Teaching and pioneering endoscopic retrograde cholangiopancreatography at a tertiary center in Nigeria––Year 1 experience

The apprenticeship model––Is this a viable option for Africa?

Abstract

Background: 

Nigeria is a West African country with a population of 190 million. It has approximately 110 endoscopists, of whom two perform endoscopic retrograde cholangiopancreatography (ERCP), with approximately 100 total ERCPs performed over 15 years. There is a perceived need by Nigerian physicians to increase ERCP capacity.

Aim: 

Develop and assess a 1-year ERCP training program in Nigeria using didactics and quarterly formal (“bolus”) hands on training sessions.

Materials and Methods: 

An introductory conference including didactic and hands on sessions was hosted in March 2018. From this introductory conference, six participants were selected for a 1-year training program. The program involved quarterly, in-country, week-long hands-on ERCP sessions. Sessions were led by an experienced interventional gastroenterologist trained and practicing in USA. A multidisciplinary meeting was held on day 1 of each session. Digital communication was used to transmit program information and request patient referrals from medical doctors.

Results: 

ERCP conference attendees included 15 surgical and medical endoscopists, 3 surgical trainees, 3 GI trainees, 6 nurses, 2 anesthesiologists, 1 interventional radiologist and 6 radiology technicians. Six physicians selected for the ongoing 1-year training program include 1 hepatobiliary surgeon, 2 gastroenterologists, 1 gastroenterology fellow and 2 surgical residents. One participant had prior formal ERCP training including 6 weeks hands-on training abroad. There were 109 referrals over 1 year, with an increasing trend over the year. The farthest referral site was almost 900 km away.

Conclusion: 

There is need for ERCP capacity in Nigeria. ERCP is feasible and safe in Nigeria. Awareness amongst healthcare providers to the available procedure resulted in increased patient referral.

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) was first performed in 1968 and biliary cannulation described in the early 1970s.[¹] ERCP was initially used primarily as diagnostic tool for pancreaticobiliary disease, however with increasing diagnostic imaging tools such as magnetic resonance imaging and computed tomography, ERCP is more of a therapeutic tool.[¹] ERCP is indicated in both benign and malignant diseases.[²] The benign conditions include choledocholithiasis, biliary strictures, postoperative complications such as bile leak. The malignant etiologies include cholangiocarcinoma or obstruction due to pancreatic carcinoma. Globally, choledocholithiasis is the most common cause of biliary obstruction, occurring in 10%–20% of patients with gallstones (cholelithiasis) and 3%–10% of patients undergoing a cholecystectomy.[³] Data show that biliary lithiasis (choledocholithiasis/cholelithiasis), affect 10%–20% of the Western population.[⁴⁵⁶] However, there is paucity of data from sub-Saharan Africa.

Ahmed et al.[⁷] reviewed the utilizations trends of inpatient ERCP in the USA between 2002 and 2013. In 411,409 cases, they found an increase in therapeutic ERCP (37%) and a decrease in diagnostic ERCP (57%).[⁷] In Nigeria, as in many other countries within the African continent, endoscopies are performed by both gastroenterologists and surgeons. There is a limited number of gastroenterologists with advanced endoscopist skills in Nigeria and other parts of the African continent.[⁸] In 2013, it was estimated that there was 1 gastroenterologist per 1,000,000 in South Africa[⁹] and unclear the number of endoscopists who could perform ERCPs. Nigeria is a country in West Africa with an estimated population of more than 190 million.[¹⁰¹¹] To the best of our knowledge, there are currently approximately 110 endoscopists in Nigeria, of whom 2 perform ERCPs. The ERCPs currently performed in Nigeria, are irregular with only 100 performed in the past 15 years. In a retrospective study at a University Teaching Hospital in Nigeria, Agbo et al.[¹²] analyzed 78 patients over 3 years and found biliary obstruction due to pancreas head carcinoma in 68 patients (87.2%), choledocholithiasis in 2 patients (2.2%), peri-ampullary carcinoma and cholangiocarcinoma in 1 patient. The main modality of management is surgical with poor outcomes: pre-operative mortality 11.5% (9/78), postoperative mortality 20.5% (16/78) and overall mortality 32% (25/78)[¹²]

With the rising gastrointestinal related non-communicable diseases, there is an increased need for trained competent gastroenterologists in Africa. Changes in lifestyle, westernization of diet and physical inactivity lead to increase rates of obesity and gastrointestinal cancers which require endoscopy for diagnosis and possible intervention. Africa is the second largest continent with 54 countries, total population of over 1.3 billion[¹³¹⁴] yet endoscopic services are lacking in most countries.[⁸] Loots et al.[¹⁵] conducted a cross-sectional study to assess the adequacy of endoscopic services in a South African province. The questionnaire was completed by department heads of 11 out of 12 endoscopic units showing 22,353 procedures total per year and 89 endoscopists (72 of 89 are general surgeons).[¹⁵] The challenges encountered were equipment breakdown resulting in service interruption, lack of equipment and trained personnel.[¹⁵] The authors concluded that endoscopic services were inadequate with prolonged wait time, inadequate infrastructure and equipment.[¹⁵] In another study evaluating endoscopic capacity in West Africa, a survey was conducted as part of a 3-day gastroenterology course with participants mainly from Gambia (10), Nigeria (8) and Senegal (7). Results show that less than half had resources for esophagogastroduodenoscopy (EGD), and none could perform ERCP.[¹⁶]

With this in mind, we aim to implement and assess a 1-year formal ERCP training program that includes both hands-on and didactic sessions at a tertiary teaching hospital in Nigeria. The selected hospital is Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, a 724-bed capacity hospital in South-West Nigeria. The nearest international airport is in Lagos, approximately 130 miles away. There are 3 gastroenterologists and 2 surgical endoscopists. Approximately 350 EGDs and 200 colonoscopies are performed annually, with the most common indications being peptic ulcer disease and rectal bleeding, respectively. To the best of our knowledge, the first ERCP in OAUTHC was performed in the 1980s by a radiologist. However, there have been fewer than 20 cases preceding the initiation of our program and details are scarce. Prior to initiation of our program, patients with biliary obstruction underwent surgical intervention or travelled outside the country for medical care. The need for endoscopic intervention as an alternative to surgical approach was recognized as a benefit with an expected decrease in mortality.

MATERIALS AND METHODS

Goals and curriculum

Our ERCP program was established with the goals of enhancing medical knowledge, capacity building and skill development to positively impact patient care. To enhance medical knowledge, the program provides the opportunity for didactic sessions with case review in a multidisciplinary team that involves the gastroenterologists, surgeons, anesthesiologists, radiologists, technicians, and nurses. The multidisciplinary meeting is an opportunity to discuss the indications, contraindications, and alternatives to management of biliary diseases. The curriculum was broadly developed in two categories, “hands-on bolus sessions” and “didactic sessions” [Table 1]. A model was developed for a 1-year program using quarterly formal hands-on training sessions (“bolus”) supervised by an experienced interventional gastroenterologist (Asombang). The organized didactic sessions that teach procedure indications, contraindications, interventions per case were in the form of online journal review and in person case review.

Table 1: Curriculum and program evaluation

Program implementation

An introductory ERCP conference was hosted at OAUTHC (session 1). The conference curriculum was implemented over a 5-day period. The didactic session included lectures on anatomy of the duodenoscope, indication/contraindication for ERCP, radiation exposure/protection, patient preparation for ERCP, documentation, post-op care, instrument handling, infection control, ERCP techniques, post ERCP complications and management, role of ERCP in biliary stones and biliary malignancies.

Pre-program survey

A pre-program questionnaire was administered surveying gender, specialty, years in practice, procedure volume in previous year, and prior ERCP training. All six participants completed the survey. All physician participants are male. Participant years in practice prior to the program ranged from 3 to 11 years (median 8), number of EGDs, colonoscopies performed in the past year and lifetime ERCPs ranged from 0 to 400 (median 60), 0 to 200 (median 5), and 0 to 5 (median 0), respectively. One participant had prior formal ERCP training including 6 weeks hands-on training abroad.

Didactic session

The 1-year ERCP program involved quarterly, in-country, weeklong hands-on ERCP sessions (sessions 2–5). Sessions were led by an experienced interventional gastroenterologist trained and practicing in the USA (Asombang). A multidisciplinary meeting is held on day 1 of each session. Digital communication was used to transmit program information and request patient referrals from local specialists. Didactic sessions include monthly emailed journal articles and attendance at a grand round on pancreatitis hosted at Brown University via Skype.

RESULTS

Attendees of the initial introductory ERCP program were from across the country and included 15 endoscopists (both surgeons and gastroenterologists), 3 surgical trainees, 3 gastroenterology trainees, 6 endoscopy nurses, 2 anesthesiologists, an interventional radiologist and 6 radiology technicians. From this group of attendees, 6 physicians were selected to participate in the 1-year ERCP training program at Obafemi Awolowo University: A hepatobiliary surgeon, two general gastroenterologists, 1 gastroenterology fellow and 2 surgical residents (session 2). Five endoscopy nurses were part of the introductory ERCP course and remained involved in the 1-year training course. The nurse manager received extra training in advanced endoscopy by attending various clinical observerships prior to the hands-on introductory ERCP course.

We started the 1-year program with 6 trainees and currently have 2 trainees (hepatobiliary surgeon and gastroenterologist) in the program. Over the 1-year course there have been 109 referrals, out of which 62/109 ERCPs and 23/109 EGDs were performed. The remaining cases did not have a procedure performed due to time limitation (19/109) or procedure not indicated (5/109). In the absence of the US based trainer, the local team performed at least 2 ERCPs in the 1-year time frame and at the completion of the 1-year program, perform 2–3 ERCPs on a weekly basis. The OAUTHC endoscopy nurses are now the only ERCP trained nurses in the entire country. The least number of referrals are noted in session 5, which was intentionally limited due to the simultaneous occurrence of the annual scientific meeting by the Society of Gastroenterology and Hepatology in Nigeria.

Challenges

The challenges of program implementation can be categorized as personnel and logistics. Not all personnel involved were familiar with ERCP set-up and performance hence the program required teaching not only in the indications, contraindications of the procedure but quality measures including infection control and radiation safety. Communication was an initial challenge among the team members when discussing steps of the procedure, ERCP terminology, requesting accessory devices or providing guidance to radiographers for cholangiogram. Communication with the radiographer provided challenging while utilizing the C-arm, since the patient position and equipment position had to be aligned for adequate visualization. Other challenges include availability of consumables needed for the procedure. The 1-year program endoscopic equipment, including the duodenoscope (Olympus TJF-Q190V duodenoscope) was initially leased and eventually purchased by the hospital; however, the initial consumables were donations.

Benefits

The availability of a dedicated, positively ambitious and organized local team leader served as the core of success. The support from the hospital administration was instrumental in setting up both the conference and long-term training program. In addition, there is a significant financial burden to establishing a quality ERCP program which requires understanding and support of the management. The multidisciplinary meeting to review cases at the beginning of each work week and the continuity of faculty (anesthesiologist/radiologist) over the 1 year served to strengthen the endoscopic skills and understanding of the team. The availability of ERCP provided a service needed for patients, with some patients traveling over 500 km (325 miles) to the endoscopy center [Figure 1]. The challenges regarding communication and personnel were resolved by the end of the year. The main challenge is the availability of consumables; however, we are hopeful that companies will recognize the utility of this procedure in the African continent and the business advantage.

Figure 1: Distance of referral sites from endoscopy center

DISCUSSION

There is a paucity of trained endoscopists in the African continent. There is also a lack of published research evaluating endoscopy education programs, etiology, management, and outcomes of biliary obstruction. To the best of our Knowledge, ERCP has been performed in South Africa, Kenya, Ghana, Rwanda and Egypt. The European Society of Gastrointestinal Endoscopy (ESGE) and World Endoscopy Organization (WEO) conducted a survey of endoscopic services in Africa with responses received from 15 countries, some of the responses were multiple from the same country.[⁸] The 15 countries were Algeria, Burkina Faso, Cameroon, Chad, Democratic Republic of Congo, Ghana, Ivory Coast, Kenya, Morocco, Mozambique, Nigeria, Senegal, Sudan, Tunisia, and Uganda. Results showed lack of resources at currently available endoscopy units and barriers include shortage of endoscopists with advanced training, lack of equipment and basic infrastructure.[⁸] One of the questions was specific to training in basic endoscopy (EGD/Colonoscopy) and advanced endoscopy (ERCP/endoscopic ultrasound). More than 90% of the endoscopists (8 out of 10 countries) had received basic endoscopy training, whereas less than 30% (10 out of 15 countries) had undergone advanced endoscopy training.[⁸] The report recognizes that this data is not comprehensive; however, we can conclude that these results are dismal.

ERCP was first introduced in Nigeria in the 1980s and OAUTHC, Ile-Ife, was one of the institutions to adapt this procedure early; however, it was primarily performed by a radiologist. The first ERCP performed by the surgical endoscopist and gastroenterologist at OAUTH was in March 2018 at the inaugural ERCP conference. The primary mode of management for patients with biliary obstruction is surgical which has poor outcomes or no intervention. Didactic gastroenterology courses play an important role in medical education for both doctors and nurses.[¹⁶¹⁷] Our program is the first apprenticeship model training program with both didactic and hands on sessions in Nigeria. The focus during this initial phase was feasibility of establishing the program and addressing logistical challenges. As the program advances, evaluation of the trainees will be more routinely and objectively performed using the TEESAT (the EUS and ERCP Skills Assessment Tool), an American Society for Gastrointestinal Endoscopy (ASGE) EUS/ERCP competency, validated, task specific, skills-assessment tool.[¹⁸]

Our program plays an important role in serving as a potential model for quality ERCP training in Nigeria, and possibly across the African continent. In addition, our program provides opportunity for mentorship and research. Gastrointestinal endoscopy is important in the diagnosis and management of both benign and malignant gastrointestinal disorders. Over the next 10 years, the incidence of gastrointestinal cancers is expected to increase by 73% in sub-Saharan Africa, compared to 59% globally.[¹⁹] Patient outcomes is impacted by the diagnostic capability and awareness of healthcare professionals. A robust, comprehensive multidisciplinary team is needed in providing both medical and surgical therapy, including endoscopy for the initial diagnosis, staging and therapeutic intervention.

CONCLUSION

Our team has shown that ERCP is feasible and can be safely performed in Nigeria, a resource limited setting. One of the key challenges across the African continent is obtaining consumables, which we believe will be lessened once the companies recognize this as an opportunity for growth and business expansion. Our program is a success and shows the importance of administrative support and structured curriculum needed to implement multidisciplinary care that will ultimately improve patient care. Our recommendation to establishing a successful endoscopy training programs in Africa are as follows: involvement of the healthcare institute administration, establishment of a multidisciplinary approach with local departments, collaboration with industry (medical device and equipment), partnership with experienced interventional endoscopists and development of a curriculum. Buy-in from the administration is important for financial support in program development sustainability, accountability, and logistics planning. Logistics includes equipment purchasing with maintenance and personnel support. Multidisciplinary approach improves overall patient care and contributes towards the growth of the program and capacity building. Advances in endoscopy will continue to grow as the trends in gastrointestinal disease grow hence it is important to develop programs that address technical skills, quality measures and capacity building with sustainability.

What is already known on this topic:

1. Gastrointestinal endoscopy training is limited in Africa.
2. Endoscopy is important for diagnosis and management of gastrointestinal disease.
3. Gastrointestinal endoscopy is performed by both gastroenterologists and surgeons.

What this study adds:

1. Establishing a successful ERCP training program is a multidisciplinary approach and requires involvement of not only the endoscopists but also the nurses, radiologist, anesthesiologists, and technicians.
2. Buy-in from the hospital administration is critical for a successful endoscopy program.
3. Partnership with medical device companies is integral in developing an endoscopy program.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.