Reply to the Letter of Dr. Mosca

Dear Sir,

We thank Dr. Mosca for his interest and comments regarding our recent study [1]. Our hospital is a newly equipped public community hospital which provides 24-hour emergency medical and surgical services. It has been estimated that in an average district general hospital, 125 ERCPs would be performed each year [2]. In our study, we had performed 341 ERCPs over a 20-month period (i. e. around 200 ERCPs per year). This would be a reasonable workload if we kept the number of endoscopists to a minimum. Whether it is practicable to have just one or two specialist endoscopists to perform all elective and on-call emergency ERCPs remains arguable, and would certainly depend on other factors such as hospital policy and resource allocation. A common scenario in our locality is that ERCP is performed by endoscopists with some form of training and experience. The findings from our study revealed that this practice should be re-evaluated and perhaps abandoned in order to achieve better patient care.

There has never been a perfect definition in the literature of a competent endoscopist for ERCP. A previous study has suggested that 180 - 200 procedures were required to achieve competency in ERCP training [3]. We arbitrarily chose 300 procedures in our definition in order to provide a safety margin. However, a definition of competency is not ideal which simply uses the number of procedures performed. We believe the cognitive and interpretive skills of endoscopists are equally important, and for this reason, we incorporated the gastroenterology or gastrointestinal surgical specialist qualification into our definition. Using this definition, we were able to demonstrate that “specialist endoscopists” performed more successful procedures with lesser complications [1]. We do not agree that our overall mortalities were relatively high. In fact, there was only one ERCP-related death among the three deaths in the nonspecialist group.

We believe that, in future, complicated endoscopic procedures such as ERCP should be performed by specialist endoscopists who have adequate experience and cognitive and interpretive skills. They should work in high-volume centers to maintain their proficiency. For low-volume units, a reasonable solution is to refer complicated endoscopies to tertiary centers. Alternatively, specialist endoscopists could work in more than one unit to get a reasonable workload to maintain their proficiency.

References

• 1 Lee D W, Poon C M, Chan K H, Chan A C. Should specialist endoscopists perform all complicated endoscopies?.  Endoscopy. 2002;  34 174-175
• 2 Gear M W, Dent N A, Colin-Jones D G. et al . Future needs for ERCP: Incidence of conditions leading to bile duct obstruction and requirements for diagnostic and therapeutic biliary procedures.  Gut. 1990;  31 1150-1155
• 3 Jowell P S, Baillie J, Branch M S. et al . Quantitative assessment of procedural competence: A prospective study of training in endoscopic retrograde cholangiopancreatography.  Ann Intern Med. 1996;  125 983-989