Can Surgery Residents Be Trained to Perform Diagnostic and Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) During Their Training ?

Matthew Johnson, MD, Cory Richardson, MD, Maris Jones, MD, Shawn Tsuda, MD, Adnan Mohsin, Charles St. Hill, MD, Noel Devera, RN, Louise Shadwick, RN, Nathan Ozobia, MD

University of Nevada School of Medicine

Introduction: In 1983, Nathan Ozobia(NIO) attended an advanced ERCP course in London, UK under Peter Cotton, MD where he subsequently became one of the earliest surgeons to be credentialed in ERCP. That course changed NIOs management of choledocholithiasis which prior to that time was treated exclusively by an open surgical method. From the training he received at this course NIO believed that ERCP was feasible in the supine position so an institutional review board(IRB) study was carried out successfully. That study was titled, "Is ERCP Feasible in the Management of Blunt and Penetrating Pancreatico-Biliary Injuries?” The answer was clear and the paper was presented by Dr. Marchella at a Regional Residents conference in California. The experience gathered by NIO led to an additional presentation, titled: “ONE STEP MANAGEMENT OF OBSTRUCTING BILIARY DISEASES OF THE BILE DUCT”, presented at the 6th World Congress of Endoscopic Surgery, Rome 1998. In 2000, two surgery residents, Matthew Johnson(MJ) and Randy St.Hill(RSH), approached NIO and expressed a desire to learn ERCP. This was the beginning of surgical resident ERCP training at the University of Nevada School of Medicine at University Medical Center, Las Vegas, NV and five surgical endoscopy related papers from our institution. This paper illustrates our experience to date with surgical residents performing ERCP and being successful.

Methods and Procedures: Initially, residents in training underwent ERCP simulation using an endoscopic simulation lab. This was followed by specific didactic training involving selected readings, equipment familiarity, and subsequently surgical endoscopic case proctorship under NIO. An IRB study was then developed and titled: “ONE-STEP AND TWO-STEP LAPAROSCOPIC CHOLECYSTECTOMIES”. Patients were accrued and admitted under the service of NIO. Presentations were made to emergency room physicians, internal medicine physicians, and surgical colleagues regarding collaboration. Apart from the cases from the IRB approved study, other ERCP cases included the following: complex liver injuries; diagnostic and for placement of biliary stents for bilio-peritoneal and bilio-cutaneous fistulas, acute acalculous cholecysttitis with hyperbilirubinemia, post laparoscopic cholecystectomy complications to exclude cystic and bile duct leaks, and cases of biliary pancreatitis that needed a pre-operative ERCP. The procedures were exclusively performed by the residents in over 90% of the cases.

Results: Over 200 cases have been successfully performed by the residents MJ and RSH. Two additional residents, Cory Richardson(CR) and Maris Jones(MJ) have recently started the training program. There has been been one major complication; transection of the right hepatic duct(unrelated to ERCP), treated with a Roux-en-Y and 2 cases of post-ERCP pancreatitis.

Conclusions: By utilizing a specific training paradigm under the guise of an experienced surgical endoscopist, general surgery residents can be taught to performdiagnostic and therapeutic ERCP during their training.

Session: Poster Presentation

Program Number: P141

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