Trainee involvement in ERCP: new criteria to simplify a complex problem

Studies have shown that trainee involvement in endoscopic retrograde cholangiopancreatography (ERCP) procedures results in increased time to cannulation and requirement for advanced cannulation techniques such as precut sphincterotomy [1]. The European Society of Gastrointestinal Endoscopy proposed the 5–5–1 criteria for difficult biliary cannulation: > 5 minutes attempting to cannulate, > 5 contacts with the papilla during cannulation attempts, > 1 unintended pancreatic duct guidewire cannulation or opacification [2]. We appreciate the novel 15–10–2 criteria proposed by Wang et al. for difficult cannulation for trainees involved in cannulation [3]. The study had a retrospective design and patients who underwent ERCP over 5 years were included.

The analysis wherein the 75th percentile of time, cannulation attempts, and pancreatic cannulation were used to define these new criteria seems optimal. However, there are a few limitations to the study. Although the protocol defined that trainees performed about 20 procedures on sphincterotomized papillae prior to attempts at cannulating native papillae, trainees who had performed a higher number of procedures were more likely to be better skilled [4]. Although trainees attended didactic lectures and basic training in ERCP, there is no mention as to whether objective assessment of their skill was undertaken prior to starting ERCPs on native papillae. The process of documentation of precise time taken for cannulation and charting of cannulation attempts would have been tedious considering the number of procedures performed at the center. It would have been interesting to know the protocol that the authors followed for this documentation. Although propensity score matching was performed to ensure both groups were comparable, there was higher need for advanced cannulation techniques in the trainee group despite using the simplified criteria; this need for advanced techniques remains unexplained. While the findings of this study are likely to be highly impactful on ERCP training, further prospective studies are needed for validation of the novel criteria.

Publication History

Article published online:
24 November 2021

• References

• 1 Voiosu T, Boskoski I, Voiosu AM. et al. Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial. Endoscopy 2020; 52: 115-122
• 2 Testoni PA, Mariani A, Aabakken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683
• 3 Wang X, Luo H, Tao Q. et al. Difficult biliary cannulation in ERCP procedures with or without trainee involvement: a comparative study. Endoscopy 2021; DOI: 10.1055/a-1523-0780.
• 4 Voiosu T, Bengus A, Voiosu A. et al. Trainee caseload correlates with ERCP success rates but not with procedure-related complications: results from a prospective study (the QUASIE cohort). Endosc Int Open 2016; 4: E409-E414