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• W2040744385 abstract "Many advanced endoscopists finish their fellowship with very little training on how to perform needle-knife sphincterotomies. It has been described as a procedure not for the faint of heart and a technique that should not be substituted for lack of experience. I recently spoke to John Goff, creator of the transpancreatic septotomy technique, and asked for his thoughts on the subject. His reply was “know your anatomy, know when to stop, know when to regroup and when to try again the next day.” In this month's Fellows' Corner, Drs Anastassiades and Saxena share with us the tips and tricks of successful mastery of the needle-knife technique during advanced fellowship. The purpose of this article is to share their recent personal experiences and thoughts on the current training during advanced fellowship to help current and prospective fellows make the most of their training experience.Key Points •Mastery of precut needle-knife sphincterotomy is an area of uncertainty among advanced endoscopy trainees.•This uncertainty may result from the lack of formal and/or standardized teaching and assessment methods.•A healthy, proactive, and inquisitive attitude during training will amplify and maximize the individual experience. •Mastery of precut needle-knife sphincterotomy is an area of uncertainty among advanced endoscopy trainees.•This uncertainty may result from the lack of formal and/or standardized teaching and assessment methods.•A healthy, proactive, and inquisitive attitude during training will amplify and maximize the individual experience. Reem Sharaiha, MD, MSc Fellows' Corner Editor Advanced Endoscopy Attending Division of Gastroenterology and Hepatology New York Presbyterian Hospital–Weill Cornell Medical Center New York, New York, USA The American Society for Gastrointestinal Endoscopy (ASGE) Training Committee includes sphincterotomy as part of the ERCP core curriculum for trainees.1Chutkan R.K. Ahmad A.S. Cohen J. et al.ERCP core curriculum.Gastrointest Endosc. 2006; 63: 361-376Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar The American College of Gastroenterology/ASGE Quality in Endoscopy Taskforce and the ASGE Standards of Practice Committee recognize that adverse events are inherent in the performance of ERCP and call for continuous quality improvement as an important part of ERCP programs.2Baron T.H. Petersen B.T. Mergener K. et al.Quality indicators for endoscopic retrograde cholangiopancreatography.Gastrointest Endosc. 2006; 63: S29-S34Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 3Anderson M.A. Fisher L. Jain R. et al.Complications of ERCP.Gastrointest Endosc. 2012; 75: 467-473Abstract Full Text Full Text PDF PubMed Google Scholar In preparation for an advanced endoscopy conference halfway through the academic year, we noticed an epidemic of postsphincterotomy bleeding cases in our practice, possibly at a rate higher than the frequently quoted 2%.1Chutkan R.K. Ahmad A.S. Cohen J. et al.ERCP core curriculum.Gastrointest Endosc. 2006; 63: 361-376Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 4Freeman M.L. Nelson D.B. Sherman S. et al.Complications of endoscopic biliary sphincterotomy.N Engl J Med. 1996; 335: 909-918Crossref PubMed Scopus (2153) Google Scholar We decided to take heed and perform an internal quality audit. After institutional review board approval, we retrospectively studied the endoscopic database at our academic center and identified all ERCP procedures during the course of an advanced endoscopy fellowship year for the academic year 2011-2012. Procedures performed by nongastroenterologists were excluded. A total of 370 ERCP procedures were identified, 11 of which were complicated by postsphincterotomy bleeding (3%). Clinical and endoscopic data for these patients were collected and reviewed. Precut needle-knife sphincterotomy was performed in 45% of these cases (5/11). We therefore concluded that precut needle-knife sphincterotomy was a frequent technical factor associated with postsphincterotomy bleeding during that year of advanced endoscopy fellowship training at our institution. This prompted us to consider the general issue of precut needle-knife sphincterotomy during training. Few issues generate such universal anxiety as that of gaining competence in this technique. The purpose of this article is to share our recent personal experiences and thoughts with the fellows who are currently training or look forward to training in advanced endoscopy in the hope of informing them, alleviating their fears, and helping them make the most of their training experience. To trainees, the use of needle-knife as a technique to access the bile duct may seem an endoscopic practice cloaked in mystery. A standard sphincterotomy technique involves the incision of the papilla with a precurved sphincterotome after the bile duct has already been selectively accessed. In difficult-access cases, a precut technique with a needle-knife can be used when the papilla is incised from the outside and the incision is extended superiorly toward the estimated direction of the bile duct in a much less controlled fashion than that afforded by a sphincterotome secured over a guidewire in the bile duct. Most trainees consider this precut needle-knife technique a privilege of the few and a rite of passage when the opportunity is eventually offered. “Do you get to do any needle-knives during training?” is a favorite lunchtime question asked by applicants on their interview day. The mystique of needle-knife may be perpetuated by the notion that, traditionally, precut needle-knife sphincterotomy is a last resort akin to a desperate, heroic option once everything else has failed. Even the descriptive terminology for this ERCP accessory—“needle-knife”—conveys the occult message that this is a weapon not to be trifled with. The anecdotal reluctance of trainers to allow trainees to perform this maneuver does little to dispel any myths. The ASGE ERCP core curriculum warns that “this procedure is potentially dangerous in inexperienced hands” and considerable expertise is required “before fellows can safely attempt to learn” how to perform such a procedure.3Anderson M.A. Fisher L. Jain R. et al.Complications of ERCP.Gastrointest Endosc. 2012; 75: 467-473Abstract Full Text Full Text PDF PubMed Google Scholar In a different article by an ASGE working party on grading the complexity of procedures, needle-knife sphincterotomy is not assigned a complexity grade.5Cotton P.B. Eisen G. Romagnuolo J. et al.Grading the complexity of endoscopic procedures: results of an ASGE working party.Gastrointest Endosc. 2011; 73: 868-874Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar The authors cite instead criticism of a previous publication that had classified this procedure as one of the highest complexity and argue that needle-knife sphincterotomy “is not difficult and, as a result, is used too frequently instead of a proper cannulation technique, but it is risky.”5Cotton P.B. Eisen G. Romagnuolo J. et al.Grading the complexity of endoscopic procedures: results of an ASGE working party.Gastrointest Endosc. 2011; 73: 868-874Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar What do the trainees think? Friends who have recently completed their advanced endoscopy fellowship mention that they had some exposure but are not comfortable with the procedure. Others report that they received no experience at all during their training. Others proudly announce that few cannulation attempts failed in their training, and thus a needle-knife was not frequently used, only to then realize that this stellar performance may have been more reflective of their experienced trainer's skill rather than their own; as a result, they are not sure what to do in the early stages of their independent practice should standard cannulation fail. Some say their solution would be to avoid a precut needle-knife sphincterotomy at any cost, especially at the beginning of their independent practice; they would be more inclined instead to request more senior assistance (if available). A recent advanced endoscopy fellowship graduate who has just joined private practice provisionally believes that the needle-knife has no place in (his) private practice. So, what are the rules? Whatever the case, most graduates willing to master this technique appear resigned to their needle-knife fate and accept they may eventually have to “learn by fire” when the dreaded moment comes. To complicate things a little further, some experts argue that needle-knife sphincterotomy is not necessarily a last resort; it may, in fact, be effective and safe to use early in cases of difficult access.6Kaffes A.J. Sriram P.V. Rao G.V. et al.Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional vs. a modified technique.Gastrointest Endosc. 2005; 62: 669-674Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar The catch, of course, is that this may be the case in “expert hands” only. What is the truth then and which fog lights can the trainees rely on to navigate amid the haziness of this topic? Most trainees are likely to commence their advanced endoscopy fellowship with unrestrained enthusiasm and lofty expectations. Being subsequently denied the relatively rare opportunity to fully participate in a procedure of burning interest, such as a precut needle-knife sphincterotomy, can be disheartening. There is, realistically, very little you can do to change variables such as the teaching traditions, style, volume, or practice of your training environment. You are much better off trying to favorably modify the one variable that you can control: yourself. The best way to gain an advantage is to stay involved and engage in some form of continuous self-development. There is often an army of general gastroenterology fellows, inpatient and consult gastroenterology teams, and hospitalist services available to deal with any inpatient or complicated ERCP cases requiring admission to the hospital. Sitting insulated in the endoscopy unit and waiting for 1 patient gurney after another to roll in and out of the fluoroscopy room can make you feel invincible. Your sense of invincibility is guaranteed to dissipate very soon, however; even worse, you will not be ready when this happens. A wiser approach would be to make a habit of visiting the wards and intensive care unit and see for yourself what a stroke of the needle-knife can do. This alone is a learning experience. Besides, things do not go unnoticed: your engaged attitude can help the morale of the primary service, the fellows with whom you work on a daily basis, and, above all, the patient. Last, but not least, your trainers are more likely to actively include in higher risk procedures someone who takes care of business than someone who is notoriously indifferent. A common complaint is that the advanced fellows exhibit little interest in learning how to deal with adverse events and the nonendoscopic aspects of patient care. The right attitude is up to you, not the program, so try to make the most of this 1 final year. If you want to learn it, earn it. Occasionally talking to colleagues at your own stage of training can also be beneficial, enlightening, and even comforting. How do they deal with a difficult cannulation in their own training environment and what is their experience with the needle-knife? Why do they do what they do and why do you do what you do? A friend and I found ourselves exchanging daily highlights at the end of the day, every day, during our advanced endoscopy fellowship year. We initially called this the “scoreboard” (which religiously lit up on nights and weekends too sometimes). We soon realized that this was not so much an obsessive competition against each other as it was a tenacious struggle toward a common goal, to which another person's experiences could contribute. We aptly renamed our gentlemanly system to self-improvement “scorecards,” and I think we both did learn from their study. Participation in national conferences is a different facet of the same principle: to exchange ideas and to learn from others. You do not really have to keep daily track or compare notes with anybody; just remember to “come up for air” and look around you. If nothing else, it will help you realize that everyone is in the same boat, and, with everyone rowing as hard as they can, the boat is usually headed for dry land. The watchers being your trainers, the short answer is probably nobody. Your trainers understandably reserve the right to allow or deny you participation in any aspect of any procedure. When it comes to a precut needle-knife sphincterotomy, you could find that they are more likely to exercise this right. Whether the “rejection” stems from a (perennially) “bad day” or a totally justified lack of confidence in your endoscopic skills is irrelevant. It would be worthwhile to keep in mind, however, that this may actually reflect an agenda for themselves and not always you: will I allow an advanced endoscopy fellow, no matter how technically gifted, to perform a precut needle-knife sphincterotomy in a difficult access case in the first few months of my independent practice? No, or not at least before I am good and ready. Irrespective of the trainers' experience and your own skill, it is undoubtedly true that personal styles vary greatly. One of my experienced trainers never allowed me to perform a needle-knife sphincterotomy at any point—not even close to day 365 of my advanced year. Another experienced trainer allowed me to perform a precut needle-knife sphincterotomy fairly early on in my training in a pediatric patient in the operating room. We (ie, he) spent the next 2 hours controlling the immediate bleeding (Fig. 1) and the final 10 minutes completing the ERCP (Fig. 2). The rest of my trainers allowed me to perform a needle-knife sphincterotomy at some point in between when they felt comfortable. You must therefore appreciate that the opportunity will be offered at each trainer's discretion. If you are diligent, have a healthy attitude, and respond to feedback, then you have done whatever is in your power to invite the opportunity sooner than later and more than once.Figure 2Completion of ERCP with insertion of a temporary biliary stent after successful endoscopic hemostasis.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Even if the opportunity for hands-on participation seems limited, do not jump ship in favor of that “easier” ERCP next door just yet: learning to troubleshoot challenging cannulation cases is invaluable. One of my trainers would sometimes use a precut transpancreatic septotomy rather than the needle-knife technique with good and safe results. This essentially involves passing a guidewire into the pancreatic duct and then using a precurved sphincterotome over the same guidewire to perform an incision in the estimated direction of the bile duct, in an effort to dissect the septum and separate and expose the bile duct from the pancreatic duct orifice. None of my other trainers used this method. A quick cross-reference with friends confirmed that it can indeed work very well—across state borders, too. Finally, a quick literature review and national conference attendance not only consolidated this impression but also gave this technique a name: “Goff sphincterotomy.”7Goff J.S. Long-term experience with the transpancreatic sphincter pre-cut approach to biliary sphincterotomy.Gastrointest Endosc. 1999; 50: 642-645Abstract Full Text PDF PubMed Scopus (86) Google Scholar All of a sudden, I had now doubled my precut options and expanded my own personal repertoire. Keeping your eyes and ears open is important and will help you avoid becoming monolithic. If you have never heard of or seen something, you will not even have the option to consider it. In advanced endoscopy, it often pays off to have options. It emerges from this discussion that a large aspect of the training in precut needle-knife sphincterotomy is dependent on a number of variable and subjective forces. Is there anything that can be done to standardize the process and, if so, is standardization desirable? ASGE does publish an ERCP curriculum but does not include specifics on teaching methodology.3Anderson M.A. Fisher L. Jain R. et al.Complications of ERCP.Gastrointest Endosc. 2012; 75: 467-473Abstract Full Text Full Text PDF PubMed Google Scholar A timely Fellows' Corner article in this journal has discussed simulators and their increasing integration in gastroenterology fellowship programs.8Sedlack R.E. Incorporating simulation into the GI curriculum: the time is now.Gastrointest Endosc. 2012; 76: 622-624Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Is it possible for precut needle-knife to be practiced on a simulator? A few courses and institutions offer experience on animal models. Is this enough or at least useful for this purpose? In regular gastroenterology fellowship, many trainees have been content to somewhat passively keep track of the overall number of upper and lower endoscopies that they have performed (or to be more accurate, the number of procedure reports in which their name has been included). Is this enough for competency and is this sufficient for ERCP? In the advanced endoscopy year, it will typically take much more to satisfy you than your name on a report. Most of the postsphincterotomy bleeding procedures in which I participated occurred in the first 6 months of my training. Was this a coincidence or not? The endoscopy report says that I was there. Does it tell the whole story? Doubtful. Does it tell me anything about my degree of involvement or how well I did? No. During my regular gastroenterology fellowship, a friend tried to explore ways to more accurately define and assess gastroenterology fellow performance in colonoscopy.9Jorgensen J.E. Elta G.H. Kolars J.C. et al.Do breaks in endoscopy fellowship training decrease colonoscopy competency?.Gastrointest Endosc. 2012; 75: AB156Abstract Full Text Full Text PDF Google Scholar With input from experienced mentors, she was able to introduce a simple documentation section to the endoscopy report software; the supervising endoscopists were then able to electronically capture the portions of the procedure that the fellows were able to complete independently. This could potentially facilitate performance assessment, progress monitoring, identification of areas in need of improvement, and refinement of endoscopic teaching methods. Can similar principles be applied to ERCP? For now, the technical aspect of ERCP training remains reminiscent of an apprenticeship in which the trainee tries to soak up and learn hands-on tricks from the master at the master's subjective discretion and interpretation. Things may be changing though. Precut needle-knife sphincterotomy is a procedure whose mastery generates significant anxiety among advanced endoscopy trainees. Part of the reason may be the lack of a standardized and formal approach to imparting knowledge of this technique. This is an area that the professional societies may be able to address in the future, particularly as objective methods of assessing competency in endoscopy are increasingly being investigated, developed, and formally integrated into training programs. In the meantime, a constructive dialogue between the trainees and their trainers can help identify the best opportunities for exposure and development. The advanced endoscopy fellows overall should have faith in their training environment and their trainers. At the end of the day, when it comes to advanced endoscopic techniques, independent growth and “learning by fire” should not be feared. On the contrary, it should be embraced as an integral part of the personal and professional development process." @default.
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