Endoscopic retrograde cholangiopancreatography training conditions, results from a pan-European survey: Between vision and reality

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) still has a relatively high complication rate, underscoring the importance of high-quality training. Despite existing guidelines, real-world data on training conditions remain limited. This pan-European survey aims to systematically explore the perceptions surrounding ERCP training.

Methods: A survey was distributed through the friends of United European Gastroenterology (UEG) Young Talent Group network to physicians working in a UEG member or associated states who regularly performed ERCPs.

Results: Of 1035 respondents from 35 countries, 649 were eligible for analysis: 228 trainees, 225 trainers, and 196 individuals who regularly performed ERCP but were neither trainees nor trainers. The mean age was 43 years, with 72.1% identifying as male, 27.6% as female, and 0.3% as non-binary. The majority (80.1%) agreed that a structured training regimen is desirable. However, only 13.7% of trainees and 28.4% of trainers reported having such a structured program in their institutions. Most respondents (79.7%) supported the concept of concentrating training in centers meeting specific quality metrics, with 64.1% suggesting a threshold of 200 annual ERCPs as a prerequisite. This threshold revealed that 36.4% of trainees pursued training in lower-volume centers performing <200 ERCPs annually. As many as 70.1% of trainees performed <50 annual ERCPs, whereas only 5.0% of trainers performed <50 ERCPs annually. A low individual trainee caseload (<50 ERCPs annually) was more common in lower-volume centers than in higher-volume centers (82.9% vs. 63.4%).

Conclusions: The first pan-European survey investigating ERCP training conditions reveals strong support for structured training and the concentration of training efforts within centers meeting specific quality metrics. Furthermore, this survey exposes the low availability of structured training programs with many trainees practicing at lower-volume centers and 71% of all trainees having little hands-on exposure. These data should motivate to standardize ERCP training conditions further and ultimately improve patient care throughout Europe.

Keywords: ERCP training; advanced endoscopy training; complications; endoscopic quality improvement; endoscopy education; guidelines; performance measures; real‐world; structured training; training measures.

FIGURE 1

Concentration and volume quality indicators at ERCP training institutions. (a) Overall demand for the concentration of ERCP training at centers with specific quality indicators (79.7%) with the actual adoption rates for individually tracked quality indicator rates at higher‐ and lower‐volume centers. (b) Overall demand for a minimum number of annual procedures for ERCP training centers in the perceptions of respondents from higher‐ and lower‐volume centers with the actual annual ERCP rates at institutions/year. (c) Distribution of the demand of number of trainees finishing their training at a specific institution in the last 5 years in the opinion of the trainers and the real number of current trainees at higher‐ and lower‐volume centers. ERCP, endoscopic retrograde cholangiopancreatography.

FIGURE 2

Institutional quality indicators for ERCP training institutions. (a) Institutional quality indicators for ERCP training recommended by trainers (in green) and adoption rate at higher‐ and lower‐volume centers. Differences between adoption rates at higher‐ and lower‐volume centers for papillary cannulation rates, number of procedures, post‐ERCP pancreatitis, perforation, post‐ERCP bleeding, and mortality. (b) Distribution of demand for the maximum rate of AE at a specific institution in the opinion of trainers. AE, adverse events; ERCP, endoscopic retrograde cholangiopancreatography.

FIGURE 3

Demand and current practice for structured ERCP training. (a) Overall demand for structured ERCP training (80.1% of all respondents) with the actual adoption rates at higher‐ and lower‐volume centers. (b) Inclusion and kind of mandatory ERCP courses by center volume. (c) Distribution of required courses for ERCP training. ERCP, endoscopic retrograde cholangiopancreatography; ESGE, European Society for Gastrointestinal Endoscopy.

FIGURE 4

Assessment of ERCP training and performance standards. (a) Rates of individual quality indicators are most valid in indicating high‐quality ERCP in the opinion of trainers. (b) Distribution of a minimum native papilla cannulation rate before a trainee should be allowed to perform ERCP independently in the opinion of trainers from higher‐ and lower‐volume centers. (c) Distribution of the number of cannulation attempts trainers should allow their training before they intervene in the opinion of trainers from higher‐ and lower‐volume centers. (d) Distribution of a maximum AE before a trainee should be allowed to perform ERCP independently in the opinion of trainers from higher‐ and lower‐volume centers. AE, adverse events; ERCP, endoscopic retrograde cholangiopancreatography.

FIGURE 5

Trainer perspectives on ERCP training criteria and competency certification. (a) Minimum number of ERCP procedures a trainee should be supervised in the opinion of the trainers at higher‐ and lower‐volume centers. (b) Distribution of the kind of competence certification in ERCP a trainee, should receive to be allowed to perform ERCPs independently in the opinion of the trainers from higher‐ and lower‐volume centers. (c) Actual number of ERCPs performed in the last year by trainers and trainees of higher‐ and lower‐volume centers. (d) Preferred approach in the opinion of trainers from higher‐ and lower‐volume centers on how trainers and trainees should manage a highly complex ERCP. ERCP, endoscopic retrograde cholangiopancreatography.