Hello I'm such an wani the faculty member in the division of gastroenterology at the University of Colorado. I thank the gie editorial board for this opportunity to highlight our manuscript variation in learning curves and competence for ercp among advanced endoscopy trainees by using cumulative sum analysis ercp can be technically challenging and associated with the higher rate and a wider range of adverse events compared to standard endoscopic procedures in addition failed ercp may result in adverse events the need for additional interventions and added costs ercp as we know is operator dependent and additional training is required for the development of technical cognitive and integrative skills beyond that required for standard endoscopic procedures the number of advanced endoscopy fellowship programs has increased dramatically in the United States over the past 15 years standardization of the performance definition of competence in ERCP and demonstrating competence at the end of training are critical for optimal patient outcomes. At the present time absolute procedure volume is used to determine competence in ercp with variable threshold suggested by existing guidelines these guidelines unfortunately lack validation with regards to competence and feasibility of training. In addition these guidelines do not account for the fact that trainees differ considerably in the rates at which they learn and acquire and ask a big skills. In fact most experts believe the majority of trainees will require double the number of proposed procedures to achieve competence in ercp. It should also be recognized that there are limited data on learning curves in ercp among advanced in das kabhi trainees but greater than eighty percent cannulation rate of the duct of interest has been widely used as a surrogate for training competence. However these data include patients who have undergone prior sphincterotomy and hence are of limited applicability if deep cannulation is to be used as a benchmark for competence in ercp learning curves describing cannulation in patients with the native.

Papillon are required finally none of the studies evaluating learning curves and competence in ercp have addressed relevant end points such as sphincterotomy stone extraction tissue sampling stent placement and relevant cognitive end points during the RCP with this background using a standardized data collection tool the aims of this multicenter study was to prospectively define learning curves and measure competence in ERCP among advanced endoscopy trainees across multiple us training programs using cumulative sum analysis moving on to methodology this was a prospective multicenter study that was conducted at five tertiary care centres. That included advanced endoscopy trainees at these centres starting with the 26th hands on your CPA exam advanced. Endoscopy trainees were required to be graded on every ercp by their attending endoscopy at each center. A standardized ercp competency assessment tool was first designed by consensus opinion and review of existing literature by expert and discovers this tool was then discussed and standardized among all endoscopy and this included all key quality metrics in ercp and evaluated for all relevant technical and cognitive end points during ERCP a four-point scoring system was used to grade DN points and was standardized across all participating centers cumulative sum analysis was applied to assess learning curves with regards to individual technical and cognitive endpoints in ercp for each training moving on to results a total of five advanced endoscopy trainees from five tertiary care centres participated in this study the number of er CPS completed by advanced endoscopy trainees ranged from 270 to 430 er CPS with regards to a SG degree of difficulty grade. The vast majority of evaluations were performed in the category of biliary grade 1 arcp's the overall percentage of cases performed in patients with the native purple was thirty-nine percent with the mean number per advantage.

Oscar B trainee of 72 e or cps while the overall mean time allowed for cannulation was 3.1 minutes minutes the time for cannulation in cases where the native purple um was five point seven minutes with a standard deviation of four minutes overall. All five advanced endoscopy trainees achieved competence in basic maneuvers such as esophageal intubation achieving the short position and identification of the major papilla. Nearly all advanced endoscopy trainees crossed the threshold for acceptable performance for the endpoint of biliary cannulation with the wide variation in the threshold for case numbers to achieve this end point. However none of the advanced endoscopy trainees crossed the threshold for acceptable performance for cannulation. In patients with the native / poem similar results were noted for competence in performing sphincterotomy learning curves again demonstrating the need for ongoing observation. Nearly all advanced endoscopy trade achieved competence for relevant cognitive endpoints. The investigators acknowledged the following limitations of this study. This was a pilot study conducted at five centers all centers with an interest in the field of endoscopy training the overall number of centers and advanced endoscopy trainees participating was small all these factors limit the overall generalizability of these results while there were several objective endpoints subjective opinion of the attending in da scopus was considered as the gold standard for several endpoints in addition several attending endoscopy participated in the study with a variable cumulative experience ranging from 2 to greater than 20 years of independent practice which should again reflect multiple levels of experience and training styles in this environment. These factors may have contributed to the variability in trainee performance and should be evaluated in future studies. This study is clearly unable to provide any firm conclusions regarding learning curves involving pancreatic ERCP oracle and josh coupee and other advanced ercp techniques.

Due to the limited number of cases the vast majority of evaluations performed were for bility. ER cps there were limited number of ER cps performed in cases with native major popular and it can be argued that the time allowed for advanced endoscopy trainees to cannulate was limited. However the investigators strongly believe that this is a true representation of current clinical practice and training similarly trainee. Competence may continue to improve after completion of their advanced endoscopy training and achieve the measures of competence during independent practice. This again needs to be addressed and confirmed in future studies in summary results of this study demonstrate substantial substantial variability in ercp learning curves among advanced endoscopy trainees and that a specific case volume during training does not ensure competence in the ercp. Although advanced endoscopy trainees achieve competence in overall cannulation. There is a consistent need for more supervision of native popular cannulation which is likely to be the ideal benchmark for competence in cannulation during training and thereafter given that training in medicine has undergone major transformation with an increasing scrutiny on competency-based medical education emphasis. Clearly needs to be shifted away from the number of procedures performed and towards well-defined and validated competency thresholds ensuring that all advanced endoscopy programs achieved. These thresholds will help trainees attain the skills necessary for independent practice and will also improve upon the quality of patient. Care thank you.