S3662 When Your Colleague Asks for Help: The EUROPE-FC Approach to ERCP Failure

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) failure occurs in 5-15% of cases. There are no guidelines in the medical literature to assist a colleague after procedural failures. In this case report, we describe a collaborative approach to manage ERCP failure. Case Description/Methods: Patient is a 29-year-old woman with right upper quadrant pain, nausea and vomiting. AST 72, ALT 134, bilirubin 0.7. Ultrasound: cholelithiasis, biliary dilation at 9 mm and choledocholithiases. During ERCP by a colleague, the ampulla was edematous. Pancreatic duct was inadvertently cannulated, and a 5 Fr 4 cm stent was placed in the ventral pancreatic duct. Precut sphincterotomy was performed, but biliary cannulation was not achieved. Sphincterotomy site bled, treated by epinephrine injection. The colleague asked us to help with management of ERCP failure. Empathy was verbalized. Technical difficulties (ampullary edema, atypical orientation of the bile duct), risks of pancreatitis (young age, female gender, normal bilirubin, multiple cannulation attempts) and bleeding were discussed and understood. Respect for our colleague was expressed. An ERCP re-attempt was offered. A plan was formed to minimize the risks of pancreatitis (IVF, indomethacin suppository), bleeding (intravenous pantoprazole, avoidance of the precut sphincterotomy) and ampullary edema (intravenous methylprednisolone). Execution succeeded with biliary cannulation, biliary sphincterotomy, balloon extraction of 2 biliary stones and 7 Fr 7 cm biliary stenting. Feedback was provided to the colleague. Communications were provided to patient, colleague, and team members. Patient did well. Two weeks later, she underwent ERCP by the colleague for removal of the stents. Discussion: Professional collaboration is important in our complex medical environment. We developed these steps when a colleague asks for help: Empathy: Verbalize awareness of the situation and show sensitivity toward colleague. Understanding: Recognize the indications, technical challenges and risks of complications. Respect: Appreciate and value the clinical judgement, humility and commitment to patient care of colleague. Offer: Accept to intervene or provide alternative solutions. Plan: Strategize to minimize risks and maximize efficacy. Execution: Implement plan. Feedback: Provide input to colleague for mutual growth. Communications: Discuss all steps transparently with patient, colleague and team members. The EUROPE-FC approach can be applied to all procedures and other clinical situations to optimize patient care and foster a collaborative work culture.