Endoscopy 2023; 55(09): 804-811
DOI: 10.1055/a-2042-6288
Original article

A simple clinical score to stratify the risk of procedure-related adverse events in ERCP procedures with trainee involvement

Theodor A. Voiosu
 1   Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
 2   Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
Andreea Benguș
 1   Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
 3   Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium
 4   Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
 5   Imelda GI Research Center, Bonheiden, Belgium
 6   Department of Gastroenterology, University Hospital “Tsaritsa Yoanna – ISUL”, Sofia, Bulgaria
 7   Department of Gastroenterology, Medical University Sofia, Sofia, Bulgaria
Ivo Klarin
 8   Department of Health Studies, University of Zadar, Zadar, Croatia
 9   Gastroenterology Department, General Hospital Zadar, Zadar, Croatia
Bianca Voiosu
10   Gastroenterology Department, Cantacuzino Hospital, Bucharest, Romania
Paul Bălănescu
11   Internal Medicine Department, Carol Davila School of Medicine, Bucharest, Romania
12   Clinical Immunology Department, Colentina Clinical Hospital, Bucharest, Romania
 1   Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
Bogdan Busuioc
10   Gastroenterology Department, Cantacuzino Hospital, Bucharest, Romania
Ivo Boskoski
13   Gastroenterology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
14   Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
 1   Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
 2   Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
Radu B. Mateescu
 1   Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
 2   Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
Sachin Wani
15   University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
› Author Affiliations


Background Optimal training strategies in endoscopic retrograde cholangiopancreatography (ERCP) remain controversial despite the shift toward competence-based training models, with limited data available on patient safety during training. We aimed to assess whether pre-procedural clinical predictors could identify patients at low risk of developing procedure-related adverse-events (AEs) in a training environment.

Methods We performed a prospective, multicenter, cohort study in five training centers. A data collection system documenting indication, clinical data, trainee performance (assessed using a validated competence assessment tool), technical outcomes, and AEs over a 30-day follow-up was utilized. We developed a clinical risk score (Trainee Involvement in ERCP Risk Score [TIERS]) for patients undergoing ERCP and compared the rate of AEs in a training environment between low-risk and high-risk groups. The association between trainee performance and AE rate was also evaluated.

Results 1283 ERCPs (409 [31.9 %, 95 %CI 29.3 %–34.4 %] with trainee involvement) performed by 11 trainers and 10 trainees were analyzed. AEs were more frequent in the high-risk compared with the low-risk group: 26.7 % (95 %CI 20.5 %–34.7 %) vs. 17.1 % (95 %CI 12.8 %–22.2 %). TIERS demonstrated a high negative predictive value for AEs (82.9 %, 95 %CI 79.4 %–85.8 %) and was the only predictor of AEs on multivariable analysis (odds ratio 1.38, 95 %CI 1.09–1.75). Suboptimal trainee performance was associated with an increase in AE rates.

Conclusion Simple, clinical-based predictive tools could improve ERCP training by selecting the most appropriate cases for hands-on training, with the aim of increasing patient safety.

Supplementary material

Publication History

Received: 24 October 2022

Accepted after revision: 24 February 2023

Accepted Manuscript online:
24 February 2023

Article published online:
03 May 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

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