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ERCP • the most challenging endoscopic procedure

• thecnical difficult, may fail, carries risks

• requires:

– knowledge of biliary and pacreatic deseases and

alternative approaches

– specific and complex organization,

– complex material

– different professional skills

DIAGNOSTIC

ERCP: 1970-2010

THERAPEUTIC

ERCP PROCEDURE

• intubation,

• approach to the papilla

• cannulation

Endoscopist’s perspective

b.d.

p.d.

Deviere J. Endoscopy. 2003;35:750

wire vs contrast ?

success of cannulation

Cennamo V, Am J Gastroenterol, 2009,104:2343

HORIUCHI A. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY, 2007, 5:113

small

large

swollen

transpancreatic sphincterotomy

needle-knife precut sphincterotomy

needle-knife fistulotomy

Cennamo V. Endoscopy 2010; 42: 381 – 388

Biliary cannulation can be facilitated by pancreatic stent insertion

Placement of a biliary catheter in the pancreatic duct to aid common bile duct cannulation

Addley J Endoscopy 2009; 41: E35. Fry LC .Endoscopy 2003; 35:97

Endoscopic

sphincterotomy and

stone extraction

endoscopic stenting

for malignant jaundice

metal stent

leakage

post operative bile duct injuries

stricture

variations in complication rates

Freeman ‘96 Loperfido ‘98 Masci ‘01

ERCP’s 3356 2444

E.S. 2347

Complications (%) 9.8 4 5

Pancreatitis (%) 5.4 1.3 1.8

Bleeding (%) 2 0.8 1.2

Perforation (%) 0.3 0.6

Cholangitis (%) 1.5

consensus definitions of complications

criteria of severity

• lenght of hospital stay

• intervention required

Cotton PB, Gastrointest Endosc, 1991, 37:383

Cotton PB, Gastrointest Endosc, 1991, 37:383

Cennamo V. Endoscopy 2010; 42: 381 – 388

Selezionare per scrivere o eliminare il sottotitolo

Cotton PB, Gastrointest Endosc, 1991, 37:383

Post-ERCP pancreatitis

Post-ERCP pancreatitis

Cotton PB, Gastrointest Endosc, 1991, 37:383

Cennamo V. Endoscopy 2010; 42: 381 – 388

Cotton PB, Gastrointest Endosc, 1991, 37:383

“ERCP is challenging and not for all

gastroenterologist” P.Cotton

• is the most challenging endoscopic procedure

• is thecnical difficult, may fail, carries risks

• requires:

– knowledge of biliary and pacreatic deseases and

alternative approaches

– specific and complex organization,

– complex material

– different professional skills

Competence:

“the point at which a traineee can practice independently”

criteria for competence in ERCP ?

• “Threshold” numbers :

– 100 (75 Dx, 25 Tx) (ASGE ‘86)

– 200 unassisted (CCRT - AU)

• performance results:

– minimal standards: 80% biliary cannulation (ASGE ‘02)

• list of needed skills, without goals (JAG - BR)

1 2 3

Competent 80-90 % - -

Proficient 90+ % 80+ % -

Expert 98+ % 95+ % 90+ %

Degrees

of

difficulty Diagnostic Therapeutic

1

Standard

Selective deep cannulation

Diagnostic sampling

Biliary sphincterotomy

Stones < 10 mm

Stents for leaks

Low tumors

2

Advanced

Billroth II diagnostics

Minor papilla cannulation

Stones > 10 mm

Hilar tumors

Benign biliary strictures

3

Tertiary

Manometry

Whipple

Roux-en-y

Intraductal endoscopy

Billroth II therapeutics

Intrahepatic stones

Pancreatic therapies

simulators for training and assessing skill

type Pro Contr

computer

Basic

orientation

Laks realism;

No tactile

sensation

ex vivo

Real scope

and

accessories

More difficult

for

anatomical

variations

in vivo Closest

resemblance Ethic

This training also may be obtained gradually after

completion of training in collaboration and mentoring by

an experienced adult or pediatric gastroenterologist with

expertise in the specific procedures or during focused

participation in an adult therapeutic endoscopy training

program and subsequent mentoring by a pediatric or

adult gastroenterologist with experience in performing

these procedures in pediatric patients.

SIED - R E Q U E S T - Audit

REte sulla QUalità della ERCP, dei Servizi di Endoscopia e del Training

UK: ERCPist requirements

• 0.9 ERCP/1000/year

• 2 ERCPist

• predicted reteirement

rate

• needs: 30 trainees/year

should complete ERCP

training

AUDITABLE RECORDS

• <10%ERCP without tx intent

• >80% decompression

• ERCP failed alternative

decompression in 5 d (1d if

cholang)

• <1% trasfusion

• <2% perforation

• <5% pancreatitis

• <1% mortality

SIED - R E Q U E S T - Audit

REte sulla QUalità della ERCP,

dei Servizi di Endoscopia e del Training

SIED - R E Q U E S T - Audit

REte sulla QUalità della ERCP, dei Servizi di Endoscopia e del Training

18 182 procedures performed by the 63 endoscopists

conclusion

• ERCP is challenging: thecnical difficult, may

fail, carries risks;

• requires:

– knowledge of pancreatic and biliary deseases

– skills

– training

– continuous monitoring of performance

• and…is not for all gastroenterologist !