Making ERCP training safe: A protocol-based strategy to minimize complications during selective biliary cannulation

Background and aims: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced procedure with significant complication rate of 5 to 10%. Scant data is available on quality indicators for trainee-involved ERCP. In our study, we evaluated the outcome of trainee-involved ERCPs in which a protocol-based strategy to minimize complications during selective biliary cannulation was adopted.

Patients and methods: Hands-on training was excluded if patients had ASA grade > 3. The trainee's attempts at selective biliary cannulation were stopped and the procedure taken over by the supervising expert endoscopist if the following factors were encountered: (1) failed cannulation after 5 attempts; (2) unsuccessful cannulation after 10 minutes; (3) edematous papilla; (4) pancreatic duct cannulation ≥ 2 times. After successful ductal cannulation, the trainee was allowed to continue additional hands on training in other aspects such as stone extraction and stenting.

Results: During the study period, 331 patients underwent ERCP. Trainee group (TG) consisted of 85 patients; mean age 70 (range 27-99). Expert group (EG) consisted of 246 patients; mean age 65 (range 19-98). The overall technical success rate was 97.9% and there was no significant difference between TG (98.8%) and EG (97.6%). The overall complication rate was 3.9% and there was no difference between TG (3.5%) and EG (4%). In TG, although inadvertent pancreatic duct cannulation occurred in 12/85 (14.1%), acute pancreatitis developed only in 3/85 (3.5%).

Conclusion: The high success and low complication rates in trainee-involved and expert-only ERCP procedures were similar. While using a protocol-based strategy, good clinical outcome during the provision of hands-on training for ERCP was observed.