Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States

Table 1 Literature review of criteria for endoscopic retrograde cholangiopancreatography privileging and practice

First author, Journal, Year study published	Type of study	Proposed Minimum number of ERCPs or other criteria for determining competence	Quality indicator or comments
Wigton et al[37], American College of Physicians, Ann Intern Med 1988	Position paper, American College of Physicians	35 supervised ERCPs. No quality indicators specified.	Document to include degree of success of ERCP. Types of ERCP not specified.
Watkins et al[38], Gastrointest Endosc 1996	Original prospective report of point at which GI fellow achieves 85% rate of cannulation of both pancreatic and bile ducts	100 supervised ERCPs	Point at which GI fellow achieves 85% rate of cannulation of desired duct (either pancreatic duct or bile duct)
Jowell et al[40], Ann Intern Med 1996	Prospective study involved grading of 1796 ERCPs among 17 GI fellows	180 supervised ERCPs	Number of ERCPs for individual skills: 160 for cholangiography, 160 for pancreatic duct cannulation, 120 for stone extraction, and 60 for stent insertion.
Eisen et al[41], Gastrointest Endosc 2002	Position paper, American Society for Gastrointestinal Endoscopy	180 supervised ERCPs	80% ability to cannulate the duct of interest (either bile duct or pancreatic duct)
Garcia-Cano[39], Surg Endosc 2007	Letter to editor based on personal experience as surgeon training in ERCP	200 ERCPs	Based on personal experience at point at which achieved 80% rate of cannulation of bile duct. Anecdotal evidence.
Verma et al[43], Gastrointest Endosc 2007	Retrospective review of single operator ERCP learning curve	> 80% rate of successful deep cannulation of bile duct	Achieved at performing 350-400 ERCPs
Shahidi et al[42], Gastrointest Endosc 2015	Systematic review encompassing 9 studies	Competency achieved after 79 to 300 ERCPs, depending upon learning curve of individual trainee	Competency for specific quality indicators: 70 to 160 ERCPs for pancreatic duct cannulation, and 160 to 400 ERCPs for deep bile duct cannulation
Cotton[26], Gastrointest Endosc 2015	Editorial	Supports guidelines set by Australian Conjoint Committee of 200 ERCPs	To include a minimum of 80 sphincterotomies with intact papillary sphincters, and a minimum of 60 stents
Adler et al[44], Gastrointest Endosc 2015	Position paper, American Society for Gastrointestinal Endoscopy Quality Assurance in Endoscopy Committee	> 90% rate of deep cannulation of duct of interest with native papilla, > 90% rate of extraction of common bile duct stone < 1 cm in patient with normal bile duct anatomy, > 90% successful stent placement in patient with normal anatomy	---
Ekkelenkamp et al[47], Endoscopy 2015[47]	Nationwide analysis of 8575 ERCPs by 171 endoscopists in Holland during 1 yr.	Overall rate of “successful” ERCPs was 83.4% for native papilla and 89.4% after sphincterotomy.	Provides a reasonable estimate of expected success rate for ERCP operators.
Wani et al[48], Gastrointest Endosc 2016	Prospective multicenter trial conducted among 5 advanced GI endoscopy fellows at 5 medical centers	Number of ERCPs to achieve successful cannulation rate > 90% of biliary duct varied from 26 to 211 ERCPs.	Demonstrates variability in learning curves to achieve competence in ERCP as determined by > 90% rate of bile duct cannulation
Wani et al[49], Clin Gastroenterol Hepatol 2017	Prospective multicenter study of 22 advanced GI endoscopy trainees at 20 medical centers	Demonstrated substantial variability in learning curves for cognitive and technical ability in ERCP. This suggests basing criteria for competence not on volume, but on achieving landmarks for quality indicators (e.g., successful cannulation rate).	Variable learning curves for achieving cognitive and technical success in ERCPs upon completion of advanced endoscopy fellowship
Wani et al[45], Gastrointest Endosc 2018	Gastrointestinal Endoscopy white paper	Developed comprehensive data collection and reporting tool for assessing ERCP performance	Demonstrated feasibility of using a central database to monitor GI fellow performance
Faulx et al[50], Gastrointest Endosc 2017	American Society for Gastrointestinal Endoscopy Standards of Practice Committee Guideline	200 supervised ERCP procedures for assessing competency. Additionally, independently perform > 80 sphincterotomies and > 60 biliary stent placements
Wani et al[53], Gastroenterology 2018	Prospective multicenter clinical trial involving 22 advanced GI endoscopy fellows	After completing an advanced endoscopy fellowship, ERCP operators achieved an average successful cannulation rate of 94.9% in private practice.	This work shows that advanced endoscopy fellowship training leads to successful ERCP performance in private practice.
Cotton[60], Gastrointest Endoscopy 2017	Survey of 1126 responding United States gastroenterologists	No written guidelines for initial ERCP credentialing-21%. No written guidelines for repeat credentialing process-54%.	Urgent need to improve credentialing process.
Cassani et al[63], Gastrointest Endosc 2017	Editorial on sorry state of ERCP credentialing	“Despite repeated studies, editorials, gastroenterology society papers, credentialing committees have yet to take the initiative and require increased scrutiny for both hospital and (ERCP) procedural outcomes.”	Frank discussion of current failures in credentialing process.
Wani et al[4], Gastrointest Endoscopy 2019	Prospective multicenter study determining standards for competency for ERCP based on learning curves for 37 advanced endoscopy fellows in 32 programs.	Advanced endoscopy fellow required an average of 226 ERCPs to achieve competency in native papillary cannulation, and required an average of 120 sphincterotomies to achieve competency in biliary sphincterotomy.	Provides guidance on threshold number of ERCPs at which to assess competency.

ERCP: Endoscopic retrograde cholangiopancreatography; GI: Gastrointestinal.