Provision of ERCP services and training in the United Kingdom.

BACKGROUND AND STUDY AIMS: A rising demand for hands-on training in endoscopic retrograde cholangiopancreatography (ERCP) has coincided with a need for increased scrutiny of outcomes (clinical governance) and the development of less invasive methods of pancreaticobiliary imaging. We surveyed the current provision of ERCP facilities and training throughout the United Kingdom. METHODS: Questionnaires were sent to senior endoscopists in 252 acute hospitals and to 500 trainees in gastroenterology. RESULTS: Completed forms were returned from 180 hospitals (a 71% response rate) and from 233 trainees (a 47% response rate). A median of 210 ERCPs per year are carried out at each centre (range 40-1000), under the supervision of 345 senior endoscopists. ERCP training had been started by 163 trainees (70%), of whom 42 (26%) had been given one or fewer procedures to start per week. Trainees rated their training as excellent (25%), good (28%), adequate (24%) or inadequate (22%); 193 (83%) perceived that they needed training in ERCP to ensure that future career opportunities were not denied to them. CONCLUSIONS: Some centres have insufficient capacity for training in ERCP. Some form of preselection for both trainers and trainees may be required to ensure that quality is maintained. Gastroenterology training programmes should move away from encouraging all trainees to learn ERCP, and should promote the acquisition of alternative skills.

Atkinson tubes are a good cost-effective means of palliating inoperable oesophageal malignant strictures: an eight-year experience.

OBJECTIVE: To determine how many oesophageal and oesophago-gastric malignancies could be successfully intubated endoscopically with an Atkinson tube, and how often a metal mesh tube would be required instead. DESIGN: A consecutive series of 125 patients underwent endoscopy and intubation. METHODS: A total of 142 Atkinson tubes were inserted into 122 patients, and four metal mesh stents were put into three patients. The median hospital stay was 3 days, and 28 patients were treated as day cases. RESULTS: Atkinson tube insertion failed in only one patient. There were eight oesophageal perforations (5.6%); the procedure-related mortality was 4%. Three patients required a metal mesh stent, as dilatation proved difficult because of prior radiotherapy in two and prior surgery in one. CONCLUSION: Atkinson tubes are the stents of choice for inoperable oesophageal tumours because of low complication rates and cost efficiency. In 20% of patients, day case insertion was successful. Metal mesh stents should be reserved for those patients with tight post-radiotherapy or post-surgical strictures when dilatation is difficult.

Metachronous small-bowel adenocarcinoma in coeliac disease: gluten-free diet is not protective.

Coeliac disease is associated with an increased risk of certain gastrointestinal malignancies, especially of the small bowel. Metachronous malignancies are well established in the colon, where adenocarcinoma is common, but are exceptional in the small intestine. We describe a young woman with a long history of malabsorption who was shown to have coeliac disease complicated by a small-bowel adenocarcinoma. The cancer was resected, and the coeliac disease went into complete remission on a strict gluten-free diet. Fifteen years later she developed iron deficiency anaemia. Investigations showed a metachronous small-bowel adenocarcinoma but continuing remission of the coeliac disease. The case provides strong evidence against a causative role for the enteropathy of active coeliac disease in small-bowel adenocarcinoma and against a protective effect of a gluten-free diet in tumour development. Predisposition to adenocarcinoma in coeliac disease is probably genetic.