Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial
submitted 22 July 2019
accepted after revision 25 October 2019
25 November 2019 (online)
Background Training in advanced endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP) should be driven by key performance measures and standardized competence assessment in order to provide safe and high-quality interventions. We aimed to determine whether the involvement of trainees influences the outcome of the procedure and the incidence of ERCP-related adverse events.
Methods This was an international, multicenter, prospective, observational study conducted at six high- and low-volume centers across Europe between October 2016 and October 2018, and included independent operators and their trainees. Standard report forms documenting indication, trainee involvement, technical outcome, and complications over a 30-day follow-up of consecutive ERCP procedures were included in the analysis. Technical success of the procedure and procedure-related adverse events were compared between procedures in the trainee group and the control group using bivariable and multivariable analysis.
Results 21 trainees and 16 control endoscopists performed 1843 ERCPs during the study period. Trainee involvement in ERCP procedures did not decrease technical success (92.4 % vs. 93.7 %; P = 0.30) or increase the risk of adverse events (14.7 % vs. 14.6 %; P > 0.99). Conversely, there were significantly more moderate or severe adverse events in the control group compared with the trainee group (6.2 % vs. 3.4 %, P = 0.01). On multivariable analysis, only increased bilirubin levels, time to cannulation, and procedure difficulty level increased the risk of any procedure-related adverse event.
Conclusion Trainee involvement in ERCP interventions within a proper teaching setting is safe and does not compromise the success of the procedure.
- 1 Jorgensen J, Kubiliun N. ASGE Training Committee. et al. Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum. Gastrointest Endosc 2016; 83: 279-289
- 2 Domagk D, Oppong KW, Aabakken L. et al. Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50: 1116-1112
- 3 Voiosu T, Bălănescu P, Voiosu A. et al. Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: a systematic review of the literature. United European Gastroenterol J 2019; 7: 239-249
- 4 Wani S, Keswani RN, Han S. et al. Competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, from training through independent practice. Gastroenterology 2018; 155: 1483-1494.e7
- 5 Cheng CL, Sherman S, Watkins JL. et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006; 101: 139-147
- 6 Ekkelenkamp VE, Koch AD, Rauws E. et al. Competence development in ERCP: the learning curve of novice trainees. Endoscopy 2014; 46: 949-955
- 7 Schutz SM, Abbott RM. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc 2000; 51: 535-539
- 8 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1997; 37: 383-393
- 9 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
- 10 Isaacs P. Endoscopic retrograde cholangiopancreatography training in the United Kingdom: a critical review. World J Gastrointest Endosc 2011; 3: 30-33
- 11 Voiosu T, Voiosu A, Benguş A. et al. 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?. Rom J Intern Med 2018; 56: 55-61
- 12 Cotton PB, Romagnuolo J, Faigel DO. et al. The ERCP quality network: a pilot study of benchmarking practice and performance. Am J Med Qual 2013; 28: 256-260
- 13 Kapral C, Duller C, Wewalka F. et al. Case volume and outcome of endoscopic retrograde cholangiopancreatography: results of a nationwide Austrian benchmarking project. Endoscopy 2008; 40: 625-630
- 14 Frost JW, Kurup A, Shetty S. et al. Does the presence of a trainee compromise success of biliary cannulation at ERCP?. Endosc Int Open 2017; 5: E559-E562
- 15 Iida T, Kaneto H, Wagatsuma K. et al. Can trainees safely perform endoscopic treatments for common bile duct stones? a single-center retrospective study. Intern Med 2018; 57: 923-928
- 16 Kwek BE, Ang TL, Teo EK. et al. Making ERCP training safe: a protocol-based strategy to minimize complications during selective biliary cannulation. J Interv Gastroenterol 2012; 2: 66-69