Abstract Background Endoscopic retrograde cholangiopancreatography (ERCP) is a ubiquitous and high-risk procedure with variable performance across providers and centres. In this review, we aimed to summarize the evidence related to ERCP practice in 4 domains: indications and alternatives, quality indicators, training and credentialing, and facility standards. Methods We searched MEDLINE, Embase, Cochrane databases, and the grey literature (2000-2026) for ERCP quality standards published by professional societies or health agencies. Records were included if they included recommendations related to the 4 above-mentioned domains. Recommendations were described qualitatively. For quality indicators, we described benchmarks for performance, strength of recommendations, and quality of evidence when available. Results Fifty-seven reports were included from 4 continents. Eighteen unique indications were identified. Seventeen procedural quality indicators were identified. Priority indicators included appropriate indication (benchmark >90% of cases), cannulation success rate (≥85%-90%), management of common bile duct stones <1 cm (≥75%-90%) stent placement below the bifurcation (≥80%-95%), post-ERCP pancreatitis rate (≤6%-10%), and unplanned hospital visit within 30 days of ERCP (<15%). Training recommendations suggested minimum volumes of 100-300 supervised procedures and highlighted a shift towards competency-based assessment tools like The EUS and ERCP Skills Assessment Tool or Direct Observation of Procedural Skills. Facility standards focused on radiation safety, duodenoscope reprocessing/infection control, and mandatory photodocumentation. Conclusion There was substantial alignment among societies on several core ERCP quality metrics, yet variability remains in training and credentialing and facility standards. Significant gaps exist regarding maintenance of competence and ERCP assistant training. This evidence can support health authorities seeking to develop and implement ERCP quality improvement initiatives.

Background:Patients with pancreatic ductal adenocarcinoma (PDAC) experience debilitating symptoms, yet factors associated with symptom burden and severity are not well described. Methods:This population-based cohort study included patients diagnosed with PDAC and who completed Edmonton Symptom Assessment System (ESAS) between 1 month before and 2 months after diagnosis between January 1, 2007 and December 31, 2020 in Ontario, Canada. The ESAS contains 9 symptoms on a scale from 0 to 10. The primary outcome was moderate to severe (ESAS scores ≥4) symptoms (pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, well-being, and shortness of breath) 2-6 months after diagnosis. We used multivariable logistic regression models to evaluate associations between the primary outcome and baseline demographic and clinical variables, cancer-specific factors, and baseline symptom scores. Results:We included 4918 patients (mean age 68 years, 52% male). Near the time of diagnosis, 13.8% (nausea) to 38.5% (well-being) of patients reported moderate to severe symptoms. At 2-6 months after diagnosis, 23.0% (dyspnea) to 57.5% (poor well-being) reported moderate to severe symptoms. A range of baseline demographic, clinical, and cancer-specific risk factors were identified for reporting of moderate to severe symptoms. The presence of baseline symptoms for each of the 9 included symptoms was associated with reporting of the same symptom with moderate to high severity 2-6 months after diagnosis. Conclusions:Patients with PDAC face a high symptom burden following diagnosis. Universal physician symptom screening for patients diagnosed with PDAC may enable improved symptom identification and management.

BACKGROUND:Accurate staging is crucial for managing cholangiocarcinoma (CCA). Endoscopic ultrasound (EUS) with tissue acquisition (EUS-TA) may enhance cross-sectional imaging-based staging. However, the impact of EUS on CCA management decision-making is unclear. METHODS:Six electronic databases were searched through July 10, 2025 for studies on EUS-TA in staging CCA eligible for surgical resection or liver transplantation. The primary outcome was the pooled proportion of patients excluded from curative-intent surgery based on EUS-findings, which included newly detected findings and confirmation by EUS-TA of cross-sectional imaging findings. Secondary outcomes included the pooled incremental benefit of EUS (IBEUS) over cross-sectional imaging and EUS-specific adverse events. The IBEUS was defined as the proportion of patients with malignant lymph nodes identified by EUS-TA but not by cross-sectional imaging, relative to all patients who underwent cross-sectional imaging. RESULTS:Nine studies with 831 patients were included. The rate of exclusion from curative-intent surgery based on EUS findings was 10% overall (95% CI: 6%-18%; 9 studies), 7% for perihilar CCA (pCCA) (95% CI: 2%-19%; 5 studies), 10% for those planned for resection (95% CI: 4%-22%; 5 studies), and 8% for those planned for transplantation (95% CI: 3%-22%; 3 studies). The pooled IBEUS was 3% (95% CI: 1%-10%; 5 studies) overall, 4% (95% CI: 1%-17%; 3 studies) for pCCA1% (95% CI: 0%-3%; 2 studies) in patients intended for operative resection, and 7% (95% CI: 1%-26%; 2 studies) in those intended for transplantation. CONCLUSION:EUS may impact CCA staging and support treatment decisions.

Background and study aims:Endoscopic retrograde cholangiopancreatography (ERCP) is important in acute cholangitis (AC) management but is not available at all hospitals. The association between on-site ERCP availability and cholangitis outcomes is unknown. Patients and methods:We included adults diagnosed with AC at 27 hospitals in Ontario through the GEMINI network. We collected data on demographics, clinical and laboratory values, and interventions. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, intensive care unit (ICU) admission, readmission rates, and requirement for percutaneous or surgical decompression. We used multivariable regression analyses to assess the impact of on-site ERCP availability on the primary and secondary outcomes with adjustment for relevant variables. Results:Our cohort included 4492 patients with a median age of 75. Patients at ERCP sites had higher unadjusted rates of undergoing ERCP (55.7% at ERCP sites, 40.8% at non-ERCP sites). Patients at ERCP sites compared with non-ERCP sites did not have significantly different in-hospital mortality (adjusted odds ratio [aOR] = 2.19, 95% confidence interval [CI] = 0.86-5.55). Compared with non-ERCP sites, patients at ERCP sites with underlying stricturing biliary disease or pancreaticobiliary malignancy (aOR = 1.94, 95% CI = 1.14-13.58) or severe cholangitis (aOR = 2.17, 95% CI = 1.17-4.02) had higher odds of in-hospital mortality. In a post-hoc propensity score-based analysis, there was no significant difference between patients at ERCP sites compared with those at non-ERCP sites for in-hospital mortality. Conclusions:Patients at ERCP sites compared with non-ERCP sites did not have significantly different mortality. Subgroups of patients with underlying stricturing biliary disease or pancreaticobiliary malignancy and severe cholangitis, who have higher mortality at ERCP sites, warrant further study.

INTRODUCTION:Patients with pancreatic ductal adenocarcinoma (PDAC) face challenging treatment decisions following their diagnosis. We developed and validated a survival prognostication model using routinely available clinical information, patient-reported symptoms, performance status, and initial cancer-directed treatment. METHODS:This retrospective cohort study included patients with PDAC from 2007 to 2020 using linked administrative databases in Ontario, Canada. Patients were randomly selected for model development (75%) and validation (25%). Using the development cohort, a multivariable Cox proportional hazards regression with backward stepwise variable selection was used to predict the probability of survival. Model performance was assessed on the validation cohort using the concordance index and calibration plots. RESULTS:There were 17,450 patients (49% female) with a median age of 72 years (interquartile range 63-81) and a mean survival time of 9 months. In the derivation cohort, 1,469 patients (11%) had early stage, 4,202 (32%) had advanced stage disease, and 7,417 (57%) had unknown stage. The following factors were associated with an increased risk of death by more than 10%: tumor in the tail of the pancreas; advanced stage; hospitalization 3 months before diagnosis; congestive heart failure or dementia; low, moderate, or high pain score; moderate or high appetite score; high dyspnea and tiredness score; and a performance status score of 60-70 or lower. The calibration plot indicated good agreement with a C-index of 0.76. DISCUSSION:This model accurately predicted one-year survival for PDAC using clinical factors, symptoms, and performance status. This model may foster shared decision making for patients and their providers.

Abstract Background Real-time endoscopic optical diagnosis involves detailed visualization of the digestive mucosal and microvascular pattern, allowing for prediction of histology. This is advantageous as it can guide endoscopic resection decisions, surgical referrals and provide cost savings to histopathology. There is, however, no standardized or widely implemented curriculum for endoscopists or trainees to learn optical diagnosis skills. Aims To evaluate the impact of a course for the optical diagnosis of esophageal squamous cell carcinoma (ESCC), early gastric cancer (EGC), Barrett’s esophagus (BE), and colorectal polyps Methods 19 gastroenterology trainees were invited to the 2-day course in Kingston, Canada. Number of procedures previously performed was recorded. The impact of the course on lesion diagnosis accuracy was evaluated using a pre-test, immediate post-test, and delayed post-test administered 6 weeks after the course. A repeated measures ANOVA was performed to compare the mean score (%) between the three tests. Results 13 trainees completed all the tests (Table 1). Mean score % values for the overall tests and test scores for esophageal, gastric, and colon lesions were summarized on Table 1. The repeated measures ANOVA determined that the mean score % had a statistically significant difference between the three tests (F (2,24)=5.63, P=0.01). Pairwise comparisons revealed that there was a statistically significant increase in mean scores between pre- and post-tests (13.86 (95% confidence interval (CI) of 4.36 to 23.33), p<0.01) with no significant difference between post and delayed post-tests (8.46 (95% CI of -0.12 to 17.04), p>0.05) (Figure 1). The mean correct % from the delayed post-test was higher than the pre-test but there was no statistical significance (5.39 (95% CI of -3.72 to 14.49), p>0.05). Conclusions This novel optical diagnosis course improved trainee accuracy in diagnosing ESCC, EGC, BE and colorectal polyps. Learning retention was evident, with no significant score difference between immediate and delayed post-tests. This study was limited by the low sample size and low number of test items. Further investigation is required to validate the course for international trainees and explore its clinical transferability. Demography and Mean Score % Figure 1. Mean score %. (*) denotes p<0.05. Funding Agencies None

BACKGROUND:Endoscopy has traditionally been taught with novices practicing on real patients under the supervision of experienced endoscopists. Recently, the growing awareness of the need for patient safety has brought simulation training to the forefront. Simulation training can provide trainees with the chance to practice their skills in a learner-centred, risk-free environment. It is important to ensure that skills gained through simulation positively transfer to the clinical environment. This updated review was performed to evaluate the effectiveness of virtual reality (VR) simulation training in gastrointestinal endoscopy. OBJECTIVES:To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy, and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience. SEARCH METHODS:We searched the following health professions, educational, and computer databases until 12 July 2017: the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, BIOSIS Previews, CINAHL, AMED, ERIC, Education Full Text, CBCA Education, ACM Digital Library, IEEE Xplore, Abstracts in New Technology and Engineering, Computer and Information Systems Abstracts, and ProQuest Dissertations and Theses Global. We also searched the grey literature until November 2017. SELECTION CRITERIA:We included randomised and quasi-randomised clinical trials comparing VR endoscopy simulation training versus any other method of endoscopy training with outcomes measured on humans in the clinical setting, including conventional patient-based training, training using another form of endoscopy simulation, or no training. We also included trials comparing two different methods of VR training. DATA COLLECTION AND ANALYSIS:Two review authors independently assessed the eligibility and methodological quality of trials, and extracted data on the trial characteristics and outcomes. We pooled data for meta-analysis where participant groups were similar, studies assessed the same intervention and comparator, and had similar definitions of outcome measures. We calculated risk ratio for dichotomous outcomes with 95% confidence intervals (CI). We calculated mean difference (MD) and standardised mean difference (SMD) with 95% CI for continuous outcomes when studies reported the same or different outcome measures, respectively. We used GRADE to rate the quality of the evidence. MAIN RESULTS:We included 18 trials (421 participants; 3817 endoscopic procedures). We judged three trials as at low risk of bias. Ten trials compared VR training with no training, five trials with conventional endoscopy training, one trial with another form of endoscopy simulation training, and two trials compared two different methods of VR training. Due to substantial clinical and methodological heterogeneity across our four comparisons, we did not perform a meta-analysis for several outcomes. We rated the quality of evidence as moderate, low, or very low due to risk of bias, imprecision, and heterogeneity.Virtual reality endoscopy simulation training versus no training: There was insufficient evidence to determine the effect on composite score of competency (MD 3.10, 95% CI -0.16 to 6.36; 1 trial, 24 procedures; low-quality evidence). Composite score of competency was based on 5-point Likert scales assessing seven domains: atraumatic technique, colonoscope advancement, use of instrument controls, flow of procedure, use of assistants, knowledge of specific procedure, and overall performance. Scoring range was from 7 to 35, a higher score representing a higher level of competence. Virtual reality training compared to no training likely provides participants with some benefit, as measured by independent procedure completion (RR 1.62, 95% CI 1.15 to 2.26; 6 trials, 815 procedures; moderate-quality evidence). We evaluated overall rating of performance (MD 0.45, 95% CI 0.15 to 0.75; 1 trial, 18 procedures), visualisation of mucosa (MD 0.60, 95% CI 0.20 to 1.00; 1 trial, 55 procedures), performance time (MD -0.20 minutes, 95% CI -0.71 to 0.30; 2 trials, 29 procedures), and patient discomfort (SMD -0.16, 95% CI -0.68 to 0.35; 2 trials, 145 procedures), all with very low-quality evidence. No trials reported procedure-related complications or critical flaws (e.g. bleeding, luminal perforation) (3 trials, 550 procedures; moderate-quality evidence).Virtual reality endoscopy simulation training versus conventional patient-based training: One trial reported composite score of competency but did not provide sufficient data for quantitative analysis. Virtual reality training compared to conventional patient-based training resulted in fewer independent procedure completions (RR 0.45, 95% CI 0.27 to 0.74; 2 trials, 174 procedures; low-quality evidence). We evaluated performance time (SMD 0.12, 95% CI -0.55 to 0.80; 2 trials, 34 procedures), overall rating of performance (MD -0.90, 95% CI -4.40 to 2.60; 1 trial, 16 procedures), and visualisation of mucosa (MD 0.0, 95% CI -6.02 to 6.02; 1 trial, 18 procedures), all with very low-quality evidence. Virtual reality training in combination with conventional training appears to be advantageous over VR training alone. No trials reported any procedure-related complications or critical flaws (3 trials, 72 procedures; very low-quality evidence).Virtual reality endoscopy simulation training versus another form of endoscopy simulation: Based on one study, there were no differences between groups with respect to composite score of competency, performance time, and visualisation of mucosa. Virtual reality training in combination with another form of endoscopy simulation training did not appear to confer any benefit compared to VR training alone.Two methods of virtual reality training: Based on one study, a structured VR simulation-based training curriculum compared to self regulated learning on a VR simulator appears to provide benefit with respect to a composite score evaluating competency. Based on another study, a progressive-learning curriculum that sequentially increases task difficulty provides benefit with respect to a composite score of competency over the structured VR training curriculum. AUTHORS' CONCLUSIONS:VR simulation-based training can be used to supplement early conventional endoscopy training for health professions trainees with limited or no prior endoscopic experience. However, we found insufficient evidence to advise for or against the use of VR simulation-based training as a replacement for early conventional endoscopy training. The quality of the current evidence was low due to inadequate randomisation, allocation concealment, and/or blinding of outcome assessment in several trials. Further trials are needed that are at low risk of bias, utilise outcome measures with strong evidence of validity and reliability, and examine the optimal nature and duration of training.

Abstract Background Cholangitis is a well-described adverse event (AE) following endoscopic retrograde cholangiopancreatography (ERCP) that is associated with significant morbidity and mortality. Despite this, contemporary characterization of this AE using high-quality prospective data is incomplete. Aims In this study we describe post-ERCP cholangitis incidence, risk factors, and outcomes in a large, international multicenter population of patients undergoing ERCP. Methods We analyzed prospective data from nine centers in Canada, USA, and Europe between 2018-2024 with 30-day follow-up. The primary outcome was post-ERCP cholangitis, defined as (1) temperature <36.0°C or >38.0°C or white blood cells <4 x109/L or >10x109/L, (2) accompanying rise in bilirubin or transaminases to >1.5 times the upper limit of normal or any increase compared to pre-procedure, and (3) emergency department visit or hospital admission and/or prolongation of existing admission. Multivariable logistic regression was performed to identify risk factors, with results presented as odds ratios (OR) with associated 95% confidence intervals. Outcomes following cholangitis were also described. Results Post-ERCP cholangitis occurred following 134 (1.7%) of 8,119 ERCPs (mean onset of symptoms 2.0 days). Repeat ERCP was required in 53.7% of these cases. Mortality attributed to cholangitis occurred in 8.2% of incident cases. Male sex (OR 1.48, 1.02-2.19), longer procedural time (OR 1.01, 1.00-1.02 per additional minute) and presence of a biliary stricture (OR 3.24, 1.98-5.30) were all independent risk factors for post-ERCP cholangitis, while placement of a biliary stent (OR 0.59, 0.36-0.95), and biliary sphincterotomy (OR 0.59 0.39-0.87) were both protective against post-ERCP cholangitis. Conclusions Post-ERCP cholangitis is common and associated with high mortality rates. Adequate pre-procedural counseling and early recognition is advised, especially in patients at increased risk. Funding Agencies None