Time Given to Trainees to Attempt Cannulation During
Endoscopic Retrograde Cholangiopancreatography
Q2
Varies by
Training Program and Is Not Associated With Competence
Q17
Anna Duloy, * Rajesh Keswani,
‡
Matt Hall, * Andrew Y. Wang,
§
Gregory A. Cote,
k
Eva M. Aagaard,
¶
Linda Carlin, * Christopher J. DiMaio,
#
Steven Edmundowicz, *
Swan Ellert, ** Samuel Han, * Sri Komanduri, * Raman Muthusamy,
‡‡
Amit Rastogi,
§§
Raj J. Shah, * Violette Simon, * and Sachin Wani *
Q3
*University of Colorado, Anschutz Medical Campus, Aurora, Colorado;
‡
Northwestern University, Chicago, Illinois;
§
University
of Virginia, Charlottesville, Virginia;
k
Medical University of South Carolina, Charleston, South Carolina;
¶
Washington University
in St Louis, St Louis, Missouri;
#
Icahn School of Medicine at Mount Sinai, New York City, New York; **Colorado Clinical and
Translational Sciences Institute, Aurora, Colorado;
‡‡
University of California-Los Angeles, Los Angeles, California;
§§
University
of Kansas, Kansas City, Kansas
Q10 Q11
Q12
A
dvanced endoscopy training programs (AETPs)
were developed as a result of the lack of
comprehensive endoscopic retrograde chol-
angiopancreatography (ERCP) training during gastroen-
terology fellowships. There is no standardized
curriculum for AETPs and the influence of program- and
trainer-associated factors on trainee competence in ERCP
has not been investigated adequately. In prior work, we
showed that advanced endoscopy trainees (AETs)
achieve ERCP competence at varying rates.
1,2
The aims
of this study were to measure the variability in time
given to AETs to attempt cannulation between AETPs
and throughout the 1-year training period, and to deter-
mine the association between AET cannulation time and
AET competence at the end of training.
Methods
We performed a pooled analysis of data from 2 large
prospective multicenter cohort studies—the Rapid
Assessment of Trainee Endoscopy Skills and the Rapid
Assessment of Trainee Endoscopy Skills 2—that assessed
ERCP competence among AETs.
1,2
In these studies, Amer-
ican Society for Gastrointestinal Endoscopy–recognized
AETPs were invited to participate and AETs were graded
on ERCPs using the Endoscopic Ultrasound
Q13
and ERCP Skills
Assessment Tool; a validated tool that assesses technical
and cognitive competence in a continuous fashion.
3
Trainees were graded on technical and cognitive aspects
of biliary ERCP and given an overall assessment of their
performance, as previously described.
1,2
Individual
learning curve results were created using cumulative sum
analysis. Success was defined as an Endoscopic Ultrasound
and ERCP Skills Assessment Tool score of 1 or 2. For can-
nulation, a score of 4 was defined as failure. We defined
AET cannulation time as the time from when the cannula-
tion device exited the duodenoscope accessory channel to
the time when biliary cannulation was successful by the
AET or when the trainer took over (the time given to the
AET to attempt cannulation, regardless of whether can-
nulation was achieved). We modeled the time to cannulate
and relationship between AET cannulation times and
competence using a generalized linear mixed-effects
model. We used an AR(1)
Q14
covariance structure to capture
the time-ordered nature of the data. A covariance test was
used to assess the variation in cannulation times across
AETPs. Statistical analyses were performed with SAS v.9.4
(SAS Institute, Cary, NC) and P values less than .05 were
considered statistically significant.
Results
This analysis included 22 AETPs and 40 AETs. Overall,
2962 ERCPs were graded; the majority were performed for
choledocholithiasis (34%) and biliary strictures (33%),
and were an American Society for Gastrointestinal Endos-
copy grade 1 degree of difficulty (76%). At the end of
training, overall technical competence was confirmed in
60% (n ¼ 24) of AETs. Competence in cannulation of the
desired duct was confirmed in 60% (n ¼ 24) in all cases
and in 18% (n ¼ 7) in native papilla (NP) cases.
The mean time allowed for cannulation was 3.8 minutes
(SD, 4.3 min) in all cases, 5.3 minutes (SD, 4.9 min) in NP
cases, and 8.3 minutes (SD, 5 min) among failed trainee
cannulation cases (time allowed in failed cannulation at-
tempts before an attending took over). There was signifi-
cant variability in cannulation times (all, NP, and failed
trainee cannulation cases) across AETPs (P < .01 for all)
(Figure 1A). During the training year, cannulation times
allowed increased among failed
Q15
trainee cannulation cases
from a mean of 7.1 (SD, 0.89) during the first block of 5
Abbreviations used in this paper: AET, advanced endoscopy trainee;
AETP, advanced endoscopy training program; ERCP, endoscopic retro-
grade cholangiopancreatography; NP, native papilla.
© 2019 by the AGA Institute
1542-3565/$36.00
https://doi.org/10.1016/j.cgh.2019.09.039
Clinical Gastroenterology and Hepatology 2019;-:-–-
SSU 5.6.0 DTD YJCGH56778_proof 5 November 2019 7:32 pm ce DVC
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