Can We Improve Quality in ERCP and EUS?

ERCP and EUS are essential in treating a variety of disease entities. Metrics exist to measure performance quality, but data are necessary to improve quality when deficiencies are identified. Authors of a new practice guideline from the American Society for Gastrointestinal Endoscopy systematically examined the published 2016 priority indicators for ERCP and EUS and reviewed the literature to identify interventions to enhance the quality of the priority indicators. These interventions could be used by providers and endoscopy centers falling below reported benchmarks for these indicators.

Quality indicators and interventions that might improve ERCP quality

Appropriate indication and documentation of the indication in >90% of cases:

• Audit and feedback

Cannulation rate in patients without surgically altered anatomy in >90% of cases:

• Prone position versus other positions
• Deep versus moderate sedation
• Sphincterotomes versus cannulas
• Physician-controlled wire-guided cannulation versus standard techniques
• Limited data on educational interventions using mechanical simulators for trainees and advanced cannulation techniques to improve cannulation success rates with high-volume endoscopists

The extraction rate of stones <1 cm in >90% of cases:

• Extraction balloon versus basket in select cases
• Sphincteroplasty with or without sphincterotomy versus sphincterotomy alone
• Cholangioscopy or intraductal ultrasound in select cases

Stent placement rate for biliary obstruction below the bifurcation in patients with nonsurgically altered anatomy in >90% of cases:

• Guidewires with a stiff shaft and hydrophilic tip versus standard wires
• Dilators (graduated catheters, stent retrievers, hydrostatic balloons)

Post-ERCP pancreatitis (rate not available/identified):

• Physician-controlled wire-guided cannulation
• Rectal indomethacin in high-risk patients
• Aggressive periprocedural hydration with lactated Ringer’s solution
• Pancreatic stents in patients with inadvertent pancreatic duct cannulation

Quality indicators and interventions that might improve EUS quality

The frequency with which all GI cancers are staged with the American Joint Committee on Cancer/International Union Against Cancer tumor, node, metastasis staging system (should be >98%):

• Audit and feedback

Diagnostic rates and sensitivity for malignancy in solid pancreatic masses (>70% in patients with a pancreatic mass with a sensitivity for malignancy of >85% among all pancreatic cancers):

• Negative pressure suction or slow-pull and fanning technique
• Limited data for deep versus moderate sedation and core biopsy versus fine-needle aspiration (FNA), especially when rapid onsite cytopathology evaluation is unavailable

Reducing adverse events after EUS-FNA (acute pancreatitis <2%, perforation <0.5%, bleeding <1%, infection N/A): 

• Selective antibiotic use
• Discontinue antithrombotic therapy when FNA/fine-needle biopsy is anticipated