduralist and review the current training paradigms for gastrointestinal endoscopists and surgeons.
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Affiliation(s)
- L Campbell Levy
- Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
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Affiliation(s)
- Eldo E. Frezza
- Division of General Surgery Department of Surgery Texas Tech University Health Sciences Center Lubbock, Texas
| | - Ari Halldorsson
- Division of General Surgery Department of Surgery Texas Tech University Health Sciences Center Lubbock, Texas
| | - John A. Griswold
- Division of General Surgery Department of Surgery Texas Tech University Health Sciences Center Lubbock, Texas
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Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the investigation and management of pancreaticobiliary disease. There is a recognized potential for significant morbidity, and a number of studies have identified patient and operator risk factors for the development of complications, including small case volume. We look at the outcomes of ERCP from a single operator at a rural centre and compare these with published figures. METHOD Findings from 700 consecutive ERCP were collected prospectively between August 1997 and May 2006. Patients were included on an intention to treat basis, and all predetermined morbidity criteria were recorded. RESULTS Five hundred and forty-four therapeutic and 156 diagnostic ERCP were included in the study. There were a total of 40 complications (5.71%), with three cases of ERCP-specific mortality (0.4%). The success of therapeutic intervention was 94.3%. CONCLUSIONS The importance of comparing personal audit to published prospective studies has been emphasized. This has provided quality assurance finding, confirming that comparable success rates, morbidity and mortality are possible in a low-volume rural centre with an operator who has been properly trained and has ongoing ties with a tertiary hepatobiliary unit, a dedicated and skilled local team and suitable patient selection.
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Affiliation(s)
- Philip E Dundee
- Department of Surgery, Northeast Health Wangaratta, Victoria, Australia.
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García-Cano J. 200 supervised procedures: the minimum threshold number for competency in performing endoscopic retrograde cholangiopancreatography. Surg Endosc 2007; 21:1254-5. [PMID: 17484011 DOI: 10.1007/s00464-006-9013-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2006] [Accepted: 06/02/2006] [Indexed: 01/13/2023]
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Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee. Guidelines for training in diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). Surg Endosc. 2007;21:1010-1011. [PMID: 17410399 DOI: 10.1007/s00464-007-9341-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 02/08/2007] [Indexed: 12/20/2022]
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