Post-ERCP pancreatitis: is the endoscopist's experience the major risk factor?

The assumption that the endoscopist is an important factor in outcome of ERCP is not easy to document. There are plenty of reasons for the difficulties in defining experience and skill of an endoscopist, and establishing suitable endpoints for their measurement. Suitable proxy variables are ERCP-frequency (ongoing volumes) and ERCP-experience (life-time volumes) of the endoscopist, as well as individual and institutional conditions. Important confounders are difficulty of ERCP, patient-related and procedure-related risk factors and risk-reducing factors. Endpoints should include success and (specific) complications of ERCP. Only few studies are available that analyse the influence of the endoscopist's skills on post-ERCP pancreatitis. Studies with a high preponderance of dominating patient-related risk factors for post-ERCP pancreatitis, e.g. suspect of SOD and unexplained abdominal pain, failed to prove such a dependence. On the other hand, evidence increases from studies with patient populations of more traditional indications for ERCP that suggests the existence of an association between ERCP-frequency of the endoscopist or ERCP-frequency of the environment and the incidence of post-ERCP pancreatitis and other complications. ERCP-experience measured in overall live-time volumes, however, does not seem to influence the risk of pancreatitis due to ERCP, although the data are very limited. During the ERCP-training of young endoscopists an impaired success rate appears more important than an increased complication rate. Nevertheless, all undesired outcomes of ERCP should be applied to the endpoints of quality assessment in ERCP-training. Further studies on this topic are needed. Since many variables significantly interact with the endpoints post-ERCP pancreatitis and complications of ERCP, a special study design appears indispensable to conclusively prove a relationship between an endoscopist's expertise and specific complications of ERCP.