Young GI Angle: How to manage complications in interventional endoscopy

Junior perspective: Henriette Heinrich

You have managed to get a coveted spot for advanced interventional endoscopy training. Deep down, you know you are ready for this, and that you have the skill, will and dedication. ¹ Nevertheless, you are aware that procedures such as endoscopic retrograde cholangiopancreatography (ERCP), therapeutic endoscopic ultrasound (EUS), endoscopic submucosal dissection or third-space endoscopy are a completely different ball game to your regular upper or lower endoscopies with the odd polyp resected. Advanced endoscopic procedures are associated with a higher and wider range of complications, which are operator dependent, as many studies have shown. Indeed, regarding ERCP, a meta-analysis (13 studies, 59,437 patients) found that complications were less frequent with high-volume endoscopists (odds ratio (OR)  =  0.7; 95% confidence interval (CI) 0.5–0.8). ² A more recent multi-centre study (1191 patients) identified less experienced endoscopists (<200 ERCP procedures) as an independent risk factor for post-ERCP acute pancreatitis (OR = 1.63; 95% CI 1.05–2.53). ³ Moreover, trainees in advanced endoscopy might, according to one study, take more risks and therefore experience higher complication rates compared with fellows in their general gastroenterology training.^4,5

You, like every other advanced endoscopist, will inevitably cause serious complications to your patients, not only in the beginning but throughout your whole career. Keep this in mind and learn how to manage complications, not only with your endoscope but, even more importantly, with good patient communication.

Know the indication and the patient

Determining if your planned advanced endoscopy procedure is indicated is probably one of the most challenging aspects of interventional endoscopy. Discussing all aspects of your patients’ conditions with your trainer or during a multidisciplinary team meeting in case of a more complex situation is crucial. Communicating with your patient openly about the risks and benefits of the procedure as well as about the risks and benefits of not performing the intervention is also important. ⁶ Good doctor–patient communication is fundamental and will help in the long run should complications arise during or after the intervention.

Know the procedure – and its complications

Be aware of all milestones of any advanced procedure as well as their pitfalls. ERCP is probably the best example: the first challenge being blindly passing the side-view scope through the upper oesophageal sphincter, second visualising the papilla in the right position and then attempting cannulation. Specific adverse effects can occur at all these steps, and early recognition and management is mandatory. Be aware that there exist numerous previously unknown ways of things not working out as you planned initially (‘If anything bad can happen, it probably will’). Your knowledge can be expanded by observing more experienced endoscopists and querying their decisions, following live courses and training on hands-on models.

Know how and who can fix complications

You will get more confident (slowly) and start performing interventions solo. Great! Nevertheless, you should still stay alert and critical concerning your ability to manage complications (such as treating ERCP-related perforations with stents). Before starting the intervention, make sure that you are the person who can handle a complication sufficiently or that someone is around to help you should things go sideways!

Know when to call your trainer

Being self-critical and knowing your limits are the cornerstone of interventional endoscopy. A general rule of thumb: if the nurses suggest you call someone, you should have done it 10 minutes ago. Another rule of thumb: forget your ego – this is about patient safety. So, if you cannot cannulate the papilla, stop, take your eyes of the screen and look at the patient, just to remind you where the stakes are. Call early, ask for advice – even the best endoscopists do it.

When it goes wrong

It will go wrong – and when it does, don’t run and do not hide. Manage the complication endoscopically as well as you can, call for help early and if a surgeon is needed, involve her/him in a timely fashion. Communicate clearly and openly with the patient and the patient’s family about the situation, outline the next diagnostic or treatment steps and, if push comes to shove, the need for surgery. Keep in daily contact with the patient throughout his/her stay. Stay involved in all further treatment decisions, even if they are made by another speciality. Stay with your patient.

Know the learning curve

Your learning curve will be flat, period. You will not reach competency at the stellar pace you mastered upper and lower gastrointestinal (GI) endoscopy. ⁷ Your trainer will not leave you for a long time, and you should be glad. The weight of responsibility is divided onto two sets of shoulders. There will be phases where you feel that you finally got it. Then, the next procedure or complication will teach you how to eat humble pie again. Be aware that numbers do not necessarily mean competence and that advanced endoscopy procedures have differing (but mostly flat) learning curves. ⁸ Be patient. Persevere. Learn.

Over time, your ability to perform advanced procedures will increase alongside your ability to manage complications (that you caused). The most important thing is to communicate with your patient, have a sound indication and perform the intervention to the best of your knowledge and technical ability. And if something goes wrong, stay with your patient every step of the way.

Senior perspective: Marianna Arvanitakis

Does trainee involvement increase the complication rate?

Training in endoscopy has been traditionally based on the master–apprentice model, through which fellows develop the necessary skills and expertise, first by observing and then through hands-on experience. ⁴ Although it has been shown that procedure volume alone does not fully reflect competence, it can certainly help in achieving the specific milestones in training programmes based on standardised competency assessments. ⁸ For this reason, trainee involvement in advanced endoscopic procedures is a well-established situation. The burning question is whether trainee involvement jeopardises patient safety. A recent, prospective, observational, multi-centre study included 21 trainees and 16 control endoscopists who performed 1843 ERCPs in six high- and low-volume centres. ⁹ Interestingly, trainee involvement did not decrease technical success (92.4% vs. 93.7%; p = 0.30) or increase the risk of adverse events (14.7% vs. 14.6%; p > 0.99). ⁹ Undoubtedly, this implies a proper teaching setting and close surveillance, but it is already a reassuring fact regarding our training programmes.

Should all GI fellows receive training in therapeutic endoscopy?

Now that we are confident that training in interventional endoscopy such as ERCP can be offered without additional risk for the patient in a proper teaching setting, the next question is whether all GI fellows should receive training in interventional endoscopy. Clearly, the answer is no. The 3-year curriculum offered in most countries covering gastroenterology, hepatology, nutrition, digestive oncology and basic endoscopy cannot include interventional endoscopy, which requires an additional separate fellowship in a tertiary care training centre. Furthermore, as mentioned earlier, the rate of adverse events depends on procedure volume, and maintaining the acquired competence entails a minimum annual threshold of procedures to maintain technical skills and optimal clinical outcomes. ² Conversely, only a limited number of trainees will have a high exposure to advanced therapeutic procedures after their fellowship. A survey demonstrated that only 9.0% and 4.5% of general GI trainees had anticipated volumes of more than 200 ERCP and EUS procedures, respectively. ⁴ All these arguments reinforce the strategy of selecting a limited number of GI fellows who will be trained in interventional endoscopy. The training programme should develop not only technical dexterity but also adequate cognitive and non-endoscopic skills, such as decision making, judgement and team communication, with the main focus being patient-centred care. ¹⁰

When the going gets tough: How to prepare the trainee?

One of the aspects of a gifted operator in interventional endoscopy is the ability to recognise an unexpected turn in a well-known procedure, identify the reason behind the event and seek a realistic solution, taking into consideration the existing possibilities. Obviously, capacities beyond technical skills, such as keen judgement and decision making, as well as team management are crucial. The teacher should also convey these skills through the training programme. The trainee will learn progressively, initially by observing, but also by being faced with a difficult situation. In an evidence-based view, a randomised controlled trial sought to determine the ideal threshold regarding time allocated to a trainee who is attempting biliary cannulation in a patient with native papilla. ¹¹ A total of 256 patients were randomly assigned to the 5-minute (n = 84), 10-minute (n = 86) or 15-minute (n = 86) groups for four trainees. Finally, a time of 10 minutes was considered to be appropriate for trainees to attempt cannulation, with acceptable cannulation success rates and complications. Although this study proves in an elegant way that this threshold exists, it cannot be generalised to all trainees, all patients or all type of advanced endoscopic procedures.

When the trainee is facing difficulty or even a complication during a procedure, the trainer should offer uninterrupted surveillance and encouragement, coupled with precise verbal guidance based on standard terminology. It is difficult to determine at what point the trainee should pass on the scope; this depends largely on the type of relationship between the student and the teacher regarding trust and confidence. An additional factor is the amount of assurance the teacher feels facing the complicated situation. At one point, when the chance of success decreases and patient safety is at stake, the teacher should take over the scope. Even if the teacher completes the procedure instead of the trainee, a constructive assessment following the procedure, including discussion of alternative scenarios, can be very fruitful and educational.

When can the trainee be considered independent?

Training programmes in interventional endoscopy are increasingly based on standardised competency assessment for every step of a specific procedure. The scale is graded according to readiness for independent practice from 1 to 4. ¹² This grading system can address specific milestones, identify weakness and help in building individual learning curves for each trainee. It has been shown that through this training system, the majority of trainees in advanced endoscopy will meet the quality indicator thresholds for EUS and ERCP at the end of their first year of independent practice. ¹²

Despite the recent developments in teaching methods, most programmes still rely on procedure volume and subjective evaluations. In this case, the best way to become a successful and safe independent operator is to launch one’s individual practice. Determining the indication for each procedure wisely, knowing one’s limits, taking all necessary recommended preventive measures to avoid complications and deciding on timely referrals in case of failure can further develop competence while keeping the patient safe during the early years of independent practice.