ERCP (endoscopic retrograde cholangiopancreatography) is an advanced endoscopic skill that requires significant experience to master, and regular practice to maintain currency. It is no longer acceptable to be a purely “diagnostic” ERCP endoscopist: a variety of therapeutic skills, including sphincterotomy, stent placement, removal of bile duct stones, are necessary to perform this procedure safely and effectively. Under national guidelines (of the American Society for Gastrointestinal Endoscopy (ASGE)), the endoscopist to must have received formal training in ERCP in a recognized teaching program where he/she performed a minimum number of procedures under supervision, and subsequently received credentials to do unsupervised procedures based on the recommendation of his/her teacher(s).
Notably, failure to access the bile duct in this setting is not a deviation from the standard of care in itself; even experts have a fail rate, albeit quite small (<5%). However, failure to complete the procedure due to lack of necessary experience and/or an inadequate skill set would be below acceptable standards. Acute pancreatitis following ERCP (post-ERCP pancreatitis (PEP)) is the most feared complication of this procedure. Fortunately, most cases of PEP are “mild” by agreed definition, with pain, nausea, and vomiting due to pancreatic swelling (edema) that typically settles in a few days. This is an unpleasant experience for the patient, but rarely life-threatening. However, a small proportion of patients suffer severe PEP, which is a life-threatening condition. In severe PEP, part or all of the pancreatic tissue undergoes necrosis, which leads to prolonged hospitalization, multisystem complications, further procedures (e.g., radiologically guided drainages, surgery) and, sometimes, death. The mortality of severe acute pancreatitis is in the 10-20+% range and depends significantly on the age and health (or otherwise) of the patient at the time of the insult.
Since ERCP was introduced as a nonsurgical intervention for bile duct and pancreatic disorders in the 1970s, considerable efforts have been made to reduce the risk of PEP. In particular, many pharmacologic interventions have been tried to prevent this problem; most have failed, and the few that appear “promising” have yet to be widely adopted. The risk of PEP can be reduced considerably – but not abolished completely – by good technique. Experts generally have a PEP rate below 5%, and rarely see severe cases. The most important development in the prevention of PEP in the last decade has been the placement of small-caliber, prophylactic pancreatic duct stents in “high risk” situations. It has long been recognized that repeated instrumentation of the pancreatic duct during a failed attempt to enter the bile duct is likely to precipitate pancreatitis. Indeed, one published study showed that >10 pancreatic duct entries (“cannulations”) was associated with 100% risk of subsequent acute pancreatitis. Placing a pancreatic duct stent early in a case, after just a few failed bile duct entries, avoids further instrumentation of the pancreas and allows guide wire-assisted or other adjunctive techniques (e.g., needle knife papillotomy over the stent) to be used to enter the bile duct.
Endoscopic retrograde cholangiopancreatography (ERCP) medical expert witness specialties include gastroenterology, hepatology, biliary surgery, general surgery, and pediatric surgery.