Can Trainees Safely Perform Endoscopic Treatments for Common Bile Duct Stones? A Single-center Retrospective Study

Iida, Tomoya; Kaneto, Hiroyuki; Wagatsuma, K.; Sasaki, Hajime; Naganawa, Yumiko; Nakagaki, Suguru; Satoh, Shuji; Shimizu, Haruo; Nakase, Hiroshi

doi:10.2169/internalmedicine.9737-17

Cited by 6 publications

(13 citation statements)

References 29 publications

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“…There is conflicting prior data with regards to the success and safety profile of ERCPs with involvement of trainees. 5,32,33 A recent study utilizing the NIS database from 2008 to 2012 found a higher mortality associated with ERCPs in teaching hospitals but no significant difference in the rate of PEP. 34 On the contrary, a recent prospective study did not show any differences in procedural adverse events with the involvement of trainees.…”

Section: Discussionmentioning

confidence: 99%

Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis

Mutneja

Vohra

et al. 2020

Endoscopy

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BACKGROUND AND STUDY AIMS: Post-ERCP pancreatitis (PEP) is the most common and serious complication of ERCPs. Our aim was to estimate the nationwide incidence, temporal trends and mortality of PEP and establish its risk-factors in the United States. METHODS: This was a retrospective cohort study analyzing the Nationwide Inpatient Sample (NIS) data from 2011 to 2017 using ICD codes. The primary outcomes were to assess the trends of post-ERCP pancreatitis (PEP) and the predictors of occurrence of PEP. Secondary outcomes were in-hospital mortality, length of stay and ICU admission. RESULTS: Of the 1,222,467 adult patients who underwent inpatient ERCP during the study period, 55,225 (4.5%) developed post-ERCP pancreatitis. The hospital admission rate of PEP increased by 13.3% from 7,735 in 2011 to 8,920 in 2017 (OR 1.23, 95% CI 1.04-1.46; p = 0.016). The overall rate of mortality increased from 2.75% of PEP cases in 2011 to 4.38% in 2017 (OR: 1.62, 95% CI 1.10-2.38, p = 0.014). Multiple patient-related (alcohol use, cocaine use, obesity, chronic kidney disease, heart failure), procedure-related (therapeutic ERCP, sphincterotomy, pancreatic duct stent placement, sphincter of Oddi dysfunction) and hospital-related factors (teaching hospitals, hospitals located in West and Mid-west) that impact the occurrence of PEP were identified. CONCLUSIONS: Our study shows a rising hospital admission rate and mortality associated with PEP in the United States. This calls for a greater recognition of this life-threatening complication and amelioration of its risk-factors, whenever possible.

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Section: Discussionmentioning

confidence: 99%

Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis

Mutneja

Vohra

et al. 2020

Endoscopy

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“…While Frost et al [14] showed that trainee involvement does not negatively influence either successful cannulation or time to cannulation, other data suggest that trainee involvement might actually increase the use of precut in order to facilitate access to the CBD [11]. With respect to patient safety, although available data [11,14,15] suggest that patient safety is not compromised by trainee involvement, these studies are usually underpowered for the analysis of complication rates.…”

Section: Potential Risk Factorsmentioning

confidence: 99%

Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial

et al. 2019

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Background Training in advanced endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP) should be driven by key performance measures and standardized competence assessment in order to provide safe and high-quality interventions. We aimed to determine whether the involvement of trainees influences the outcome of the procedure and the incidence of ERCP-related adverse events. Methods This was an international, multicenter, prospective, observational study conducted at six high- and low-volume centers across Europe between October 2016 and October 2018, and included independent operators and their trainees. Standard report forms documenting indication, trainee involvement, technical outcome, and complications over a 30-day follow-up of consecutive ERCP procedures were included in the analysis. Technical success of the procedure and procedure-related adverse events were compared between procedures in the trainee group and the control group using bivariable and multivariable analysis. Results 21 trainees and 16 control endoscopists performed 1843 ERCPs during the study period. Trainee involvement in ERCP procedures did not decrease technical success (92.4 % vs. 93.7 %; P = 0.30) or increase the risk of adverse events (14.7 % vs. 14.6 %; P > 0.99). Conversely, there were significantly more moderate or severe adverse events in the control group compared with the trainee group (6.2 % vs. 3.4 %, P = 0.01). On multivariable analysis, only increased bilirubin levels, time to cannulation, and procedure difficulty level increased the risk of any procedure-related adverse event. Conclusion Trainee involvement in ERCP interventions within a proper teaching setting is safe and does not compromise the success of the procedure.

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“…Only three out 20 studies (15%) report the percentage of procedures completed by trainees without hands‐on intervention from a supervisor 18 , 20 , 21 . Iida et al 20 . report a success rate of 63.3% for common bile duct (CBD) stone clearance, while Voiosu et al 21 .…”

Section: Resultsmentioning

confidence: 99%

“…Explicit estimates of trainee and supervisor caseloads prior to study inception were lacking or unclear in 8/20 (40%) and 16/20 (80%) of studies respectively. Furthermore, the threshold between trainee and trainer is further muddled by the fact that in two studies the definition of expert/supervisor is based on previous experience of only 300 and 500 ERCPs respectively, 20,23 a low volume which practically overlaps caseloads accrued by some trainees during the study period in some of the other included articles. 18,25 Achieving competence in ERCP Table 1.…”

Section: Training Protocol Ercp Trainees and Supervisorsmentioning

confidence: 99%

“…Only three out 20 studies (15%) report the percentage of procedures completed by trainees without hands-on intervention from a supervisor. 18,20,21 Iida et al 20 report a success rate of 63.3% for common bile duct (CBD) stone clearance, while Voiosu et al 21 and Verma et al 18 report a success rate of 33.9% and 66% respectively for trainees completing procedures with a wide range of indications (i.e. stone extraction, stenting of benign and malignant strictures, treatment of bile leaks, etc.…”

Section: Achieving Competence In Ercp: Looking Beyond Cannulation Ratesmentioning

confidence: 99%

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Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature

et al. 2019

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Background: Current recommendations on training in endoscopic retrograde cholangiopancreatography are predicated on a performance-centred approach designed to ensure that trainees achieve appropriate skills. We aimed to analyse how competence in endoscopic retrograde cholangiopancreatography is defined in the literature and what proportion of trainees actually reach this threshold. Methods: We conducted a systematic MEDLINE search for studies reporting on endoscopic retrograde cholangiopancreatography training programmes in a clinical setting. The main outcome measure was threshold for achieving competence in endoscopic retrograde cholangiopancreatography; the secondary outcome measure was assessment of trainee performance. Quality was assessed using the Cochrane Risk of Bias tool and the Methodological Index for Non-Randomized Studies criteria. Results: Of 522 initially identified articles, 20 were included in the analysis; most studies showed a high risk of bias. Cannulation rate of the desired duct was the main marker of competence in all studies; however, only 8/20 studies reported on the performance of individual trainees, who achieved their respective standard of competence in only 25.6% of reported cases. Conclusions: Current literature identifies cannulation rate of a native papilla to be the most appropriate measure of endoscopic retrograde cholangiopancreatography competence; however, most trainees do not reach predefined competence thresholds. Furthermore, due to the limitations of available studies, the most appropriate competence measure remains subject for debate.

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Can Trainees Safely Perform Endoscopic Treatments for Common Bile Duct Stones? A Single-center Retrospective Study

Cited by 6 publications

References 29 publications

Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis

Temporal trends and mortality of post-ERCP pancreatitis in the United States: a nationwide analysis

Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial

Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature

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