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ASGE ACG quality indicators_ERCP

Pdf Summary

This document from the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG) outlines updated quality indicators for endoscopic retrograde cholangiopancreatography (ERCP), a complex, operator-dependent therapeutic procedure for biliary and pancreatic diseases with significant risks such as pancreatitis, bleeding, and cholangitis.

Key aspects include:  
1. <strong>Preprocedure indicators</strong> emphasize appropriate ERCP indications (target 98% adherence), detailed informed consent covering ERCP-specific risks, and prophylactic antibiotic administration for select cases (e.g., incomplete biliary drainage, cholangioscopy, liver transplant recipients). Notably, ERCP should be largely therapeutic, with evolving criteria for suspected choledocholithiasis to minimize unnecessary diagnostic ERCP.

2. <strong>Intraprocedure indicators</strong> focus on technical outcomes: deep cannulation success in native papillae (target 90%), successful extraction of extrahepatic bile duct stones (target 90%), radiation exposure measurement with dose-reduction strategies (target 98%), routine use of rectal NSAIDs (indomethacin or diclofenac) for preventing post-ERCP pancreatitis (PEP) in patients with intact papillae (target 90%), and documentation and tracking of prophylactic pancreatic stent placement (PSP) in high-risk cases (target 98%). The document advises careful patient selection and skilled technique, noting that over-aggressive interventions may increase adverse events.

3. <strong>Postprocedure indicators</strong> include monitoring and documenting unplanned hospital visits and unplanned biliary interventions within 30 days post-ERCP (target ≤15% each), as these reflect comprehensive procedural quality. Process measures mandate documenting rates of PEP, clinically significant hemorrhage after sphincterotomy, and cholangitis/cholecystitis within 30 days (target 95%), acknowledging variability due to case mix and reporting challenges.

The document underscores that quality indicators aim to improve care delivery rather than serve as rigid credentialing standards and encourages providers to prioritize “priority indicators” initially for quality improvement. A balance between outcome and process measures is highlighted, given challenges in consistent outcome measurement.

Important updates include stricter indication criteria, endorsement of rectal NSAIDs for all patients with intact papillae (not just high risk), and renewed emphasis on documenting prophylactic pancreatic stent use. The indicators collectively seek to reduce variability in ERCP quality, enhance patient safety, and optimize resource use across diverse practice settings.

Keywords

Endoscopic retrograde cholangiopancreatography

ERCP quality indicators

American Society for Gastrointestinal Endoscopy

American College of Gastroenterology

Preprocedure ERCP guidelines

Intraprocedure ERCP targets

Postprocedure ERCP monitoring

Pancreatitis prevention

Prophylactic pancreatic stent

Rectal NSAIDs for ERCP