{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,24]],"date-time":"2026-06-24T08:46:31Z","timestamp":1782290791498,"version":"3.54.5"},"reference-count":29,"publisher":"Oxford University Press (OUP)","issue":"1209","license":[{"start":{"date-parts":[[2026,1,12]],"date-time":"2026-01-12T00:00:00Z","timestamp":1768176000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"DOI":"10.13039\/501100012166","name":"National Key R&D Program of China","doi-asserted-by":"publisher","award":["2022YFC2505100"],"award-info":[{"award-number":["2022YFC2505100"]}],"id":[{"id":"10.13039\/501100012166","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Noncommunicable Chronic Diseases-National Science and Technology Major Project","award":["2023ZD0501400"],"award-info":[{"award-number":["2023ZD0501400"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,24]]},"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Endoscopic retrograde cholangiopancreatography (ERCP) is intricate and necessitates comprehensive training. The conventional hands-on approach in ERCP training may not be essential for improving trainee performance or ensuring procedure safety. We hypothesized that hands-off assistance would be non-inferior to hands-on assistance in terms of cannulation success by trainees during ERCP training.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n A total of 770 patients with native papilla were randomized to either the hands-off (intervention, n\u2009=\u2009389) group, where trainers offered verbal guidance via teleguidance using real-time endoscopic and fluoroscopic feeds, or the hands-on (control, n\u2009=\u2009381) group, where trainers provided on-site verbal and restrictive hands-on assistance. Eight trainees with preliminary cannulation experience were involved. The primary outcome was the successful cannulation rate within 10\u00a0min by trainees. ITT analysis was performed and non-inferiority was established if the lower bound of the 95% confidence interval for the difference in success rates exceeded \u221210%.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Cannulation success rates were nearly identical (222\/389, 57.1% vs. 218\/381, 57.2%; absolute difference\u2009\u2212\u20090.1%, 95%CI \u22127.1% to 6.8%; noninferiority P\u00a0=\u2009.002). There was no difference in total cannulation time and attempts between the two groups. Verbal instruction and performance scores were comparable between the two groups. The incidence of adverse events was 8.2% (32\/389) vs. 9.2% (35\/381) (P\u00a0=\u2009.73), including pancreatitis (5.7% vs. 6.8%), bleeding (1.3% vs. 0), and cholangitis (2.1% vs. 2.6%) (all P\u00a0&gt;\u2009.05). Trainers in the hands-off group received minimal radiation exposure.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n The hands-off training showed non-inferior effectiveness and safety to the hands-on training. The alternative method can be integrated into the traditional ERCP training.<\/jats:p>\n Key messages What is already known on this topic: Conventional endoscopic retrograde cholangiopancreatography (ERCP) training relies heavily on direct, hands-on supervision by experienced endoscopists to guide trainees during procedures. While teleguidance (remote supervision using real-time imaging) has been proposed as a potential alternative, robust evidence comparing its effectiveness and safety to traditional hands-on assistance has been lacking. What this study adds: This randomized trial demonstrates that hands-off assistance using teleguidance is non-inferior to hands-on assistance for trainee cannulation success rates (57.2% vs. 57.1%) and overall patient safety (complication rates 8.2% vs. 9.2%). It also significantly reduces radiation exposure for trainers without increasing trainees\u2019 fluoroscopy time or compromising procedural outcomes. How this study might affect research, practice, or policy: The findings support integrating hands-off training via teleguidance into ERCP curricula, offering a viable alternative that maintains trainee performance while reducing trainer radiation risk. This approach could expand training capacity, particularly in settings with limited expert availability, and prompts further research into optimizing remote supervision for complex cases and long-term competency assessment.<\/jats:p>\n <\/jats:sec>","DOI":"10.1093\/postmj\/qgaf178","type":"journal-article","created":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T12:18:33Z","timestamp":1760012313000},"page":"645-652","source":"Crossref","is-referenced-by-count":0,"title":["Effect of hands-on versus hands-off assistance on trainee performance in ERCP training: a randomized controlled study"],"prefix":"10.1093","volume":"102","author":[{"given":"Xu","family":"Wang","sequence":"first","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lijun","family":"Lou","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chenxi","family":"Kang","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gui","family":"Ren","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui","family":"Luo","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiangping","family":"Wang","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shuhui","family":"Liang","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mingxing","family":"Xia","sequence":"additional","affiliation":[{"name":"Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University , 225 Changhai Road, Yangpu District, Shanghai 200438 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bo","family":"Ning","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University , 74 Linjiang Road, Yuzhong District, Chongqing 400010 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yong","family":"Lv","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaoyu","family":"Kang","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jing","family":"Li","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lina","family":"Zhao","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Xijing Hospital, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daiming","family":"Fan","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yanglin","family":"Pan","sequence":"additional","affiliation":[{"name":"State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University , 127 Changle West Road, Xincheng District, Xi\u2019an, Shaanxi 710032 ,","place":["China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,1,12]]},"reference":[{"key":"2026062403512939200_ref1","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1016\/j.gie.2015.11.006","article-title":"Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum","volume":"83","author":"Jorgensen","year":"2016","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref2","doi-asserted-by":"publisher","first-page":"394","DOI":"10.1016\/j.gie.2006.03.933","article-title":"Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy","volume":"65","author":"Verma","year":"2007","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref3","doi-asserted-by":"publisher","first-page":"1160","DOI":"10.1016\/j.gie.2019.01.030","article-title":"Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees","volume":"89","author":"Wani","year":"2019","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref4","doi-asserted-by":"publisher","first-page":"1071","DOI":"10.1055\/a-1537-8999","article-title":"Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) position statement","volume":"53","author":"Johnson","year":"2021","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref5","doi-asserted-by":"publisher","first-page":"1017","DOI":"10.1055\/a-0991-0044","article-title":"ERCP assessment tool: evidence of validity and competency development during training","volume":"51","author":"Siau","year":"2019","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref6","doi-asserted-by":"publisher","first-page":"1371","DOI":"10.1016\/j.gie.2018.02.009","article-title":"Training in EUS and ERCP: standardizing methods to assess competence","volume":"87","author":"Wani","year":"2018","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref7","doi-asserted-by":"publisher","first-page":"770","DOI":"10.1055\/a-0576-6667","article-title":"Changes in scoring of direct observation of procedural skills (DOPS) forms and the impact on competence assessment","volume":"50","author":"Siau","year":"2018","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref8","doi-asserted-by":"publisher","first-page":"1483","DOI":"10.1053\/j.gastro.2018.07.024","article-title":"Competence in endoscopic ultrasound and endoscopic retrograde Cholangiopancreatography, from training through independent practice","volume":"155","author":"Wani","year":"2018","journal-title":"Gastroenterology"},{"key":"2026062403512939200_ref9","doi-asserted-by":"publisher","first-page":"776","DOI":"10.1016\/j.gie.2017.09.014","article-title":"Video-based performance assessment in endoscopy: moving beyond \u201csee one, do one, teach one\u201d?","volume":"87","author":"Huang","year":"2018","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref10","doi-asserted-by":"publisher","first-page":"357","DOI":"10.1055\/s-0032-1326269","article-title":"Telemedicine: an important aid to perform high-quality endoscopic retrograde cholangiopancreatography in low-volume centers","volume":"45","author":"P\u00e5hlsson","year":"2013","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref11","doi-asserted-by":"publisher","first-page":"688","DOI":"10.1055\/s-0034-1391564","article-title":"Appropriate time for selective biliary cannulation by trainees during ERCP\u2014a randomized trial","volume":"47","author":"Pan","year":"2015","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref12","doi-asserted-by":"publisher","first-page":"266","DOI":"10.1016\/j.gie.2009.09.024","article-title":"Needle-knife sphincterotomy: factors predicting its use and the relationship with post-ERCP pancreatitis (with video)","volume":"71","author":"Bailey","year":"2010","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref13","doi-asserted-by":"publisher","first-page":"799","DOI":"10.1055\/s-0033-1344224","article-title":"Coached practice using ERCP mechanical simulator improves trainees\u2019 ERCP performance: a randomized controlled trial","volume":"45","author":"Liao","year":"2013","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref14","doi-asserted-by":"publisher","first-page":"446","DOI":"10.1016\/j.gie.2009.10.027","article-title":"A lexicon for endoscopic adverse events: report of an ASGE workshop","volume":"71","author":"Cotton","year":"2010","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref15","doi-asserted-by":"publisher","first-page":"868","DOI":"10.1016\/j.gie.2010.12.036","article-title":"Grading the complexity of endoscopic procedures: results of an ASGE working party","volume":"73","author":"Cotton","year":"2011","journal-title":"Gastrointest Endosc"},{"key":"2026062403512939200_ref16","doi-asserted-by":"publisher","first-page":"447","DOI":"10.1055\/a-1523-0780","article-title":"Difficult biliary cannulation in ERCP procedures with or without trainee involvement: a comparative study","volume":"54","author":"Wang","year":"2022","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref17","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1111\/den.14404","article-title":"International cross-sectional survey on endoscopic retrograde cholangiopancreatography training by the world endoscopy organization","volume":"35","author":"Teoh","year":"2023","journal-title":"Dig Endosc"},{"key":"2026062403512939200_ref18","doi-asserted-by":"publisher","first-page":"1004","DOI":"10.1055\/a-1217-6727","article-title":"Impact of mechanical simulator practice on clinical ERCP performance by novice surgical trainees: a randomized controlled trial","volume":"52","author":"Meng","year":"2020","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref19","doi-asserted-by":"publisher","first-page":"949","DOI":"10.1055\/s-0034-1377930","article-title":"Competence development in ERCP: the learning curve of novice trainees","volume":"46","author":"Ekkelenkamp","year":"2014","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref20","doi-asserted-by":"publisher","first-page":"722","DOI":"10.1007\/s10620-015-3939-7","article-title":"Can a computerized simulator assess skill level and improvement in performance of ERCP?","volume":"61","author":"Sahakian","year":"2016","journal-title":"Dig Dis Sci"},{"key":"2026062403512939200_ref21","doi-asserted-by":"publisher","first-page":"E145","DOI":"10.1055\/a-1315-1994","article-title":"Motion training on a validated mechanical ERCP simulator improves novice endoscopist performance of selective cannulation: a multicenter trial","volume":"9","author":"Voiosu","year":"2021","journal-title":"Endosc Int Open"},{"key":"2026062403512939200_ref22","doi-asserted-by":"publisher","first-page":"239","DOI":"10.1177\/2050640618817110","article-title":"Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: a systematic review of the literature","volume":"7","author":"Voiosu","year":"2019","journal-title":"United Eur Gastroenterol J"},{"key":"2026062403512939200_ref23","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1055\/a-1049-0359","article-title":"Impact of trainee involvement on the outcome of ERCP procedures: results of a prospective multicenter observational trial","volume":"52","author":"Voiosu","year":"2020","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref24","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1055\/a-1075-4080","article-title":"ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) guideline","volume":"52","author":"Dumonceau","year":"2020","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref25","doi-asserted-by":"publisher","first-page":"956","DOI":"10.1038\/ajg.2015.24","article-title":"Status of competency-based medical education in endoscopy training: a Nationwide survey of US ACGME-accredited gastroenterology training programs","volume":"110","author":"Patel","year":"2015","journal-title":"Am J Gastroenterol"},{"key":"2026062403512939200_ref26","doi-asserted-by":"publisher","first-page":"847","DOI":"10.1055\/a-2041-7546","article-title":"Validity evidence for observational ERCP competency assessment tools: a systematic review","volume":"55","author":"Khan","year":"2023","journal-title":"Endoscopy"},{"key":"2026062403512939200_ref27","doi-asserted-by":"publisher","first-page":"350","DOI":"10.1002\/ueg2.12377","article-title":"A portrait of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound training programs in Europe: current practices and opportunities for improvement","volume":"11","author":"De Campos","year":"2023","journal-title":"United Eur Gastroenterol J"},{"key":"2026062403512939200_ref28","doi-asserted-by":"publisher","first-page":"90","DOI":"10.1002\/sres.2442","article-title":"The paradoxes of telehealth: a review of the literature 2000\u20132015","volume":"35","author":"Standing","year":"2018","journal-title":"Syst Res Behav Sci"},{"key":"2026062403512939200_ref29","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1016\/j.gie.2018.03.008","article-title":"A pilot single-center prospective randomized trial to assess the short-term effect of a flashing warning light on reducing fluoroscopy time and radiation exposure during ERCP","volume":"88","author":"Zeng","year":"2018","journal-title":"Gastrointest Endosc"}],"container-title":["Postgraduate Medical Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/pmj\/article-pdf\/102\/1209\/645\/66375920\/qgaf178.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/pmj\/article-pdf\/102\/1209\/645\/66375920\/qgaf178.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,24]],"date-time":"2026-06-24T07:51:36Z","timestamp":1782287496000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/pmj\/article\/102\/1209\/645\/8422745"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,12]]},"references-count":29,"journal-issue":{"issue":"1209","published-online":{"date-parts":[[2026,1,12]]},"published-print":{"date-parts":[[2026,5,24]]}},"URL":"https:\/\/doi.org\/10.1093\/postmj\/qgaf178","relation":{},"ISSN":["0032-5473","1469-0756"],"issn-type":[{"value":"0032-5473","type":"print"},{"value":"1469-0756","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,7]]},"published":{"date-parts":[[2026,1,12]]}}}