ERCP training: for the few, not for all

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that requires considerable training and experience to perform effectively and safely.1 It is the most dangerous procedure regularly performed by gastrointestinal endoscopists, with morbidity and mortality of 5–10% and 0.1–1%, respectively.2 In the United States, recommendations for ERCP training have evolved from ridiculously low “guesstimates” of procedure numbers required for competence3 (e.g. 25, 50) to the current consensus—based on a large prospective study4—that at least 180–200 diagnostic and therapeutic procedures are needed. ERCP is an integral part of the management of hepatobiliary and pancreatic (HBP) disorders, but it is only a part. Trainee gastroenterologists wishing to become experts in dealing with these disorders need to learn many clinical as well as procedural skills; it is useful to think of this as HBP training. The would be HBP specialist must work as part of a multidisciplinary team, and learn a great deal about body imaging (e.g. ultrasound, computed tomography, magnetic resonance), interventional radiology, gastrointestinal pathology and cytology, hepatology, oncology, surgery, and nutrition. Although perhaps only half of the cases seen in a specialist unit require ERCP, those intending to perform this procedure should be fully trained. There is no place for the purely “diagnostic” ERCP endoscopist: all endoscopists who perform ERCP must be able to decompress an obstructed biliary tree by sphincterotomy, stenting or nasobiliary drainage.5 The trained ERCP endoscopist’s success rate for cannulating the duct …