GI Unit Leadership: Shaping a High-Performing Endoscopy Unit (On-Demand) | February 2026-ASGE interventions to improve ERCP EUS performance

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This American Society for Gastrointestinal Endoscopy (ASGE) document reviews evidence-based interventions aimed at improving quality indicators in two advanced endoscopic procedures: endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). ERCP and EUS have evolved from specialized techniques to widely used procedures with variable performance across practitioners. Despite established quality metrics for these procedures, there is limited evidence on how to effectively improve them.<br /><br />For ERCP, key quality indicators include appropriate indications for the procedure, successful cannulation of the duct of interest (≥90% success in native papillae), complete stone extraction (≥90% for stones ≥1 cm), successful stent placement for biliary obstruction (≥90%), and reduction of post-ERCP pancreatitis (PEP). Interventions supported by evidence include: auditing and feedback to reduce inappropriate ERCP use; use of sphincterotomes over cannulas for biliary cannulation; prone patient positioning; deep sedation in select cases; physician-controlled wire-guided cannulation (WGC); and gaining expertise in advanced cannulation techniques. For stone extraction, balloon catheters are preferred over baskets, and sphincteroplasty (with or without sphincterotomy) can improve success, especially in large stones. For challenging biliary strictures, guidewires with stiff shafts and hydrophilic tips and various dilators may improve stent placement. To reduce PEP, rectal nonsteroidal anti-inflammatory drugs (NSAIDs), prophylactic pancreatic duct stents (especially in high-risk cases or inadvertent pancreatic duct cannulation), physician-controlled WGC, and aggressive periprocedural intravenous hydration with lactated Ringer’s solution are recommended.<br /><br />In EUS, quality indicators focus on appropriate cancer staging using standardized TNM systems, diagnostic accuracy of tissue acquisition in pancreatic masses, and minimizing adverse events. Interventions improving staging documentation include audit and feedback and use of standardized reporting templates. To enhance diagnostic yield in EUS-guided tissue acquisition (EUS-TA), applying negative pressure suction or slow-pull techniques, using fanning during needle passes, choosing core biopsy needles over fine-needle aspiration needles (especially when rapid on-site evaluation [ROSE] is unavailable), and considering anesthesia-administered sedation may be beneficial. Adverse events are rare; prophylactic antibiotics are generally unnecessary except possibly for mediastinal cysts or perirectal lesions. Patients should safely discontinue nonaspirin antithrombotic therapy before EUS-TA to reduce bleeding risk.<br /><br />Overall, the evidence mostly supports technical and pharmacologic procedural modifications rather than strategies targeting low-performing endoscopists. There remains a substantial gap in validated interventions to ensure appropriate use and to improve skill-based performance in ERCP and EUS. The ASGE urges further research to develop effective remediation for underperforming practitioners and to advance quality assurance in advanced endoscopy. Table 2 in the document summarizes the key interventions identified for improving quality indicators in both ERCP and EUS.

Meta Tag

Concept Endoscopic Retrograde Cholangiopancreatography

Concept Post-ERCP Pancreatitis

Concept Endoscopic Ultrasound Guidance

Concept Endoscopy Quality Indicator

Concept Cannulation Success

Keywords

American Society for Gastrointestinal Endoscopy

ASGE

endoscopic retrograde cholangiopancreatography

ERCP

endoscopic ultrasound

EUS

quality indicators

post-ERCP pancreatitis

tissue acquisition

advanced endoscopic procedures

Endoscopic Retrograde Cholangiopancreatography

Post-ERCP Pancreatitis

Endoscopic Ultrasound Guidance

Endoscopy Quality Indicator

Cannulation Success