Who Performs ERCP: Gastroenterologists and Surgeons
Both gastroenterologists and general surgeons are qualified to perform ERCP, with gastroenterologists currently performing the majority of procedures, though appropriately trained surgeons can safely and effectively provide this service. 1, 2
Provider Qualifications
The American College of Radiology formally recognizes both gastroenterologists and general surgeons as qualified providers of ERCP. 1, 2
Both specialties typically perform ERCP in interventional suites or operating rooms under general anesthesia, using a side-viewing endoscope advanced into the duodenum to cannulate the ampulla and access the biliary tree. 1, 2, 3
ERCP skills are beneficial for endoscopists learning advanced EUS-guided procedures, and proficiency in ERCP techniques should be incorporated into training programs for interventional endoscopy. 1
Current Practice Patterns
Gastroenterologists currently perform the vast majority of ERCPs in most healthcare systems, with surgical patients comprising approximately 48% of all ERCP procedures but having these procedures performed by gastroenterologists. 4
A significant volume of therapeutic interventions for surgical patients (72% therapeutic vs 22% diagnostic ERCPs) are being "outsourced" to gastroenterology services, with surgical patients waiting an average of 2.43 days from request to procedure. 4
However, surgeon-led ERCP services can achieve excellent outcomes that meet or exceed national performance standards, with one British study demonstrating a high-volume surgical ERCP service (418 procedures annually) achieving 95% bile duct cannulation rates, 80% stone clearance, and only 4.3% complication rates—all meeting British Society of Gastroenterology key performance indicators. 5
Training and Competency Requirements
Competency in ERCP requires substantially more procedures than older guidelines suggest, with current evidence indicating trainees need 70-400 ERCPs to achieve competency (defined as ≥80% successful cannulation rate), depending on the specific skill being assessed. 6
For native papilla deep common bile duct cannulation specifically, competency may require 350-400 procedures, well above North American training guideline thresholds. 6
The British Society of Gastroenterology recommends endoscopists perform a minimum of 100 OGDs annually to maintain high-quality examination standards, and similar volume requirements apply to ERCP practice. 1
Training should include observation in high-volume centers, hands-on training with porcine models, and supervised performance in patients, with ERCP skills being particularly beneficial for those learning interventional EUS techniques. 1
Clinical Implications
The choice of provider should be based on local expertise, availability, and procedural volume rather than specialty alone, as both gastroenterologists and appropriately trained surgeons can safely perform ERCP. 2, 5
Surgical patients requiring ERCP differ significantly from medical patients, with higher rates of therapeutic interventions (72% vs 38%) and longer hospital stays (6.7 vs 3.9 days), suggesting potential benefits of surgeon-performed ERCP for surgical pathologies. 4
Given that management of common bile duct stones (a common surgical pathology) represents the primary indication for ERCP with 80-95% clearance rates, appropriately trained surgeons should consider maintaining ERCP skills. 2, 7