Endoscopic Retrograde Cholangiopancreatography (ERCP): Core Curriculum
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Communication from the ASGE Training ERCP CORE CURRICULUM Committee Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum Prepared by: ASGE TRAINING COMMITTEE Jennifer Jorgensen, MD, Nisa Kubiliun, MD, Joanna K. Law, MD, Mohammad A. Al-Haddad, MD, FASGE, Juliane Bingener-Casey, MD, PhD, Jennifer A. Christie, MD, Raquel E. Davila, MD, FASGE, Richard S. Kwon, MD, Keith L. Obstein, MD, MPH, Waqar A. Qureshi, MD, FASGE, Robert E. Sedlack, MD, MHPE, Mihir S. Wagh, MD, FASGE, Daniel Zanchetti, MD, Walter J. Coyle, MD, FASGE, previous Committee Chair, Jonathan Cohen, MD, FASGE, Committee Chair This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy This is one of a series of documents prepared by the “Training in Endoscopy,” of the Gastroenterology Core American Society for Gastrointestinal Endoscopy (ASGE) Curriculum (a combined effort of the ASGE, American Col- Training Committee. This curriculum document contains lege of Gastroenterology, and American Association for the recommendations for training and is intended for use by Study of Liver Diseases) review the overall objectives of endoscopy training directors, endoscopists involved in endoscopic training, the requirements for endoscopic teaching endoscopy, and trainees in endoscopy. It was trainers, and the training process itself.1-4 The “ASGE GI developed as an overview of techniques currently favored Core Curriculum” also has a chapter on Training in Biliary for the performance and training in endoscopic retro- Tract Diseases and Pancreatic Disorders, which is perti- grade cholangiopancreatography (ERCP) and to serve nent.1 The evolving issues of tracking outcomes and as- as a guide to published references, videos, and other sessing competency during endoscopy training are also resources available to the trainer. By providing informa- reviewed. These core documents are recommended to tion to endoscopy trainers about the common practices both endoscopic trainers and trainees alike. Entrustable used by experts in performing the technical aspects of Professional Activities are pre-identified competencies the procedure, the ASGE hopes to improve the teaching that can be trained and are measurable and specific with and performance of ERCP. direct impact on the professional activity at hand5; Entrust- able Professional Activities have recently been developed specifically for pancreatic and biliary diseases and are excel- INTRODUCTION AND IMPORTANCE lent resources.6 Acquiring the skills to perform ERCP safely, effectively, and competently requires not only technical training but GOALS OF TRAINING also an understanding of the indications, risks, benefits, limitations, and alternatives to the procedure. As a prereq- Programs offering training in ERCP should define the uisite, competence in upper endoscopy is required, goals of their training program. Specifically, training pro- including visualization of the upper GI tract, minimizing grams should determine whether they intend to offer fel- patient discomfort, proper identification of normal and lows only exposure to ERCP, training to a level of abnormal findings, and mastery of basic therapeutic tech- competence sufficient for independent practice, or niques. Only then can competency in using a side- tertiary-level advanced skills, such as require a fourth viewing endoscope and the ability to selectively cannulate year of commitment. the bile duct and/or the pancreatic duct be achieved. It All GI trainees require some exposure to ERCP to further requires competence in the production and inter- develop an understanding of the diagnostic and therapeu- pretation of cholangiograms and pancreatograms while tic roles of the procedure including the indications, contra- minimizing risk to the patient. The ASGE guideline, ‘‘Prin- indications, and possible adverse events. This exposure is ciples of Training in GI Endoscopy,’’ and the section, generally accomplished within the context of a 3-year gastroenterology fellowship training program. However, Copyright ª 2016 by the American Society for Gastrointestinal Endoscopy procedural exposure should not be equated to procedural 0016-5107/$36.00 competence. There is no consensus as to how many cases http://dx.doi.org/10.1016/j.gie.2015.11.006 or how many months of rotation on an ERCP service are www.giejournal.org Volume 83, No. 2 : 2016 GASTROINTESTINAL ENDOSCOPY 279 ERCP core curriculum necessary to gain satisfactory exposure for trainees not in- Faculty tending to perform ERCP. Programs dedicated to teaching ERCP should have more For individuals seeking credentialing to perform inde- than 1 faculty member expert in ERCP who is well experi- pendent ERCP after training, current ASGE guidelines enced in performing diagnostic and therapeutic proce- emphasize objective measures over case volume. Histori- dures.1 It is expected that the ERCP faculty will have cally, an accepted benchmark was set at a successful cannu- sufficient case volume and breadth to provide for a well- lation rate of greater than 80%.7 Others have suggested rounded training environment. Involved faculty should that a higher standard of 90% successful cannulation have a track record of effective endoscopic teaching and rate is more appropriate for those seeking independent must be willing to provide the trainee access to their practice upon completion of training. This level of compe- patients and ERCP cases. Regular didactic education should tency is seldom achieved within a standard 3-year GI also be provided to the trainee by the ERCP faculty. Regu- fellowship.8 lar formative and summative feedback should be provided The “Gastroenterology Core Curriculum,” published in to the trainee. This ideally should occur after each case in 2007, suggests that the minimum number of ERCPs addition to periodic formal feedback sessions. required before competency is assessed should be at least 1 200. The ASGE privileging guidelines clearly state that Facilities a trainee is not considered competent simply by reaching ERCP is typically performed in a hospital-based endos- this threshold and that competence should be determined copy unit. A processor, duodenoscope, fluoroscopic unit, by objective criteria and direct observation rather than and adequate accessories are the basic equipment neces- 9 based on procedure numbers alone. The growing body of sary to perform ERCP. Ideally, training programs should published data indicates that most trainees are not compe- also have the availability to perform EUS because many tent at this number of procedures and there is significant pancreaticobiliary diseases and ERCP procedures are com- 8,10,11 variation in the rate of skill acquisition among trainees. plemented by EUS. Issues to consider in addition to procedural volume fi include the degree of fellow participation and the dif culty Endoscopic experience of each procedure performed. It is important for training di- The training program should be able to provide an rectors to recognize that there can be considerable variation adequate breadth of cases. The decision to train 1 or in how much of each procedure logged by a fellow was actu- more fellows each year to achieve sufficient competency ally performed independently by the fellow. Trainee will depend on the volume of ERCPs performed at the logbook records should specify particular skills completed institution and the availability of experts in ERCP to super- by the fellow (cannulation, sphincterotomy, stent place- vise the training of fellows. With data suggesting that well ment, tissue sampling) and indicate both the degree of dif- over 200 cases are required for most trainees to consis- fi culty of the attempted procedure (ie, hilar stricture, altered tently cannulate the desired duct, programs with a limited anatomy, etc.) and the number of complete cases the case volume will have to weigh their training objectives trainee performed without assistance. Training programs with what is feasible.1 Fellows must be aware of this infor- should emphasize that documented achievement of mation, which can be obtained directly from the programs fi de ned threshold standards (eg, deep biliary cannulation or found on the ASGE training website (http://www.asge. rates in the setting of a normal papilla), and not only case org/education).3 However, as mentioned previously, the numbers, will form the primary basis for credentialing. emphasis should be on competency as assessed by objec- Another important consideration in using benchmarks tive measures and not just procedural volume. such as cannulation rates to gauge competency is the inherent difficulty of the attempted procedures. In a single-center study, Schutz and Abbot12 developed a TRAINING PROCESS grading scale for ERCP based on difficulty. A modification of this score was adopted by the ASGE as part of their quality Overview assessment document and is shown in Table 1.13,38 To provide a well-rounded and comprehensive training Trainees who elect to pursue additional training in ERCP experience, fellows should have a balanced exposure to pa- to attain procedural competence should have completed at tient care, didactics, and the technical aspects of ERCP. The least 18 months of a standard gastroenterology training cognitive aspects of ERCP training are critically important. program.1 The minimum duration for training required This includes a thorough knowledge of pancreaticobiliary to achieve advanced technical and cognitive skills is usually anatomy, including common variants, physiology,