Reply to Arvanitakis et al.

The authors would like to thank Arvanitakis et al. for their insightful comments. Despite intense efforts to standardize training in endoscopic retrograde cholangiopancreatography (ERCP), we still lack an evidence-based approach to this endeavor. Deep biliary cannulation, the cornerstone of ERCP, presents mentors with a conundrum: trainees require a longer time on the papilla to acquire cannulation skills [1], but prolonged cannulation attempts can compromise the procedure and increase the risk for the patient [2], even when experts eventually take over. Duloy et al. [3] showed that the time allowed for cannulation attempts is variable among endoscopy training programs. Trainees were allowed more time, even in failed attempts, as their training progressed, which could reflect mentors trusting their trainees with more responsibilities as they advance in their training.

We agree that the lack of randomization and the training differences between centers could limit the generalizability of our study. Given the complexity of the procedure and the potential risks for the patient, a randomized multicenter trial of training in ERCP was not deemed feasible or, indeed, ethical at this point in time. However, the large number of procedures included in our cohort and the use of thorough multivariate analysis should minimize the impact of selection bias in the interpretation of our results. Furthermore, as pointed out by Arvanitakis et al., competence in ERCP is about much more than proficiency in cannulation.

ERCP procedures have steadily grown in scope and complexity, while the training paradigm has been slow to follow suit. One solution could be a two-tier training system, with novices focusing on acquiring the basic cannulation skills and more advanced training (grade 2 and 3 procedures) being reserved for endoscopists who are already deemed competent in basic cannulation. In the meantime, as we strive to improve training methods, we should acknowledge that ERCP is still an art, rather than a precise science [4].

Publikationsverlauf

Artikel online veröffentlicht:
25. März 2020

• References

• 1 Pan Y, Zhao L, Leung J. et al. Appropriate time for selective biliary cannulation by trainees during ERCP-a randomized trial. Endoscopy 2015; 47: 688-695
• 2 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
• 3 Duloy A, Keswani R, Hall M. et al. Time given to trainees to attempt cannulation during endoscopic retrograde cholangiopancreatography varies by training program and is not associated with competence. Clin Gastroenterol Hepatol 2019; DOI: 10.1016/j.cgh.2019.09.039.
• 4 Hawes RH, Devière J. How I cannulate the bile duct. Endoscopy 2018; 50: 75-77