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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 !