ERCP Curriculum

Published online: 2021-07-26
Position Statement
Curriculum for ERCP and endoscopic ultrasound training in

Europe: European Society of Gastrointestinal Endoscopy (ESGE)
Position Statement
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Authors
Gavin Johnson1, George Webster1, Ivo Boškoski 2 , Sara Campos 3, Stefan Karl Gölder 4 , Christoph Schlag 5, Andrea
Anderloni 6, Urban Arnelo 7, Abdenor Badaoui 8, Noor Bekkali 9, Dimitrios Christodoulou 10, László Czakó11, Michael
Fernandez Y Viesca12, Istvan Hritz 13, Tomas Hucl14, Evangelos Kalaitzakis15, 16, Leena Kylänpää 17, Ivan Nedoluzhko18,
Maria Chiara Petrone19, Jan-Werner Poley20, Andrada Seicean 21, Juan Vila22 , Marianna Arvanitakis 12, Mario Dinis-
Ribeiro23, Thierry Ponchon 24, Raf Bisschops 25
Institutions 16 Digestive Disease Center, University Hospital of

1 University College London Hospitals, London, UK Copenhagen/Herley, University of Copenhagen,
2 Gastroenterology and Digestive Endoscopy, Copenhagen, Denmark
Fondazione Policlinico Gemelli, Rome, Italy 17 Department of Gastrointestinal Surgery, Helsinki
3 Gastroenterology Department, Digestive Unit, University Hospital, Helsinki, Finland
Champalimaud Foundation, Lisbon, Portugal 18 Moscow Clinical Scientific Center n.a. A.S. Loginov,
4 Department of Internal Medicine III, University Moscow, Russia
Hospital Augsburg, Augsburg, Germany 19 Pancreato-Biliary Endoscopy and Endosonography
5 Department of Gastroenterology and Hepatology, Division, Pancreas Translational and Clinical Research
University Hospital Zurich, Switzerland Center, San Raffaele Scientific Institute IRCCS, Milan,
6 Division of Gastroenterology, Digestive Endoscopy Italy
Unit, Humanitas Clinical and Research Center-IRCCS, 20 Department of Gastroenterology & Hepatology,
Rozzano, Italy Erasmus MC, University Medical Center Rotterdam,
7 Department of Surgical and Perioperative Sciences/ The Netherlands
Surgery, Umeå University, Umeå, Sweden 21 Regional Institute of Gastroenterology and Hepatology
8 Department of Gastroenterology and Hepatology, Cluj-Napoca, University of Medicine and Pharmacy
Université catholique de Louvain, CHU UCL Namur, “Iuliu Hatieganu”, Cluj-Napoca, Romania
Yvoir, Belgium 22 Endoscopy Unit, Gastroenterology Department,
9 John Radcliffe Hospital, Oxford University Hospitals Complejo Hospitalario de Navarra, Instituto de
Foundation Trust, Oxford, UK Investigaciones Sanitarias de Navarra (IDISNA),
10 Department of Gastroenterology, Medical School and Pamplona, Spain
University Hospital of Ioannina, Ioannina, Greece 23 Gastroenterology Department, IPO Porto, Porto,
11 Department of Medicine, University of Szeged, Szeged, Portugal
Hungary 24 Gastroenterology Division, Edouard Herriot Hospital,
12 Department of Gastroenterology, Lyon, France
Hepatopancreatology and Digestive Oncology, CUB 25 Department of Gastroenterology and Hepatology,
Hôpital Erasme, Université Libre de Bruxelles, Brussels, University Hospitals Leuven, and TARGID, KU Leuven,
Belgium Leuven, Belgium
13 Centre for Therapeutic Endoscopy, 1st Department of
Surgery and Interventional Gastroenterology, published online 26.7.2021
Semmelweis University, Budapest, Hungary
14 Department of Gastroenterology and Hepatology, Bibliography
IKEM, Prague, Czech Republic Endoscopy 2021; 53: 1071–1087
15 Department of Gastroenterology, University Hospital DOI 10.1055/a-1537-8999
of Heraklion, University of Crete, Heraklion, Greece ISSN 0013-726X
© 2021. European Society of Gastrointestinal Endoscopy
Johnson Gavin et al. Curriculum for ERCP … Endoscopy 2021; 53: 1071–1087 | © 2021. European Society of Gastrointestinal Endoscopy. All rights reserved. 1071
Position Statement
All rights reserved. degree of independence. Structured formative assessment

This article is published by Thieme. is encouraged to enhance feedback. There should be a sum-
Georg Thieme Verlag KG, Rüdigerstraße 14, mative assessment process prior to commencing indepen-
70469 Stuttgart, Germany dent practice to ensure there is robust evidence of compe-
tence. This evidence should include a review of a trainee’s
Tables 1 s–5 s procedure volume and current performance measures.
Supplementary material is available under A period of mentoring is strongly recommended in the early
https://doi.org/10.1055/a-1537-8999 stages of independent practice.
Corresponding author 3 Specifically for ERCP, all trainees should be competent up

Gavin Johnson, MD, University College London Hospitals, to Schutz level 2 complexity (management of distal biliary
235 Euston Rd, London, NW1 2PG, UK strictures and stones > 10 mm), with advanced ERCP requir-
[email protected] ing a further period of training. Prior to independent prac-
tice, ESGE recommends that a trainee can evidence a proce-
MAIN RECO MMENDAT IONS dure volume of > 300 cases, a native papilla cannulation rate
The European Society of Gastrointestinal Endoscopy (ESGE) of ≥ 80 % (90 % after a period of mentored independent prac-
has recognized the need to formalize and enhance training tice), complete stones clearance of ≥ 85 %, and successful
in endoscopic retrograde cholangiopancreatography stenting of distal biliary strictures of ≥ 90 % (90 % and 95 %
(ERCP) and endoscopic ultrasound (EUS). This manuscript respectively after a mentored period of independent prac-
represents the outcome of a formal Delphi process result- tice).
ing in an official Position Statement of the ESGE and pro-
vides a framework to develop and maintain skills in ERCP 4 The progression of EUS training and competence attain-
and EUS. This curriculum is set out in terms of the prerequi- ment should start from diagnostic EUS and then proceed
sites prior to training; recommended steps of training to a to basic therapeutic EUS, and finally to advanced therapeu-
defined syllabus; the quality of training; and how compe- tic EUS. Before independent practice, ESGE recommends
tence should be defined and evidenced before independent that a trainee can evidence a procedure volume of > 250
practice. cases (75 fine-needle aspirations/biopsies [FNA/FNBs]),
satisfactory visualization of key anatomical landmarks in
1 Trainees should be competent in gastroscopy prior to ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %.
commencing training. Formal training courses and the use
of simulation in training are recommended. ESGE recognizes the often inadequate quality of the evi-
dence and the need for further studies pertaining to train-
2 Trainees should keep a contemporaneous logbook of their ing in advanced endoscopy, particularly in relation to thera-
procedures, including key performance indicators and the peutic EUS.
ing high quality training for many of these techniques has been
SOURCE AND SCO PE identified in many countries [2]. Of all the commonly per-
This position statement is an official statement of the formed endoscopic procedures, endoscopic retrograde cholan-
European Society of Gastrointestinal Endoscopy (ESGE). giopancreatography (ERCP) is associated with the highest risk
It provides recommendations for a European core curri- of serious complications and with a recognized mortality [3].
culum aimed at providing high quality training in ERCP Furthermore, endoscopic ultrasound (EUS) is an important ad-
and EUS. The recommendations presented are based on junct to ERCP, and also continues to evolve as a therapeutic
a consensus among endoscopists considered to be modality in its own right. Therefore, ESGE has identified the re-
experts in the field of ERCP and EUS who are involved in quirement for a consensus on how to optimize training in ERCP
training and training courses in Europe. and EUS as an important part of improving the quality of endos-
copy [1].
In 2017, the ESGE board convened the Curricula Working
Group, which was responsible for developing curricula that de-
Introduction fined the minimum training standards for more advanced and
The European Society of Gastrointestinal Endoscopy (ESGE) has therapeutic endoscopic practice that may often go beyond the
identified quality in endoscopy as a major priority [1]. It is re- core endoscopy training curricula in each country. This process
cognized that there continues to be an accelerated develop- has been outlined previously [2] and position statements on
ment of new and complex diagnostic and therapeutic endo- three endoscopy topics have already been published [4–6].
scopic interventions and a lack of specific guidance for provid-
1072 Johnson Gavin et al. Curriculum for ERCP … Endoscopy 2021; 53: 1071–1087 | © 2021. European Society of Gastrointestinal Endoscopy. All rights reserved.
The recommendations presented in this curriculum, a total
A BB R E VI AT I ONS of 31, are given along with their quality of evidence and
ASGE American Society of Gastrointestinal Endoscopy strength of recommendation in ▶ Table 1. They are based on a
CPN celiac plexus neurolysis consensus among experts in ERCP and EUS who are involved in
DOPS Direct Observation of Procedural Skills training.
ERCP endoscopic retrograde cholangiopancreatogra-
phy
ESGE European Society of Gastrointestinal Endoscopy Aims
EUS endoscopic ultrasound The aim of this position statement is to recommend best prac-
FNA fine-needle aspiration tice to optimize ERCP and EUS training in Europe, based on the
FNB fine-needle biopsy currently published evidence and knowledge. This paper focu-
JAG Joint Advisory Group on GI Endoscopy ses on training and aims to help trainees develop, evidence,
JETS JAG Endoscopy Training System and maintain their skills in ERCP and EUS.
PFC pancreatic fluid collection
RAF-E Rotterdam Assessment Form for ERCP
TEESAT The EUS and ERCP Skills Assessment Tool Methods
UGI upper gastrointestinal In 2019, R.B. invited G.J. to develop a working subgroup of
WHO World Health Organization ERCP and EUS practitioners with an open call via ESGE commu-
nications. The curriculum was developed using consensus
▶ Table 1 Summary of recommendations, with quality of evidence and strength of recommendation.
Number Recommendation Quality of Strength of re-

evidence commendation
ERCP and EUS training in general
1 Every endoscopist should have achieved competence in UGI endoscopy before commencing train- Low Strong
ing in ERCP or EUS (i. e. having personal experience of at least 300 gastroscopies and meeting the
ESGE quality measures for UGI endoscopy)
2 Simulation-based training represents a positive development to accelerate the trainee’s learning Very low Weak
curve and should be encouraged. When available, trainees should start training by undertaking
structured supervised ERCP/EUS simulator-based training before commencing hands-on training
in the workplace
3 Where it is available, simulation-based training should evolve in a stepwise approach for training: Very low Weak
virtual reality and mechanical simulators should be used during early training, followed by hands-
on endoscopy training
4 Trainees should undertake formal courses to complement ERCP/EUS training Low Strong
5 ERCP and EUS trainees should engage with a range of learning resources to supplement formal Very low Strong
courses and experiential learning
6 ERCP and EUS training should follow a structured syllabus to guide what is covered in workplace Very low Strong
learning, formal training courses, and self-directed study
7 A minimum training period of 12 months of high volume training is likely to be required to obtain Very low Strong
minimum proficiency in both ERCP and diagnostic EUS. At least a further year of dedicated training
is likely to be required for trainees to reach competence in advanced ERCP (Schutz 3 and 4) and
therapeutic EUS. Should there be an interruption to training, a longer period may be required
8 A significant proportion of ERCP and EUS training should be based in high volume training centers Very low Strong
that are able to offer trainees a sufficient wealth of experience for at least 12 months
9 An ERCP/EUS training center should ideally be able to provide: Very low Weak
▪ facilitation of trainee involvement in multidisciplinary meetings
▪ onsite hepaticopancreaticobiliary surgery and interventional radiology
▪ ERCP and EUS simulation
▪ support for trainee involvement in research and service improvement initiatives
10 A traineeʼs principal trainer should ideally have more than 3 years’ experience of independent ERCP Very low Weak
and/or EUS practice
11 A traineeʼs principal trainer should be performing adequate volumes of EUSs and/or ERCPs to de- Very low Strong
monstrate maintenance of their own competence
Position Statement
▶ Table 1 (Continuation)

12 ERCP and EUS competence should be defined as the ability to independently assess the need for Low Strong
and carry out successful and safe procedures, with good patient satisfaction across a range of case
difficulties and clinical contexts
13 Formal assessments tools (e. g. Direct Observation of Procedural Skills [DOPS] and The EUS and Moderate Strong
ERCP Skills Assessment Tool [TEESAT]) should be used regularly during ERCP and diagnostic and
therapeutic EUS training to track the acquisition of traineesʼ competence and to support trainee
feedback
14 Trainees should be encouraged to undertake self-assessment and keep a contemporaneous log- Low Strong
book of all cases, which includes the degree of trainer support that was needed for each aspect of
the procedure
15 A trainee should undergo a formal summative assessment process prior to commencing independ- Low Weak
ent practice in ERCP and EUS
16 The attainment of competence in ERCP and EUS is not a single event, but a career-long process. It is Very low Strong
recommended that, once competent in ERCP and EUS, endoscopists should be supported to con-
tinue a period of mentored practice with an experienced colleague
ERCP training
17 ERCP competence should be considered in two stages: Low Strong

▪ basic ERCP (Schutz level 1 and 2 procedures)
▪ advanced ERCP (Schutz level 3 and 4 procedures)
18 Competence in ERCP should take account of predicted procedure complexity. All those delivering Low Strong
independent ERCP practice should achieve competence in basic ERCP (i. e. Schutz 1 and 2 levels of
complexity)
19 Competence in advanced procedures (Schutz level 3 and 4) may be achieved after reaching compe- Low Strong
tence in basic ERCP and requires additional formal training following the commencement of inde-
pendent practice
20 The number of ERCPs performed may be a surrogate marker of competence, but in isolation is an Moderate Strong
inexact means to demonstrate competence. Most trainees are likely to need to have performed
> 300 ERCPs to be in a position to demonstrate competency
21 The following performance measures should be used to indicate a trainee’s competence in basic Moderate Strong
ERCP to continue to independent mentored practice:
▪ selective native papilla cannulation rate of ≥ 80 % as an intention to treat 1
▪ complete stone clearance ( < 10 mm) in ≥ 85 % cases following successful selective cannulation2
▪ successful stenting of distal biliary strictures of ≥ 90 % of cases following successful selective
cannulation 2
Following a period of mentored independent practice, to bring these performance measures into
line with the ESGE Quality Improvement Initiative for ERCP and EUS, they should be:
1
at least 10 % higher
2
5 % higher
22 An individual undertaking ERCP independently should be able to demonstrate an overall post-ERCP Low Weak
pancreatitis rate of ≤ 10 %
EUS training
23 Competence in radial EUS is not a prerequisite to commence linear-array EUS Low Weak
24 Competence in diagnostic EUS is a prerequisite for therapeutic EUS. Competence in ERCP is man- Very low Strong
datory for therapeutic EUS, and competence in therapeutic luminal endoscopy is advantageous
25 EUS training should be defined as two stages: diagnostic EUS, including tissue acquisition, and Very low Strong
therapeutic EUS
26 EUS-guided FNA/FNB can be commenced early in training, once safe handling and stable position- Low Weak
ing of the echoendoscope has been accomplished
27 Once competent in diagnostic EUS, training in therapeutic EUS may commence with less complex Very low Weak
procedures (such as EUS-guided drainage of PFCs) and, when competence has been achieved, may
progress to more advanced interventions (including EUS-guided gallbladder or biliary drainage, or
EUS-guided anastomosis creation)
▶ Table 1 (Continuation)

28 The number of EUSs performed may be a surrogate marker of competence, but in isolation is an Moderate Strong
inexact means to demonstrate competence. Trainees are likely to need to have performed > 250
diagnostic EUSs to be able to demonstrate competency
29 The following performance measures should be used to indicate a trainee’s competence in diag- Low Strong
nostic EUS:
▪ successful documentation of anatomical landmarks in ≥ 90 % of cases
▪ EUS-guided FNA/FNB accuracy rate of ≥ 85 %
30 Trainees are likely to need to have performed 75 EUS-guided FNA/FNBs to be able to demonstrate Low Strong
competency in tissue acquisition
31 Until more robust data are available, an endoscopist can be considered competent to undertake Low Weak
therapeutic EUS when they can demonstrate acceptable rates of clinical success and adverse events
that equate to the rates described in published case series. It is recommended that at least the first
25 cases of any intervention should be performed under the supervision of an endoscopist experi-
enced in that intervention
ERCP, endoscopic retrograde cholangiopancreatography; ESGE, European Society of Gastrointestinal Endoscopy; EUS, endoscopic ultrasound; FNA, fine-needle
aspiration; FNB, fine-needle biopsy; PFC, pancreatic fluid collection; UGI, upper gastrointestinal.
methodology, so the constitution of this working party was se- groups drew upon expert opinion to develop statements that
lected by G.J. and R.B. to ensure that the group was broadly went forward into the Delphi process.
representative in terms of a wide range of nationalities, levels The statements were distributed electronically in August
of clinical experience, and clinical backgrounds, and also in- 2019. In October 2019, there was a second face-to-face meet-
cluded trainee representation. ing where the statements and supportive evidence were discus-
The first meeting of the subgroup was in April 2019. At this sed in turn, resulting in further modification of the statements.
meeting, the overall aims of the project were defined and the The first round of anonymous electronic voting took place in
methodology was agreed. At this kick-off meeting, three princi- November 2019 and was based on a 5-point Likert scale, rang-
pal topics were identified, as previously defined by the ESGE [2]; ing from “Strongly Disagree,” through to “Strongly Agree.” Any
from these, specific questions were developed using the Popu- statement receiving at least an 80 % level of “agreement” or
lation, Intervention, Comparator, Outcome (PICO) format “strong agreement” was accepted.
where possible: Thereafter G.J. modified any statements based on feedback
a) Pre-adoption requirements to start training (skills required to improve their acceptability. The new statements were dis-
prior to engaging in ERCP/EUS training) cussed in a teleconference in January 2020, before a second
b) Training/learning steps (the steps to achieve competence in electronic vote between February and July 2020. Owing to the
ERCP and EUS, including requirements for training pro- paucity of evidence, all statements should be considered
grams) GRADE weak, with low or very low quality evidence or based
c) Definition and assessment of trainee competence (the ESGE on expert opinion, with the exceptions of recommendations
definition of competence for ERCP and EUS, and the evi- that consider the learning curves for ERCP and diagnostic EUS,
dence of competence in terms of prior training and per- which are based on moderate quality evidence.
formance measures to be attained before certification for
independent ERCP/EUS practice). 1 ERCP and EUS training in general
A Pre-adoption requirements to start ERCP and EUS
Two subgroup members were nominated as the leads for each
training
topic. A Delphi process was then used to review the evidence
and develop consensus statements for each topic. Each topic
was the subject of a systematic literature review using major RECOMMENDATION 1
databases (PubMed, Embase, and the Cochrane Library) from Every endoscopist should have achieved competence in
1990 to April 2019. Any publications emerging during the Del- upper gastrointestinal (UGI) endoscopy before commen-
phi process and manuscript writing were also considered for in- cing training in ERCP or EUS (i. e. having personal experi-
clusion. Statements were drafted based on this evidence and ence of at least 300 gastroscopies and meeting the ESGE
subjected to an appraisal using the Grading of Recommenda- quality measures for UGI endoscopy).
tions Assessment, Development and Evaluation (GRADE) Level of agreement 100 %.
framework [3, 7]. In situations where there was a paucity of evi-
dence in an aspect of training that was deemed important, the
Position Statement
Both ERCP and EUS require the skilled execution of endo- Several studies have proposed the implementation of simu-
scope maneuvers to obtain a stable position in order either to lator training in endoscopic training, given the potential for
undertake specific therapy or to obtain optimal endosono- more rapid progression up the early learning curve [14–17].
graphic images. Proficiency in diagnostic gastroscopy, as de- Training in advanced endoscopy in ERCP/EUS should include
fined by the ESGE performance measures [8], is therefore a pre- in-room ERCP/EUS observation of live cases and then evolve as
requisite before training in both ERCP and EUS, and experience follows:
of therapeutic upper gastrointestinal (UGI) endoscopy and co- 1. independence in UGI endoscopy and experience of thera-
lonoscopy is also desirable. peutic luminal endoscopy
2. virtual reality and mechanical simulators during early train-
B Training/learning steps in ERCP and EUS ing
3. hands-on basic ERCP/diagnostic EUS training
RECO MMENDATION 2 4. ex vivo or in vivo simulators later in training and for
Simulation-based training represents a positive develop- advanced training of more complex procedures
ment to accelerate the trainee’s learning curve and 5. hands-on advanced ERCP/therapeutic EUS training
should be encouraged. When available, trainees should 6. ex vivo and in vivo simulators for acquiring expertise in new
start their training by undertaking structured supervised interventions, or maintaining competence in low volume
ERCP/EUS simulator-based training before commencing procedures.
hands-on training in the workplace.
Level of agreement 82 %.
RECOMMENDATION 4
Trainees should undertake formal courses to complement
Simulation-based training refers to different educational ERCP/EUS training.
tools that allow for repetitive instruction in a non-patient care Level of agreement 100 %.
environment, without stress and risks. In endoscopy, it includes
[9–11]:
▪ mechanical simulators
▪ animal models – in vivo and ex vivo (hybrid) Formal courses/workshops in ERCP and EUS training are
▪ computer-based/virtual reality simulators. defined as a structured course with clear learning objectives,
expert faculty, and a range of learning methods. Supervised
Each of these has its own characteristics, advantages, and dis- hands-on training is encouraged and, depending on the com-
advantages, but they all aim to help trainees to practice naviga- petence delegates demonstrate, this can be on simulators
tion skills and learn the basic milestones, as shown in Table 1 s, and/or patients. Formal ERCP courses have been shown to
see online-only Supplementary material [12–14]. change practice and improve confidence [18], and have been
Trainees just starting in ERCP and EUS will benefit from be- shown to improve performance in workshops using mechanical
coming familiar with accessories and practicing endoscopic simulators [15, 17]. There is evidence from the UK that an
and accessory maneuvers in a simulated setting with less cog- intense 5-day colonoscopy course could lead to a sustained po-
nitive overload. Early training that includes simulation-based sitive impact on performance [19].
training should be encouraged as an adjunct to attendance dur- These courses should be led by faculty who are experienced
ing endoscopy lists, formal courses, and e-learning tools. and skilled trainers. Learning methods should include theory
A structured simulation-based training program developed sessions, facilitated group discussions, live demonstrations,
with specific goals should be defined. As endoscopic interven- and closely supervised hands-on sessions. The hands-on ses-
tions increase in their scope and complexity, hands-on training sions should be on simulators in early training and on real cases
on patients, even for experienced trainees, is often limited for courses involving more experienced trainees, and should
owing to concerns about maintaining patient safety in new result in individualized feedback. Course directors should seek
and/or complex procedures, and simulation can fulfil an impor- formal quality assurance of their courses from national or
tant role. regional training organizations if these structures are in place.
RECO MMENDATION 3 RECOMMENDATION 5

Where it is available, simulation-based training should ERCP and EUS trainees should engage with a range of
evolve in a stepwise approach for training: virtual reality learning resources to supplement formal courses and
and mechanical simulators should be used during early experiential learning.
training, followed by hands-on endoscopy training. Level of agreement 100 %.
Trainees are encouraged to participate in self-directed learn- –
effective in-room leadership and communication
ing during training to: –
appropriate patient positioning
▪ develop a knowledge base to support contemporary –
safe esophageal and duodenal intubation
evidence-based practice –
duodenoscope and echoendoscope handling and posi-
▪ underpin their appreciation of normal and abnormal anato- tioning
my, and improve pathology recognition – selection of ERCP accessories, EUS needles, and guide-
▪ be familiar with safe and effective ERCP and EUS techniques. wires appropriate for the required intervention
– structured systematic performance of diagnostic endos-
Self-directed learning should take advantage of the significant copy and execution of therapy, for example:
range of training resources now available: textbooks, guide- • station assessment in EUS
lines, e-learning modules, web-based instructional video cases, • in ERCP, appropriate algorithm selection for difficult
congress proceedings, and live endoscopy workshops. selective cannulation, safe sphincterotomy, stent
choice and deployment, and stone management
• steps for safe and effective tissue acquisition and
RECO MMENDATION 6 handling in EUS
ERCP and EUS training should follow a structured syllabus – optimization and storage of endosonographic and
to guide what is covered in workplace learning, formal fluoroscopic imaging, whilst minimizing ionizing radia-
training courses, and self-directed study. tion exposure to the patient and to clinical staff, which for
Level of agreement 100 %. EUS includes the amplification or time gain compensa-
tion, color Doppler imaging, contrast-enhancement, and
elastography
– application of measures to prevent post-ERCP pancreatitis
Performing ERCP and EUS safely and effectively requires fun- and cholangitis.
damental knowledge, and technical and non-technical skills. It ▪ Post-procedure:
is recommended that training covers the following domains. – effective comprehensive report writing
▪ Pre-procedure: – recognition and appropriate early management of com-
– knowledge of the risks, indications, and alternatives for plications
ERCP, and diagnostic and therapeutic EUS, and the ability – defining and communicating post-procedure instructions
to explain these to a patient and/or their carer to obtain for care
valid informed consent – explaining the onward short- and long-term management
– understanding the principles of safe conscious sedation, plan to the patient and/or their carers.
deep sedation, and general anesthesia
– knowledge of mediastinal and upper abdominal anatomy
(plus pelvic/perirectal anatomy if undertaking per-rectal RECOMMENDATION 7
EUS), and an understanding of related imaging: ultra- A minimum training period of 12 months of high volume
sound, computed tomography, magnetic resonance ima- training is likely to be required to obtain minimum profi-
ging, and functional imaging ciency in both ERCP and diagnostic EUS. At least a further
– understanding of the guidance on the use of prophylactic year of dedicated training is likely to be required for trai-
antibiotics and the management of patients on antiplate- nees to reach competence in advanced ERCP (Schutz 3
let and anticoagulant medications and 4) and therapeutic EUS. Should there be an interrup-
– knowledge of the hardware and its ergonomic configura- tion to training, a longer period may be required.
tion in the endoscopy room (fluoroscopy, processors, and Level of agreement 96 %.
endoscopes, including being able to troubleshoot scope
malfunction)
– familiarity with the safe use of accessories used in ERCP
and EUS, allowing the ability to select accessories and In the following section, it will be demonstrated that the
guidewires appropriately in different situations rates at which trainees achieve competence in different aspects
– contribution to decision-making and patient counselling of EUS and ERCP vary [20–22]. The factors contributing to this
in pancreaticobiliary disease by contributing to outpati- variation relate to the innate skills, previous experience, and
ent clinics, ward care, and specialist multidisciplinary dedication of the trainee; the skills of the trainer; and the qual-
meetings. ity of the training program and training environment. There-
▪ Intraprocedure: fore, defining a minimum period of training in ERCP and EUS is
– ensuring effective teamwork and promoting an environ- difficult and could be challenged. However, there is still the
ment to minimize risk and medical error in endoscopy need to structure training into programs, so an indication of
(e. g. World Health Organization [WHO] endoscopy safety the minimum period required for the majority of trainees to
checklist, team debrief after case, involvement in mortal- reach competence is needed. A training period of at least 12
ity and morbidity audit) months is likely to be required for trainees to undertake the
Position Statement
indicated minimum number of procedures required for compe-

tence (300 ERCPs, 250 diagnostic EUSs). Even in very high vol- RECOMMENDATION 9
ume training centers in Europe, at least another year of dedica- An ERCP/EUS training center should ideally be able to pro-
ted training is likely to be required for a trainee to attain com- vide:
petence in advanced ERCP and therapeutic EUS. ▪ facilitation of trainee involvement in multidisciplinary
Whether interruptions to training affect the learning curve meetings (Level of agreement 100 %)
of trainees is unclear. Short breaks to colonoscopy training ▪ onsite hepaticopancreaticobiliary surgery and interven-
(less than 6 weeks) in a US study had only a small effect on cecal tional radiology (Level of agreement 100 %)
intubation rate, but the detrimental effect increased for each ▪ ERCP and EUS simulation (Level of agreement 82 %)
subsequent 4-week break [23]. In the large studies of learning ▪ support for trainee involvement in research and service
curves for gastroscopy and colonoscopy using the UK Joint improvement initiatives (Level of agreement 96 %).
Advisory Group on GI Endoscopy (JAG) Endoscopy Training Sys-
tem (JETS); the nationwide electronic training portfolio), train-
ing breaks of up to 6 months were not shown to be detrimental
to learning curves [24, 25]. There is no equivalent data for ERCP These centers will provide the trainee with experience of all
and EUS training. The length of the interruption to training that aspects of the syllabus (recommendation 17), such as proce-
may affect a trainee’s acquisition of competence is likely to vary dure planning, involvement in the planning of interventional
widely owing to factors such as prior experience and the train- strategies, management of complications, and trainee involve-
ing intensity upon restarting training. ment in the whole inpatient stay. The benefits of simulation are
more likely to be provided by recognized ERCP and EUS training
units in specialist centers.
RECO MMENDATION 8
A significant proportion of ERCP and EUS training should
be based in high volume training centers that are able to RECOMMENDATION 10
offer trainees a sufficient wealth of experience for at least A traineeʼs principal trainer should ideally have more than
12 months. 3 years’ experience of independent ERCP and/or EUS
Level of agreement 96 %. practice.
Training centers that can provide adequate procedure RECOMMENDATION 11

experience for ERCP and EUS are likely to be referral centers/ A trainee's principal trainer should be performing ade-
specialist centers for patients with pancreaticobiliary disorders, quate volumes of EUSs and/or ERCPs to demonstrate
and oncological centers requiring the support of an advanced maintenance of their own competence.
endoscopy service. It is recognized that regional hospitals pro- Level of agreement 96 %.
viding an effective and important ERCP and EUS service play a
vital role in training. However, trainees will benefit from spend-
ing a significant proportion of their time in specialist centers
that can provide a multidisciplinary environment for the man- Being an effective endoscopy trainer is challenging and
agement of patients. It is evidenced that procedure experience made more difficult when a procedure is both technically diffi-
is an important determinant of competence [26–28], but also cult and carries significant risks of patient harm. Arguably the
there is evidence from UK colonoscopy training that the inten- best trainers are those equipped with effective teaching skills
sity of training (the rate at which cases are accrued) may have a (engagement, performance-enhancing feedback skills etc.).
positive effect on training [25]. It follows therefore that ERCP However, whilst evidence is lacking, it follows that a trainer’s
and EUS training should include a significant period of time in own experience in ERCP and EUS is likely to influence their
a high volume center, which will ensure that a trainee is able to effectiveness as a trainer. With experience, an endoscopist
undertake a sufficient volume of procedures in a short amount moves from being a novice to becoming an expert.
of time to achieve competence. Adult cognitive load theory is relevant to both endoscopy
trainees and trainers [29, 30], and states that an individual’s
working memory can only process a finite amount of informa-
tion at any one time and this creates a “bottleneck” for learn-
ing. Cognitive load theory identifies three types of cognitive
load that impact on working memory: the intrinsic load (per-
formance of essential aspects of the task), the extraneous load
(non-essential aspects of the task), and the germane load (the
deliberate use of cognitive strategies that facilitate learning).
One aspect of being an expert is practicing with “unconscious
competence,” such that experts have a reduced “intrinsic load” Assessment is central to determining an individual’s compe-
so are better able to observe and inform all facets of the train- tence. Formative assessments are conducted by trainers to
ing encounter to the benefit of the trainee’s learning and devel- highlight a trainee’s strengths and weaknesses, so as to
opment. improve the quality of the feedback and to improve perform-
There is no evidence to support a strong recommendation ance [16, 34]. Siau et al. used data from the UK national trainee
on how long an endoscopist should have been practicing inde- e-portfolio to provide evidence that the ERCP DOPS formative
pendently before becoming a principal trainer, but the consen- assessment has validity and reliability and is to be used for sum-
sus time was a minimum of 3 years. mative assessment [28]. The reliability of the DOPS was shown
Trainers should consider undertaking a recognized “train the to improve when the assessment of performance was based on
endoscopy trainer” course to improve their skills as a trainer. the degree of supervision required by the trainee [27]. Wani et
Effective feedback benefits training outcomes. It has been al. have validated the TEESAT for use in competence assessment
shown that colonoscopy trainees randomized to receive feed- for ERCP and EUS, and it is recommended for use in North
back, rather than no feedback, had significantly improved cecal American advanced endoscopy programs [22, 35, 36].
intubation rates [31]. It follows therefore that courses that in- The DOPS and TEESAT are broadly alike in their structure,
struct trainers in the fundamentals of adult learning theory to with the steps of the procedure deconstructed into domains,
improve their skills as trainers, such as providing a framework which are further divided into individual “performance items.”
for effective feedback, setting goals for each session, and using The assessor is required to assess the quality of the perform-
consistent training terms benefit trainees [29, 32]. JAG in the ance for each item based on the degree of supervision/assist-
UK, and the American Society for Gastrointestinal Endoscopy ance that was required. Both assessments encourage reflection
(ASGE) in the USA recommend “train the trainers” courses that on the training episode.
are specific to the endoscopic modality. Greater engagement with the process of formative assess-
ment has been shown to be an independent predictor of per-
C Definition and assessment of trainee competence formance [28]. ASGE recommends that at least 20 % of a trai-
for ERCP and EUS nee’s cases are subject to assessment with the TEESAT [36]; in
the UK, it is recommended that a formative DOPS assessment is
RECO MMENDATION 12 undertaken approximately every 10 ERCPs.
ERCP and EUS competence should be defined as the abil- The DOPS or the TEESAT are recommended as they are
ity to independently assess the need for and carry out openly available for use and have been validated. If trainers
successful and safe procedures, with good patient satis- wish to develop their own tool to structure trainee feedback,
faction across a range of case difficulties and clinical con- Tables 2 s and 3 s outline a suggested “performance item”
texts. checklist that can be tailored for their use.
RECOMMENDATION 14
Trainees should be encouraged to undertake self-
This definition of ERCP and EUS competence pins compe- assessment and keep a contemporaneous logbook of all
tence to whether the endoscopist can undertake effective and cases, which includes the degree of trainer support that
safe procedures, and recognizes the importance of patient ex- was needed for each aspect of the procedure.
perience and the range of case complexity and contexts. ASGE Level of agreement 100 %.
defines competence as the minimum level of skill, knowledge,
and/or expertise derived through training and experience that
is required to safely and proficiently perform a task or proce-
dure [33]. The definition of ERCP and EUS competence includes attain-
ment of key performance measures, as well as a minimum num-
ber of procedures before a trainee can perform ERCP and EUS
RECO MMENDATION 13 independently. It therefore follows that a trainee is encouraged
Formal assessments tools (e. g. Direct Observation of Pro- to keep a record of all their endoscopy cases and the degree to
cedural Skills [DOPS] and The EUS and ERCP Skills Assess- which the trainer was involved. In the UK, trainees use a nation-
ment Tool [TEESAT]) should be used regularly during wide electronic portfolio (JETS) to log procedures and to pro-
ERCP and diagnostic and therapeutic EUS training to track vide a record of their formative assessments [37]. Ekkelenkamp
the acquisition of trainees’ competence and to support et al. have shown that continuous self-assessment using the
trainee feedback. Rotterdam Assessment Form for ERCP (RAF-E) can demonstrate
Level of agreement 96 %. a trainee’s learning curve and key performance measures [20,
38].
Tables 4 s and 5 s outline suggested logbook fields to be
completed by a trainee for each ERCP and EUS procedure. As a
trainee documents the degree of supervision required for each
Position Statement
aspect of a procedure, a picture builds up as to the particular 2 ERCP training

aspects of ERCP/EUS in which a trainee is already demonstrat-
ing competence. Furthermore, logbooks are an important
A Pre-adoption requirements to start ERCP
source of evidence for a trainee’s key performance measures, Trainees should be competent in gastroscopy prior to commen-
such as cannulation rate for ERCP and fine-needle aspiration cing ERCP training.
(FNA) or fine-needle biopsy (FNB) accuracy in EUS.
B Training/learning steps in ERCP
RECO MMENDATION 15 RECOMMENDATION 17

A trainee should undergo a formal summative assess- ERCP competence should be considered in two stages:
ment process prior to commencing independent practice ▪ basic ERCP (competence in Schutz level 1 and 2 proce-
in ERCP and EUS. dures)
Level of agreement 92 %. ▪ advanced ERCP (Schutz level 3 and 4 procedures).
ESGE proposes that the national legislature responsible for
accreditation in endoscopy undertakes a formal assessment of ESGE advocates using the Schutz classification to define ba-
trainees prior to independent ERCP and EUS practice. This pro- sic and advanced ERCPs [39]. Competence in basic ERCP is
cess should include an independent review to determine that therefore defined as competence in:
the procedure numbers and performance measures outlined in ▪ selective cannulation
this document have been attained. This process can also review ▪ extraction of stones > 10 mm
whether a trainee has undertaken formal training courses and ▪ treatment of a bile leak
their progress in formative assessment, when these have been ▪ successful stenting of an extrahepatic biliary stricture
brought into national training programs. Accreditation bodies ▪ placement of a prophylactic pancreatic stent.
should also consider a summative assessment, whereby a trai-
nee is observed undertaking ERCPs and EUSs by independent Competence in advanced ERCP is defined as competence in:
assessors as a further robust test of competence beyond train- ▪ stenting of a hilar obstruction
ing experience and performance measures. ▪ removal of intrahepatic stones
▪ any pancreatic therapy
▪ ampullectomy
RECO MMENDATION 16 ▪ ERCP in surgically altered anatomy.
The attainment of competence in ERCP and EUS is not a
single event, but a career-long process. It is recommend-
ed that, once competent in ERCP and EUS, endoscopists RECOMMENDATION 18
should be supported to continue a period of mentored Competence in ERCP should take account of predicted
practice with an experienced colleague. procedure complexity. All those delivering independent
Level of agreement 100 %. ERCP practice should achieve competence in basic ERCP
(i. e. Schutz 1 and 2 levels of complexity).
When an endoscopist reaches the standards defined in the

previous sections, it is not the end of the learning process, but RECOMMENDATION 19
merely a checkpoint at which independent practice can com- Competence in advanced procedures (Schutz level 3 and
mence. This transition presents new challenges and is often 4) may be achieved after reaching competence in basic
daunting. ESGE proposes that endoscopists starting to practice ERCP and requires additional formal training following
independently are mentored by a more experienced colleague the commencement of independent practice.
for a defined period of time. A mentor should be available to Level of agreement 100 %.
join or advise on a challenging case at the request of the endos-
copist. Newly independent endoscopists should continue to
keep a record of their cases to evidence that they are retaining
acceptable key performance measures and complication rates Jaundice from extrahepatic biliary obstruction and cholangi-
as part of a regular appraisal process, and seek opportunities tis from gallstones represent the majority of indications for
to upskill or undergo further supervised practice when neces- ERCP, and a patient presenting with these problems will often
sary. There is no evidence to support a recommendation as to need treatment urgently. Therefore, it is essential that every
how long the mentoring period should be, but to be worthwhile endoscopist undertaking ERCP independently is competent in
a period of at least 6 months is likely to be required. cases with this degree of difficulty. More complex indications
for ERCP (Schutz 3 and 4) are undertaken less commonly and
should be undertaken in a high volume referral center, with sur- RECOMMENDATION 21
gical and radiological support, so competence in these pro- The following performance measures should be used to
cedures is not mandated for all trainees wanting to practice in- indicate a trainee’s competence in basic ERCP to continue
dependent ERCP. Additional training is required to attain com- to independent mentored practice:
petence in advanced ERCP. ▪ selective native papilla cannulation rate of ≥ 80 % as an
intention to treat1 (Level of agreement 96 %)
C Definition and assessment of trainee competence ▪ complete stone clearance (< 10 mm) in ≥ 85 % of cases
for ERCP and EUS following successful selective cannulation2 (Level of
agreement 91 %)
RECO MMENDATION 20 ▪ successful stenting of distal biliary strictures in ≥ 90 % of
The number of ERCPs performed may be a surrogate cases following successful selective cannulation 2 (Level
marker of competence, but in isolation is an inexact of agreement 91 %).
means to demonstrate competence. Most trainees are
likely to need to have performed > 300 ERCPs to be in a Following a period of mentored independent practice, to
position to demonstrate competency. bring these performance measures into line with the
Level of agreement 100 %. ESGE Quality Improvement Initiative for ERCP and EUS,
they should be:
1
at least 10 % higher
2
5 % higher.
It has been conventional for training programs to use proce-
dure volume as a surrogate marker of competence, and unsur-
prisingly there is strong evidence endoscopists’ experience of a
procedure has consistently been shown to be a predictor of Performance measures have been widely proposed and
competence [25–27, 40]. However, there is significant variation adopted in endoscopy to benchmark satisfactory performance
in learning curves for ERCP [20, 22, 26, 28], as other trainee, [33, 45, 46]. In 2018, Domagk et al. presented performance
trainer, and training program factors, such as prior endoscopic measures for ERCP and EUS as part of the ESGE’s quality
skills, trainer teaching skills, access to simulation, and training improvement initiative [45]. It follows that ESGE proposes that
intensity, inform the rate at which competence is attained. the same performance measures are used to define the compe-
Therefore, defining an absolute threshold in terms of numbers tence of a trainee prior to independent practice but, for expe-
of procedures required for competence can be questioned, and diency, the evidence underpinning these performance meas-
there has been a move away from endoscopic competence ures is not discussed in this paper.
being defined solely by procedure volume [33, 41, 42]. Despite Selective biliary cannulation is a fundamental skill in ERCP as
this trend, endoscopy training program directors and new trai- without this no therapeutic intervention can proceed. However,
nees need to have an idea of the approximate case numbers at it provides no information on an individual’s ability to execute
which competence is likely to be attained (subject to other other specific aspects of ERCP, such as sphincterotomy or stent
measures of competence). deployment, and therefore cannot be used in isolation as a
Ekkelenkamp et al. in 2014 demonstrated in a single training measure of competence.
center that only one of 15 trainees reached a native papilla can- In patients with a native papilla and conventional anatomy,
nulation rate of 85 % after 200 procedures [20]. A systematic Domagk et al. proposed a selective biliary cannulation rate of
review in 2015 included nine studies overall but, in the five ≥ 90 % (on an intention-to-treat basis). However, the consensus
looking at selective cannulation, the range of procedure vol- of the curriculum group was that achieving this standard may
umes required was 79–300 [43]. In 2019 Siau et al. reported be difficult for trainees. ESGE defines a difficult biliary cannula-
from the UK on the outcomes of formative ERCP assessment tion as more than five contacts with the papilla; more than 5
from the nationwide electronic training portfolio and demon- minutes spent attempting to cannulate following visualization
strated that the competency benchmark for selective cannula- of the papilla; or more than one unintended pancreatic duct
tion of 89 % was only achieved after 300 procedures [28]. Also cannulation or opacification [47]. The point at which a trainer
in 2019, Wani et al. reported on the learning curves of 62 ad- takes over the procedure when cannulating will always vary
vanced endoscopy trainees and concluded that the average between trainers, but it follows that, in the relatively common
trainee required 250 cases to achieve core skills in ERCP, and scenario of a cannulation becoming difficult, a trainer may well
305 cases for the more complex Grade 2 cases [44]. ESGE there- take over the endoscope. If the trainer is successful at cannula-
fore recommends a trainee is likely to require an ERCP proce- tion with either conventional or adjunct techniques, the case
dure volume of 300 cases before there can be an expectation would count as being an unsuccessful cannulation attempt for
of competence and, even then, competence must be better evi- the trainee. Even very experienced and competent trainees
denced than by case numbers alone. skilled in adjunct cannulation techniques will encounter cases
in which the trainer will be required to take over the procedure,
for example where there are time-pressures on a list or issues
Position Statement
related to sedation or anesthesia, so they will not be in a posi- array echoendoscope, which may infer a particular advantage in
tion to reach the successful cannulation rates of equally compe- the examination on the pancreas [49]. Therefore, ESGE propo-
tent independent endoscopists. When the trainee proceeds ses that it is not essential that training commences with radial
into independent practice then the majority of these cases EUS, or that radial EUS is learned alongside linear EUS.
would be achieved successfully, such that the individual’s can-
nulation rate is likely to improve. It is therefore proposed that
the definition of ERCP competence includes a selective cannula- RECOMMENDATION 24
tion rate of ≥ 80 %, with the aim of achieving the proposed ESGE Competence in diagnostic EUS is a prerequisite for thera-
standard of ≥ 90 % in the period following independent practice peutic EUS. Competence in ERCP is mandatory for thera-
(preferably during a period of mentorship). peutic EUS, and competence in therapeutic luminal
With the same logic, it is proposed that the definition of endoscopy is advantageous.
ERCP competence for a trainee includes successful stone clear- Level of agreement 91 %.
ance (≤ 10 mm) and successful stenting of an extrahepatic bili-
ary obstruction with rates that are both 5 % lower than those
proposed by Domagk for the ESGE quality improvement initia- Diagnostic EUS, including tissue acquisition, is considered a
tive (≥ 85 % and ≥ 90 %, respectively). The difference of 5 % prerequisite for therapeutic EUS [50], given that effective tar-
between a trainee’s performance standard and that proposed get recognition and puncture with an accessory are the initial
by ESGE is lower than that for cannulation. This is because trai- steps for any EUS-guided therapies. Furthermore, much of
ners are likely to be prepared to allow trainees longer to exe- therapeutic EUS requires mastery of ERCP skills (such as the
cute these therapies because they are inherently less likely to use of wires, stents, accessories, and fluoroscopy), so there is
cause harm than a difficult cannulation of a native papilla. strong consensus that ERCP competence should be mandatory
when training in therapeutic EUS [45, 50].
There is currently no established guidance for determining a
RECO MMENDATION 22 trainee’s competence to independently perform effective ther-
An individual undertaking ERCP independently should be apeutic EUS, although some consensus exists on how to train
able to demonstrate an overall post-ERCP pancreatitis trainees to become therapeutic endosonographers [45, 48,
rate of ≤ 10 %. 50]. Trainees should know the indications, limitations, risks,
Level of agreement 91 %. and alternatives for any proposed EUS intervention and should
be able to explain this information to patients to obtain valid
informed consent [33, 51]. At a trainer’s discretion, trainees
Post-ERCP pancreatitis is the most frequent complication with enough experience of ERCP, but who are not yet certified
following ERCP and can be devastating; it is considered by the for independent practice, can commence training in straight-
ESGE to be the most appropriate indicator of the adverse event forward cases of therapeutic EUS. Competence in luminal
rate [45]. This complication rate threshold is largely drawn from endoscopy including experience in the management of endo-
a 2015 systematic review that was derived from randomized scopic complications, such as perforation and bleeding, is also
controlled trials only, including 13 296 patients, which docu- advantageous [50], given the rate at which these complications
mented an overall post-ERCP pancreatitis rate of 9.7 %, with a can occur in therapeutic EUS.
rate of 14.7 % in high risk patients.
B Training/learning steps in EUS training
3 EUS TRAINING
RECOMMENDATION 25
A Pre-adoption requirements to start EUS training EUS training should be defined as two stages: diagnostic
EUS, including tissue acquisition, and therapeutic EUS.
RECO MMENDATION 23 Level of agreement 100 %.
Competence in radial EUS is not a prerequisite to com-
mence linear-array EUS.
Although there is a variability between trainees [16, 21, 52],
EUS is considered to be a demanding technique with a long and
variable learning curve [21]. It is performed for several clinical
Diagnostic EUS should only be commenced when compe- indications [53]; the diagnostic indications for EUS are wide-
tence in gastroscopy has been attained. Competence in linear- ranging and the number of distinct interventional procedures
array EUS is essential to undertake tissue acquisition and EUS- for EUS are increasing. As such, a competent endosonographer
guided therapy, but it has been shown that training with a needs to master not only scope and accessory handling skills,
radial echoendoscope does not improve the performance of but also how to interpret and differentiate between normal
subsequent training with a linear-array echoendoscope [48]. anatomy and pathology.
Most diagnostic EUS procedures can be performed with a linear-
The training should be considered in two stages. It should ▪ step 4 – EUS-guided pancreatic duct drainage
start with diagnostic EUS, which encompasses all aspects of ▪ step 5 – EUS-guided anastomosis creation (e. g. gastro-
diagnostic EUS (luminal and pancreaticobiliary EUS, including enteric or bilioenteric anastomosis).
tissue acquisition [54, 55]). Once this has been achieved, train-
ing in therapeutic EUS can commence. Training in CPN can be considered early in advanced EUS train-
Transrectal EUS has emerged as an important adjunct in the ing. Moreover, the expanding field of EUS-guided cancer thera-
diagnosis and treatment of pelvic pathology. However, many py needs to be incorporated into training (brachytherapy, fidu-
endosonographers do not undertake lower gastrointestinal cial marker placement, ablative therapies).
EUS, and others consider it quite a low volume indication. The
working group did not have representation from any coloproc- C Assessment issues for EUS
tology surgeons, so considered the specific training require-
ments of transrectal EUS beyond the scope of the curriculum. RECOMMENDATION 28
The number of EUSs performed may be a surrogate mark-
er of competence, but in isolation is an inexact means to
RECO MMENDATION 26 demonstrate competence. Trainees are likely to need to
EUS-guided FNA/FNB can be commenced early in train- have performed > 250 diagnostic EUSs to be able to
ing, once safe handling and stable positioning of the demonstrate competency.
echoendoscope has been accomplished. Level of agreement 100 %.
EUS requires both cognitive and technical abilities, so a trai-

nee’s procedure volume does not necessarily correlate with
Commencing EUS-guided FNA/FNB (supervisor directed, their performance. As with ERCP, variables such as prior trainee
trainee performed) may safely be considered early in training experience and the quality of the trainer and training environ-
once effective scope handling has been achieved [56]. ment are likely to inform the number of cases a trainee needs
to perform in order to commence safe and effective indepen-
dent practice. However, procedure numbers are important for
RECO MMENDATION 27 training leads to develop advanced endoscopy programs. Fur-
Once competent in diagnostic EUS, training in therapeutic thermore, trainees need to have their expectations managed
EUS may commence with less complex procedures (such as to what procedure volume is likely to be typically required
as EUS-guided drainage of pancreatic fluid collections to meet defined performance measures [44, 57, 58]. Wani et
[PFCs]) and, when competence has been achieved, may al. prospectively evaluated the learning curves for 37 EUS trai-
progress to more advanced interventions (including EUS- nees and concluded that the average trainee achieved core
guided gallbladder or biliary drainage, or EUS-guided EUS competence after 225 cases, although the range was nota-
anastomosis creation). ble (median EUS procedure numbers 400, range 200–750) [44].
Level of agreement 100 %. Therefore, ESGE proposes that a minimum of 250 EUS proce-
dures are required before a trainee is likely to demonstrate
acceptable performance measures and competence.
Therapeutic EUS continues to evolve and is associated with

significant risks of major complications, and with a limited RECOMMENDATION 29
number of cases for training. Therapeutic EUS should be per- The following performance measures should be used to
formed only in centers with a multidisciplinary team that indicate a trainee’s competence in diagnostic EUS:
includes interventional endoscopists, surgeons, and interven- ▪ successful documentation of anatomical landmarks in
tional radiologists. There are few data and limited studies ≥ 90 % of cases
regarding a threshold for the minimum number of procedures ▪ EUS-guided FNA/FNB accuracy rate of ≥ 85 %.
before assessing competence in therapeutic EUS. Level of agreement 96 %.
Training should commence with drainage of PFCs and celiac
plexus neurolysis (CPN), as they are both relatively high volume
procedures. Although evidence is lacking, it has been suggest-
ed that training in therapeutic EUS should follow sequentially to Again, ESGE proposes that the performance measures advo-
reflect increasing complexity [50]: cated in the ESGE quality improvement initiative defined by
▪ step 1 – EUS-guided CPN and PFC drainage Domagk et al. are considered as benchmarks for independent
▪ step 2 – EUS-guided gallbladder drainage practice [45]. The visualization and documentation of anatomi-
▪ step 3 – EUS-guided biliary drainage (e. g. hepaticogastrost- cal landmarks and the issue of successful tissue sampling are
omy, choledochoduodenostomy, hepaticoenterostomy, central to EUS. Trainees should be able to demonstrate that
rendezvous procedures) they are performing to the required level as evidence of their
Position Statement
competence in EUS. Table 3 s lists “performance items” for learned by endoscopists competent in ERCP and diagnostic
diagnostic EUS and includes suggested anatomical landmarks. EUS, and that supervision should be in place for at least the first
25 cases. It is accepted however that the learning curves of
each trainee are different and competence should be objective-
RECO MMENDATION 30 ly demonstrated.
Trainees are likely to need to have performed 75 EUS- Competence in therapeutic EUS requires a strong under-
guided FNA/FNBs to be able to demonstrate competency standing of the indications, benefits, risks, and alternatives for
in tissue acquisition. the procedure. ESGE recommends that endoscopists audit their
Level of agreement 86 %. rates of success and adverse outcomes for diagnostic and ther-
apeutic EUS both whilst learning these procedures under super-
vision and when undertaking these cases independently. The
A study by Wani et al. concluded that the average trainee acceptable rates of success and adverse events will be different
required 110 EUS-FNAs during training to achieve competence for each EUS-guided intervention, and for endoscopists to prac-
[44]. ESGE recommends that trainees are likely to require a tice independently their success and complications should be
minimum of 75 FNA/FNB procedures before they are likely to comparable to the rates published in the largest peer-reviewed
demonstrate competence. series, and be adjusted when techniques are refined and im-
proved evidence emerges.
RECO MMENDATION 31
Until more robust data are available, an endoscopist can Conclusions
be considered competent to undertake therapeutic EUS As part of the mission of the ESGE to identify quality in endos-
when they can demonstrate acceptable rates of clinical copy as a major priority, we present this Position Statement on
success and adverse events that equate to the rates training in ERCP and EUS. The working group included repre-
described in published case series. It is recommended sentation from across Europe and included different back-
that at least the first 25 cases of any intervention should grounds in training and a range of career experience. Standard
be performed under the supervision of an endoscopist Delphi methodology was used to propose and agree state-
experienced in that intervention. ments pertaining to the prerequisites for ERCP and EUS train-
Level of agreement 96 %. ing; the steps in training and the quality of training; and the de-
finition and assessment of competence in ERCP and EUS prior to
independent practice. These proposals have no legal implica-
tion, but serve to recommend best practice in training. It is
Two studies have assessed the impact of experience on the hoped they will be of use to National Societies, program direc-
outcomes of therapeutic EUS. Harewood et al. reported in tors, and trainees in improving the provision and standard of
2003 that experience of over 20 cases improved the outcomes ERCP and EUS training.
of PFC drainage [59]. A 2008 study reported that trainees Many of the statements are drawn from low or very low qual-
should independently perform 25 EUS-guided PFC drainage ity evidence, so are derived from the expert opinion of the cur-
procedures to be proficient [60]. On account of these studies riculum working group through consensus. Arguably the best
being undertaken in the evolution of the technique and assum- quality evidence is that related to learning curves and the rate
ing that the endoscopist is competent in ERCP, the consensus at which competence is attained in terms of procedure num-
guidelines of the Asian EUS group is for trainees to undertake bers. However, this is a source of controversy as there has
5–10 procedures under supervision as the minimum require- been an understandable move away from competence being
ment to obtain competency in PFC drainage [61]. The group measured solely on the basis of the procedure volume of the
do not recommend a case number for EUS-CPN or EUS-guided trainee. ESGE has proposed that procedure numbers are
biliary or pancreatic drainage. ESGE proposes that trainees retained as they serve as guidance to lead trainers responsible
should expect to require 10–25 PFC drainage procedures for organizing training programs, as well as to trainees who
before expecting to demonstrate competency for drainage of will benefit from a benchmark to determine when full compe-
PFCs. tence in ERCP and EUS is likely to be attained. ESGE emphasizes
Oh et al. reported that experience of 33 cases is required for however that the procedure volume of a trainee is no longer
EUS-guided hepaticogastrostomy [62], and similarly James et sufficient evidence of competence and recommends that key
al. reported 40 cases being required for effective hepatico- performance measures are attained and that consideration is
enterostomy [63]. Teoh et al. reported the findings from an given by national institutions to a formal summative assess-
international multicenter registry and concluded that 25 cases ment process prior to independent practice.
were required for competence in EUS-guided gallbladder drain- There remain major challenges to delivering effective ERCP
age [64]. Given the limited number of cases, even in specialist and EUS training. It has been proposed that simulation forms a
centers, acquisition of experience in these complex procedures central part of training, although access to effective simulation
is an issue. For the current generation coming through endos- is highly variable. There is also inconsistent availability of formal
copy training, ESGE proposes that these procedures should be endoscopy courses and “train the trainer” workshops, both of
▶ Table 2 Potential research questions to be prioritized. Disclaimer
To what degree can trainee learning curves and recommended mini- ESGE Position Statements represent a consensus of best prac-
mum case volumes be improved with greater focus on:
tice based on the available evidence at the time of preparation.
▪ formal courses This is NOT a guideline but a proposal for training in ERCP and
▪ simulation
EUS. The statements may not apply in all situations and should
be interpreted in the light of specific clinical situations and re-
▪ trainer expertise
source availability. Further studies may be needed to clarify as-
▪ “immersion training” (greater intensity of case experience)? pects of these statements, and revision may be necessary as
new data appear. Clinical considerations may justify a course
What levels of objective performance measures for ERCP and EUS are
fair and attainable for trainees to attain prior to independent practice of action at variance with these recommendations.
(e. g. cannulation rates)? This ESGE Position Statement is intended to be an educa-
tional device to provide information that may assist endos-
What effects do breaks in training have on ERCP and EUS learning
copists in providing care to patients. They are not rules and
curves?
should not be construed as establishing a legal standard of
What are the most valid and feasible ways to assess a trainee’s com-
care or as encouraging, advocating, requiring, or discouraging
petence prior to independent practice?
any particular treatment.
What constitutes ideal training for an endoscopist in lower volume, The legal disclaimer for ESGE guidelines applies to the pres-
more complex, advanced therapeutic ERCP and EUS procedures, and
ent position statement [65].
how should competence be determined?
What is the suggested format for effective ERCP and EUS mentoring
once independent practice has commenced? Competing interests
ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic
ultrasound. A. Anderloni has provided consultancy for Boston Scientific (2016 to
present), Olympus (2018 to present), and Medtronic (2018–2019).
M. Arvanitakis has received lecture fees from Olympus (2019–2020).
R. Bisschops is supported by a grant from Flanders Research Founda-
which have been shown to benefit training. Given the paucity of tion; he has received speaker’s and consultancy fees from Medtronic,
evidence behind many of the statements, ESGE encourages fur- Fujifilm, and Pentax (2015 to present), and consultancy fees from
ther study into all facets of training in ERCP, diagnostic EUS, and Boston Scientific and Cook (2015 to present); his department has re-
therapeutic EUS in particular. ▶ Table 2 lists potential research ceived research grants from Pentax and Fujifilm (2015 to present),
Cook (2016–2019), Medtronic (2018 to present), and Boston Scienti-
questions that should be prioritized by investigators with an in-
fic (2019 to present). M. Dinis-Ribeiro provided consultancy for Med-
terest in enhancing ERCP and EUS services, safety, and training tronic (2020); he is also co-editor in-chief of Endoscopy. I. Hritz was a
quality. consultant and trainer for Olympus and Pentax Medical (2017–2018).
Training in therapeutic EUS remains a particular challenge. G. Johnson has received education consultancy fees from Boston Sci-
Even in specialist centers, the procedure numbers for therapeu- entific (2014 to present), Pentax (2017–2018), and Olympus (2013 to
present). J.-W. Poley has received consultancy and travel fees from
tic EUS are much lower than for ERCP and diagnostic EUS. The
Boston Scientific, Cook Endoscopy, and Pentax Medical (2015 to pres-
evidence with regard to learning curves for therapeutic EUS is ent). J.J. Vila has provided consultancy for Boston Scientific (2014 to
less robust than the equivalent data for ERCP and diagnostic present). G. Webster has received fees for invited lectures and advi-
EUS. Furthermore, endoscopists training in these procedures sory boards from Boston Scientific, Cook Endoscopy, and Pentax Med-
may already be experienced practitioners of ERCP and EUS, so ical (2010 to present) and has received support for endoscopy teach-
ing courses from Boston Scientific, Cook Endoscopy, Pentax Medical,
ensuring their appropriate supervision can be particularly diffi-
Olympus, Medtronic, and ERBE (2010 to present). U. Arnelo, A. Ba-
cult if the individual is already an independent endoscopist. The daoui, N. Bekkali, I. Boskoski, S. Campos, D. Christodoulou, L. Czakó,
solutions to these problems will vary between nations, but may S. Gölder, T. Hucl, E. Kalaitzakis, L. Kylänpää, I. Nedoluzhko, M.C. Pet-
include access to simulation, a mentoring network, and robust rone, T. Ponchon, C. Schlag, A. Seicean, and M.F.Y. Viesca declare that
ongoing audit of performance. ESGE discourages unsupported they have no conflict of interest.
endoscopists learning new therapeutic procedures on patients.

For national societies and program directors to meet the References
proposals in this position statement will be challenging, but
there is enough evidence to suggest that, if these recommen-
[1] Rutter MD, Senore C, Bisschops R et al. The European Society of Gas-
dations are delivered, the objective of the ESGE to enhance
trointestinal Endoscopy Quality Improvement Initiative: developing
quality in ERCP and EUS will have been furthered. Training in performance measures. Endoscopy 2016; 48: 81–89
ERCP and EUS is long and challenging but very rewarding and [2] Bisschops R, Dekker E, East JE et al. European Society of Gastrointes-
ESGE hopes that this position statement benefits trainees em- tinal Endoscopy (ESGE) curricula development for postgraduate
barking on this process and helps to produce independent training in advanced endoscopic procedures: rationale and metho-
endoscopists capable of delivering a safe and effective service dology. Endoscopy 2019; 51: 976–979
for their patients.
Position Statement
[3] Cohen S, Bacon BR, Berlin JA et al. National Institutes of Health State- [23] Jorgensen JE, Elta GH, Stalburg CM et al. Do breaks in gastroenterol-
of-the-Science Conference Statement: ERCP for diagnosis and ther- ogy fellow endoscopy training result in a decrement in competency in
apy, January 14–16, 2002. Gastrointest Endosc 2002; 56: 803–809 colonoscopy? Gastrointest Endosc 2013; 78: 503–509
[4] Dekker E, Houwen B, Puig I et al. Curriculum for optical diagnosis [24] Ward ST, Hancox A, Mohammed MA et al. The learning curve to
training in Europe: European Society of Gastrointestinal Endoscopy achieve satisfactory completion rates in upper GI endoscopy: an a-
(ESGE) Position Statement. Endoscopy 2020; 52: 899–923 nalysis of a national training database. Gut 2017; 66: 1022–1033
[5] Sidhu R, Chetcuti Zammit S, Baltes P et al. Curriculum for small-bowel [25] Ward ST, Mohammed MA, Walt R et al. An analysis of the learning
capsule endoscopy and device-assisted enteroscopy training in Eur- curve to achieve competency at colonoscopy using the JETS database.
ope: European Society of Gastrointestinal Endoscopy (ESGE) Position Gut 2014; 63: 1746–1754
Statement. Endoscopy 2020; 52: 669–686 [26] Wani S, Keswani R, Hall M et al. A prospective multicenter study eval-
[6] Pimentel-Nunes P, Pioche M, Albéniz E et al. Curriculum for endo- uating learning curves and competence in endoscopic ultrasound and
scopic submucosal dissection training in Europe: European Society of endoscopic retrograde cholangiopancreatography among advanced
Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy endoscopy trainees: the rapid assessment of trainee endoscopy skills
2019; 51: 980–992 study. Clin Gastroenterol Hepatol 2017; 15: 1758–1767.e1711
[7] Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus [27] Siau K, Dunckley P, Valori R et al. Changes in scoring of Direct Obser-
on rating quality of evidence and strength of recommendations. BMJ vation of Procedural Skills (DOPS) forms and the impact on compe-
2008; 336: 924–926 tence assessment. Endoscopy 2018; 50: 770–778
[8] Bisschops R, Areia M, Coron E et al. Performance measures for upper [28] Siau K, Dunckley P, Feeney M et al. ERCP assessment tool: evidence of
gastrointestinal endoscopy: a European Society of Gastrointestinal validity and competency development during training. Endoscopy
Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2016; 2019; 51: 1017–1026
48: 843–864 [29] Dilly CK, Sewell JL. How to give feedback during endoscopy training.
[9] Goodman AJ, Melson J, Aslanian HR et al. Endoscopic simulators. Gastroenterology 2017; 153: 632–636
Gastrointest Endosc 2019; 90: 1–12 [30] Young JQ, Van Merrienboer J, Durning S et al. Cognitive Load Theory:
[10] Sedlack RE. The state of simulation in endoscopy education: continu- implications for medical education: AMEE Guide No. 86. Med Teach
ing to advance toward our goals. Gastroenterology 2013; 144: 9–12 2014; 36: 371–384
[11] Desilets DJ, Banerjee S, Barth BA et al. Endoscopic simulators. Gas- [31] Harewood GC, Murray F, Winder S et al. Evaluation of formal feedback
trointest Endosc 2011; 73: 861–867 on endoscopic competence among trainees: the EFFECT trial. Ir J Med
[12] Leung JW, Wang D, Hu B et al. A head-to-head hands-on comparison Sci 2008; 177: 253–256
of ERCP mechanical simulator (EMS) and ex-vivo Porcine Stomach [32] Waschke KA, Anderson J, Macintosh D et al. Training the gastrointes-
Model (PSM). J Interv Gastroenterol 2011; 1: 108–113 tinal endoscopy trainer. Best Pract Res Clin Gastroenterol 2016; 30:
[13] Leung J, Lim B, Ngo C et al. Head-to-head comparison of practice with 409–419
endoscopic retrograde cholangiopancreatography computer and [33] Faulx AL, Lightdale JR, Acosta RD et al. Guidelines for privileging, cre-
mechanical simulators by experienced endoscopists and trainees. Dig dentialing, and proctoring to perform GI endoscopy. Gastrointest En-
Endosc 2012; 24: 175–181 dosc 2017; 85: 273–281
[14] Sedlack R, Petersen B, Binmoeller K et al. A direct comparison of ERCP [34] Siau K, Hawkes ND, Dunckley P. Training in Endoscopy. Curr Treat Op-
teaching models. Gastrointest Endosc 2003; 57: 886–890 tions Gastroenterol 2018; 16: 345–361
[15] Lim BS, Leung JW, Lee J et al. Effect of ERCP mechanical simulator [35] Wani S, Hall M, Keswani RN et al. Variation in aptitude of trainees in
(EMS) practice on trainees' ERCP performance in the early learning endoscopic ultrasonography, based on cumulative sum analysis. Clin
period: US multicenter randomized controlled trial. Am J Gastroen- Gastroenterol Hepatol 2015; 13: 1318–1325.e1312
terol 2011; 106: 300–306 [36] Wani S, Keswani RN, Petersen B et al. Training in EUS and ERCP: stan-
[16] Ekkelenkamp VE, Koch AD, de Man RA et al. Training and competence dardizing methods to assess competence. Gastrointest Endosc 2018;
assessment in GI endoscopy: a systematic review. Gut 2016; 65: 607– 87: 1371–1382
615 [37] Mehta T, Dowler K, McKaig BC et al. Development and roll out of the
[17] Liao WC, Leung JW, Wang HP et al. Coached practice using ERCP me- JETS e-portfolio: a web based electronic portfolio for endoscopists.
chanical simulator improves trainees' ERCP performance: a random- Frontline Gastroenterol 2011; 2: 35–42
ized controlled trial. Endoscopy 2013; 45: 799–805 [38] Ekkelenkamp VE, Koch AD, Haringsma J et al. Quality evaluation
[18] Sedlack RE, Petersen BT, Kolars JC. The impact of a hands-on ERCP through self-assessment: a novel method to gain insight into ERCP
workshop on clinical practice. Gastrointest Endosc 2005; 61: 67–71 performance. Frontline Gastroenterol 2014; 5: 10–16
[19] Thomas-Gibson S, Bassett P, Suzuki N et al. Intensive training over 5 [39] Schutz SM. Grading the degree of difficulty of ERCP procedures. Gas-
days improves colonoscopy skills long-term. Endoscopy 2007; 39: troenterol Hepatol (N Y) 2011; 7: 674–676
818–824 [40] Sedlack RE, Coyle WJ. Assessment of competency in endoscopy: es-
[20] Ekkelenkamp VE, Koch AD, Rauws EA et al. Competence development tablishing and validating generalizable competency benchmarks for
in ERCP: the learning curve of novice trainees. Endoscopy 2014; 46: colonoscopy. Gastrointest Endosc 2016; 83: 516–523.e511
949–955 [41] Yang D, Wagh MS, Draganov PV. The status of training in new tech-
[21] Wani S, Coté GA, Keswani R et al. Learning curves for EUS by using nologies in advanced endoscopy: from defining competence to cre-
cumulative sum analysis: implications for American Society for Gas- dentialing and privileging. Gastrointest Endosc 2020; 92: 1016–1025
trointestinal Endoscopy recommendations for training. Gastrointest [42] Patel SG, Keswani R, Elta G et al. Status of competency-based medical
Endosc 2013; 77: 558–565 education in endoscopy training: a nationwide survey of US ACGME-
[22] Wani S, Hall M, Wang AY et al. Variation in learning curves and com- accredited gastroenterology training programs. Am J Gastroenterol
petence for ERCP among advanced endoscopy trainees by using cu- 2015; 110: 956–962
mulative sum analysis. Gastrointest Endosc 2016; 83: 711–719.e711 [43] Shahidi N, Ou G, Telford J et al. When trainees reach competency in
performing ERCP: a systematic review. Gastrointest Endosc 2015; 81:
1337–1342
[44] Wani S, Han S, Simon V et al. Setting minimum standards for training [54] Eisen GM, Dominitz JA, Faigel DO et al. Guidelines for credentialing
in EUS and ERCP: results from a prospective multicenter study evalu- and granting privileges for endoscopic ultrasound. Gastrointest
ating learning curves and competence among advanced endoscopy Endosc 2001; 54: 811–814
trainees. Gastrointest Endosc 2019; 89: 1160–1168.e1169 [55] Rösch T. State of the art lecture: endoscopic ultrasonography: train-
[45] Domagk D, Oppong KW, Aabakken L et al. Performance measures for ing and competence. Endoscopy 2006; 38: (Suppl. 01): S69–S72
ERCP and endoscopic ultrasound: a European Society of Gastrointes- [56] Coté GA, Hovis CE, Kohlmeier C et al. Training in EUS-guided fine
tinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy needle aspiration: safety and diagnostic yield of attending super-
2018; 50: 1116–1127 vised, trainee-directed FNA from the onset of training. Diagn Ther
[46] Adler DG, Lieb JG 2nd, Cohen J et al. Quality indicators for ERCP. Gas- Endosc 2011; 2011: 378540
trointest Endosc 2015; 81: 54–66 [57] Meenan J, Harris K, Oppong K et al. Service provision and training for
[47] Testoni PA, Mariani A, Aabakken L et al. Papillary cannulation and endoscopic ultrasound in the UK. Frontline Gastroenterol 2011; 2:
sphincterotomy techniques at ERCP: European Society of Gastroin- 188–194
testinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: [58] Shahidi N, Ou G, Lam E et al. When trainees reach competency in
657–683 performing endoscopic ultrasound: a systematic review. Endosc Int
[48] Xu W, Liu Y, Pan P et al. Prior radial-scanning endoscopic ultrasono- Open 2017; 5: E239–E243
graphy training did not contribute to subsequent linear-array endo- [59] Harewood GC, Wright CA, Baron TH. Impact on patient outcomes of
scopic ultrasonography study performance in the stomach of a por- experience in the performance of endoscopic pancreatic fluid collec-
cine model. Gut Liver 2015; 9: 353–357 tion drainage. Gastrointest Endosc 2003; 58: 230–235
[49] Shin EJ, Topazian M, Goggins MG et al. Linear-array EUS improves de- [60] Varadarajulu S, Tamhane A, Blakely J. Graded dilation technique for
tection of pancreatic lesions in high-risk individuals: a randomized EUS-guided drainage of peripancreatic fluid collections: an assess-
tandem study. Gastrointest Endosc 2015; 82: 812–818 ment of outcomes and complications and technical proficiency (with
[50] Saumoy M, Kahaleh M. Progress in endoscopic ultrasonography: video). Gastrointest Endosc 2008; 68: 656–666
training in therapeutic or interventional endoscopic ultrasonography. [61] Teoh AYB, Dhir V, Kida M et al. Consensus guidelines on the optimal
Gastrointest Endosc Clin N Am 2017; 27: 749–758 management in interventional EUS procedures: results from the Asian
[51] ASGE. ASGE Guidelines for clinical application. Methods of privileging EUS group RAND/UCLA expert panel. Gut 2018; 67: 1209–1228
for new technology in gastrointestinal endoscopy. American Society [62] Oh D, Park DH, Song TJ et al. Optimal biliary access point and learning
for Gastrointestinal Endoscopy. Gastrointest Endosc 1999; 50: 899– curve for endoscopic ultrasound-guided hepaticogastrostomy with
900 transmural stenting. Therap Adv Gastroenterol 2017; 10: 42–53
[52] Wani S, Keswani RN, Han S et al. Competence in endoscopic ultra- [63] James TW, Baron TH. Practical applications and learning curve for
sound and endoscopic retrograde cholangiopancreatography, from EUS-guided hepaticoenterostomy: results of a large single-center US
training through independent practice. Gastroenterology 2018; 155: retrospective analysis. Endosc Int Open 2019; 7: E600–E607
1483–1494.e1487
[64] Teoh AY, Perez-Miranda M, Kunda R et al. Outcomes of an interna-
[53] Dumonceau JM, Deprez PH, Jenssen C et al. Indications, results, and tional multicenter registry on EUS-guided gallbladder drainage in pa-
clinical impact of endoscopic ultrasound (EUS)-guided sampling in tients at high risk for cholecystectomy. Endosc Int Open 2019; 7:
gastroenterology: European Society of Gastrointestinal Endoscopy E964–E973
(ESGE) Clinical Guideline – Updated January 2017. Endoscopy 2017;
[65] Dumonceau JM, Hassan C, Riphaus A et al. European Society of Gas-
49: 695–714
trointestinal Endoscopy (ESGE) Guideline Development Policy.
Endoscopy 2012; 44: 626–629

ERCP Curriculum

Uploaded by

Copyright:

Available Formats

ERCP Curriculum

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ERCP Curriculum

Uploaded by

Copyright:

Available Formats

Published online: 2021-07-26

Curriculum for ERCP and endoscopic ultrasound training in

Institutions 16 Digestive Disease Center, University Hospital of

All rights reserved. degree of independence. Structured formative assessment

Corresponding author 3 Specifically for ERCP, all trainees should be competent up

▶ Table 1 Summary of recommendations, with quality of evidence and strength of recommendation.

Number Recommendation Quality of Strength of re-

ERCP and EUS training in general

Number Recommendation Quality of Strength of re-

17 ERCP competence should be considered in two stages: Low Strong

Number Recommendation Quality of Strength of re-

RECO MMENDATION 3 RECOMMENDATION 5

indicated minimum number of procedures required for compe-

Training centers that can provide adequate procedure RECOMMENDATION 11

aspect of a procedure, a picture builds up as to the particular 2 ERCP training

RECO MMENDATION 15 RECOMMENDATION 17

When an endoscopist reaches the standards defined in the

EUS requires both cognitive and technical abilities, so a trai-

Therapeutic EUS continues to evolve and is associated with

endoscopists learning new therapeutic procedures on patients.

for their patients.

You might also like