Training surgeons in endoscopic retrograde cholangiopancreatography.

BACKGROUND: General surgeons commonly perform upper gastrointestinal endoscopy in practice, but few perform endoscopic retrograde cholangiopancreatography (ERCP), partly because of limited training opportunities. This report focuses on the value of an ERCP fellowship training program to a broad-based, mature residency in surgery and our observations on the experience required for surgeons to be trained in advanced interventional ERCP. METHODS: Since the program was initiated in 1992, 13 ERCP fellows have been trained for individual periods of 6 to 14 months. This study investigated all procedures with fellow involvement (2,008 cases) from among a total experience of 3,641 ERCPs. Data collected included type of ERCP (diagnostic/therapeutic), fellow success in cannulating the duct of interest, and faculty success in cases of fellows who failed. Of the 13 fellows, 9 had previous endoscopy experience, but none had training in ERCP. RESULTS: An 85% cannulation rate was accepted as successful, and cannulation rates for each fellow were calculated for each 3-month period. The 85% mark was reached by 4 (31%) of 13 fellows in the first period, 2 of 13 fellows (15%) in the second period, 5 of 11 fellows (45%) in the third period, 7 of 10 fellows (70%) in the fourth period, and 1 of 1 fellow (100%) in the fifth period of training. On the average, it took 7.1 months and 102 ERCPs for trainees to reach desired success levels. Success came more promptly with prior exposure to endoscopy. Fellows without prior endoscopic experience required 148 cases to reach 85% success. Resident surgical experience with major pancreatic resections increased threefold after establishment of the fellowship. CONCLUSIONS: Training in ERCP is possible within the scope of a surgical fellowship in a reasonable length of time and experience. Complication rates remain low even with fellow involvement. Establishment of an ERCP program increases the focus and experience of pancreas surgery in a surgical residency for chief residents.

Role of pancreatic duct stenting in the treatment of chronic pancreatitis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography and stent placement are relatively new alternatives to surgery for the treatment of chronic pancreatitis. The objective of this study was to determine the efficacy of pancreatic duct stent placement for the treatment of chronic pancreatitis. METHODS: This study included 89 patients treated with pancreatic stents between 1993 and 2002. The patients were contacted via telephone for a personal interview with regard to pain, medication usage, weight loss or gain, and eating patterns. Additionally, medication usage before and after treatment was documented from the Kentucky Cabinet for Health Services' electronic reporting system for narcotic use. RESULTS: Of the 89 patients, 9 were deceased, 5 either refused to interview or could not be contacted, and 75 were interviewed. Significant weight gain exceeding 15 lb after treatment was experienced by 22%, whereas only 4% lost weight. A majority of the patients (68%) noted that they had less severe relapses or no relapses after treatment. The patients reported a decrease in pain level on a 10-point scale from 8.7 to 4.1 (53% decrease) after treatment. A decrease in pain medication usage was reported by 47% of the patients, and 83% considered their treatment successful. The Kentucky All Schedule Prescription Electronic Report (KASPER) was obtained before and after treatment for 55 patients. According to this statewide electronic reporting system, 63% had a documented decrease in narcotic use. CONCLUSION: The findings of this study support the use of pancreatic duct stenting as an option before surgical intervention for these difficult-to-manage patients with chronic pancreatitis.