ERCP

The Fundamentals

Peter B. Cotton, Joseph W. Leung, Peter B. Cotton, Joseph W. Leung

• Publisher: Wiley-Blackwell
• Year: 2020
• ISBN:
  9781119601081
• Edition: 3
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

Provides the comprehensive knowledge required to perform ERCP safely and effectively

Authored by the very best in the field, this "how-to" guide to mastering the crucial yet complex gastrointestinal procedure called endoscopic retrograde cholangiopancreatography (ERCP) covers the entire range of both standard and advanced techniques, using a highly practical approach. It also places a strong emphasis on patient education, safety, and minimizing risks, offering "tips and tricks" and key points throughout to aid rapid understanding. The book is filled with over 250 illustrations

Covering ERCP preparation, techniques, clinical applications, and quality and safety, ERCP: The Fundamentals, 3rd Edition begins with chapters on "getting prepared, " including training and competence; facilities and equipment; risk assessment and reduction; sedation, anesthesia, and medications. It then covers "what can be done, " describing standard devices and techniques; intraductal therapies; ampullectomy; and reporting and documentation. Next it has chapters on "what should be done, " clinical applications of ERCP in acute cholangitis; peri-cholecystectomy; difficult bile duct stones; biliary pain; and numerous forms of pancreatitis. The book finishes with coverage of adverse events and how to ensure competent practice.

• Teaches all of the standard and advanced ERCP techniques
• Focuses on patient safety/comfort throughout
• Brilliantly-illustrated with endoscopic, EUS and radiologic images, and anatomical drawings
• Offers a step-by-step, practical approach to ERCP—highlighting potential technical and anatomical hazards
• Packed with tips and tricks boxes and key points boxes to assist comprehension
• 20 high-definition videos of ERCP performed by the experts, perfect to improve clinical technique
• Full reference to the very latest ASGE, ACG, ASG and UEGW guidelines throughout

Brought to you by world pioneers in endoscopy, ERCP: The Fundamentals, 3 rd Edition is an essential purchase for gastroenterologists and endoscopists of all levels.

Section 1
Preparation

1
Training and Assessment of Competence (Preparing the Endoscopist)

Joseph W. Leung^1,2 and Peter B. Cotton³

¹ Department of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA, USA

² Section of Gastroenterology, VA Northern California Health Care System, Sacramento VAMC, Mather, CA, USA

³ Digestive Disease Center, Medical University of South Carolina, Charleston, SC, USA

---

Key Points

• ERCP includes a range of mainly therapeutic procedures of different levels of complexity.
• Training involves both clinical and technical aspects.
• Hands‐on apprenticeship dominates, but various simulators can help.
• Competence should be assessed objectively, and the data made available to patients.

---

Background

ERCP is the most complex common endoscopic (digestive) procedure. It has great potential for benefit, but it also carries significant risk of failure, adverse events [1], and medicolegal jeopardy [2]. Clearly it must be done as well as possible, and there has been more focus on quality recently. The key questions are:

• Who should be trained?
• What should be taught, and how?
• Who should teach?
• How are training and competence assessed?
• What level of performance is acceptable?

Who Should Be Trained?

ERCP training is usually a part of the postgraduate training of selected gastroenterologists and a few surgeons. The number needed has fallen with the widespread use of magnetic resonance cholangiopancreatography (MRCP) (and also endoscopic ultrasound [EUS]). In the structured British National Health System, the number of training positions is now tailored to the projected population needs. In many countries, and especially in the United States, there is no such limitation, with the result that some trainees are short‐changed, and some have marginal volumes in ongoing practice. It is incumbent on training programs to ensure that those they train are able to reach an acceptable level of competence for safe independent practice. To limit training to less but produce more qualified trainees in the United States, some gastrointestinal (GI) programs have limited advanced endoscopy (ERCP and EUS) to a 4th year of training.

What Should Be Taught, and How?

While we focus here mainly on the difficulties involved in teaching the necessary technical skills, it is essential to realize that optimal ERCP requires that practitioners are knowledgeable about pancreatic and biliary medicine and the many alternative diagnostic and therapeutic approaches, as well as being skilled in the basic tenets of patient care. These important aspects should be well covered in basic GI training programs, such as the three‐year fellowships in United States. Hands‐on training is an integral part of ERCP practice and is done under close supervision by the trainer in a progressive manner to avoid mistakes that can be detrimental or may have a negative impact on outcome.

Levels of Complexity

ERCP is not a single procedure. The term encompasses a large spectrum of interventions performed (mainly) through the papilla. The concept of levels of complexity or difficulty, introduced by Schutz and Abbot, has recently been updated by a working party of American Society for Gastrointestinal Endoscopy (ASGE) [3]. (Table 1.1). Levels 1 and 2 together include the standard (mostly biliary) procedures, which are needed at relatively short notice at the community level. The more complex level 3 (“advanced”) and 4 (“tertiary”) procedures are mainly performed by relatively few highly trained endoscopists in referral centers.

These distinctions are clearly relevant to training. No one should be trained to less than competence at level 2. Although some practitioners will gradually advance those skills in practice (with mentoring, self‐study, and courses), there are increasing numbers of advanced positions (e.g. 4th year in the United States), providing training in the more complex procedures.

Progressive Training

Like other endoscopy procedures, basic ERCP training involves lectures, study courses, didactic teaching, and the use of books, atlases, and videos in addition to hands‐on supervised clinical practice [4–6]. Clinical teaching includes the elements of a proper history and physical examination with pertinent laboratory tests. Overall management will include work with in‐ and outpatients with pancreaticobiliary problems, with discussion on the various diagnostic and treatment op...