Training and capacity building for endoscopic retrograde cholangiopancreatography in low- and middle-income countries: gaps and context-specific strategies — a scoping review

Background Endoscopic Retrograde Cholangiopancreatography (ERCP) offers a variety of interventions in managing biliopancreatic disorders, but it is associated with a high risk of adverse events. Therefore, training is typically conducted through formal gastroenterology fellowships in high-volume centres, but may also occur informally in low- and middle-income countries (LMICs). Aims This scoping review seeks to understand the training methods available to ERCP trainees and the methods used to assess their competence, particularly in LMICs. Methods We searched MEDLINE (PubMed), Web of Science and Scopus from 2005 to August 2025, and performed a complementary Grey literature search. We included studies published in English that referenced recommendations from endoscopic societies or national accrediting bodies, and those that described ERCP training and the assessment of technical competence. Data were extracted and summarised. Results The review identified 55 articles, including 7 recommendations from endoscopic societies and accreditation bodies. Low- and middle-income countries (LMICs) were poorly represented, with only one guideline retrieved from an upper-middle-income country accreditation body. We identified eight competence assessment tools: five qualitative, one self-assessment, and two quantitative. None of the recommendations from LMICs included guidance on formal competence assessment, and no studies from these settings reported on the use of simulator-based training. The expansion of ERCP services in LMICs has relied on short-term apprenticeship training with mentorship, intermittent expert visits supported by telemedicine, and outreach placements at high-volume centres before returning to local practice. Conclusions The underrepresentation of low- and middle-income countries in ERCP training, guideline development, and competence assessment highlights an urgent need for context-specific frameworks. Establishing such guidelines in resource-limited settings is essential to enhance patient safety and provide a foundation for expanding ERCP services where they currently do not exist.