Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy

ERCP Educational Guidelines for Fellows

“…Technical competence for ERCP can be assessed after 200 procedures; however, completion of a specified number of procedures does not imply competence, and target success rates may not be achieved until trainees have completed 350 to 400 procedures (12,13). It is recommended that the documentation of competence should be based on the completion of at least 200 unassisted procedures, and that this should include at least 80 supervised, independently performed sphincterotomies and the placement of at least 60 biliary stents or nasobiliary drains (9)(10)(11).…”

“…However, subsequent studies (12,13) have reported that success rates of over 80% for deep biliary cannulation might not be achieved until trainees have performed more than 300 to 400 procedures. An analysis (14) of outcomes, based on endoscopists' experience, found that learning endoscopic sphincterotomy techniques required a minimum of 40 procedures, but the complication rate decreased further after 100 procedures.…”

“…Indeed, a recent review (15) has proposed that interested trainees who have proven endoscopic competence should be selected for specialist training in ERCP and EUS only after an assessment period during which 50 to 100 ERCPs are performed. Subsequent assessment should encompass not only the number of supervised procedures completed without assistance but also other standardized metrics (16,17) including, for example, single-operator learning curves for deep biliary cannulation (12,18).…”

ERCP training - the potential role of simulation practice

“…an 80% success with selective cannulation 24 whereas Verma et al reported that it took 350-400 ERCP procedures for a single endoscopist to achieve 80% success with selective cannulation. 25 There is no consensus at present although the American Society for Gastrointestinal Endoscopy (ASGE) recommends that trainees should have performed 200 ERCP procedures with 80% success of cannulation and at least half of the procedures being therapeutic before they are considered competent. 26 The Australians have an even tougher criterion which requires trainees to have performed 200 successful solo procedures without trainer involvement.…”

Quality matters: A protocol-based strategy in ERCP training

“…More recently, Verma et al followed a single endoscopist's learning curve for deep biliary cannulation and observed that the successful cannulation rate of >80% was achieved after 350-400 supervised procedures. 6 In order to supplement the bedside teaching, simulators have been employed by some trainers. Following are the different types of simulators that have been introduced thus far: computer simulators, live animal models, porcine ex vivo models (Erlangen EndoTrainer), modification of porcine ex vivo models (Neo-Papilla), and mechanical simulators.…”