A Proposed Curriculum for Endoscopic Retrograde Cholangiopancreatography (ERCP) Training During General Surgery Residency

Cory Richardson, MD, Maris Jones, MD, Charles R St. Hill, MD, MSc, Matthew Johnson, MD, Jenny Lam, Nathan Ozobia, MD, FACS. University of Nevada School of Medicine

Introduction: Increased interest in surgeon-performed ERCP has prompted surgical endoscopy fellowships to incorporate ERCP into their training. In 2007, SAGES published guidelines for training in diagnostic and therapeutic ERCP. Since then, our institution has established an ERCP training program for select residents and fellows and has reported on the completion of this program and acquisition of independent credentialing by the conclusion of fellowship. Presented here is a curriculum showing the same can be accomplished during the five years of a residency program with a surgical endoscopy pathway.

Methods: Yearly objectives were identified and residents with a specific interest in incorporating ERCP into their practice were selected.

Year 1

Introduced to the concept of ERCP and its incorporation into surgical practice. ERCP related research is expected. Begin performing EGD’s, PEG tubes, and colonoscopies.

Year 2
Increase focus on performing lap choles, with emphasis on IOCs, which promotes proficient laparoscopic ductal cannulation. Perform simulated ERCPs in a skills lab setting.
Year 3
Perform ERCPs with direct supervision. Procedural autonomy begins with scope manipulation and progresses towards cannulation and cholangiogram interpretation. Supine, semi-prone, and prone positions are utilized.
Year 4
Perform advanced cannulation techniques, selective ductal cannulation, and focus on therapeutic papillotomy, stone extraction, and stent placement.
Year 5

Perform all aspects of diagnostic and therapeutic ERCP. Advanced cannulation techniques and selective cannulation of the CBD and PD are performed. Stone extraction techniques are mastered. Papillotomy, balloon dilatation, biopsies, and CBD and pancreatic stenting are performed. ERCP performed for a variety of indications including stones, iatrogenic injuries, malignant pathology, and traumatic hepatopancreaticobiliary injuries.

A didactic curriculum was completed that included instruction in safe cannulation techniques, use of fluoroscopy, interpretation of cholangiography, indications for therapeutic interventions, and management of complications. Instruction complemented the surgical training program and a parallel progression occurred between surgical and endoscopic training in regards to knowledge base, patient management, operative experience, complexity of procedures, and autonomy. Metrics for competency included completion of the didactic curriculum, proficiency in perioperative care, management of complications, proficiency in performing diagnostic and therapeutic procedures, and achieving a successful cannulation rate of >90% in the final year of training.

Results: Residents in the pathway have successfully completed this ERCP curriculum during their 5-year general surgery residency. The ERCP program instructor has submitted recommendations for the first resident’s unrestricted credentialing to the hospital credentialing committee, having performed over 200 ERCPs.

Conclusions: It is possible to train select surgical residents to independently perform diagnostic and therapeutic ERCP by the end of the PGY-5 year. Because a specific number of procedures does not indicate competency, it should be the discretion of the instructing faculty to determine when a resident should be considered for independent privileging in advanced therapeutic ERCP, and their recommendation and rationale should be submitted to the residency program director and hospital credentialing committee.

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