Updated quality indicators for endoscopic ultrasound, published by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology, reflect profound innovations that have occurred in the field in recent years, particularly the rise of interventional and therapeutic EUS, which did not exist when the previous esophagogastroduodenoscopy quality indicators were published in 2015.
Lead author Girish Mishra, MD, the gastroenterology and hepatology section chief at Wake Forest University School of Medicine, in Winston-Salem, N.C., told Gastroenterology & Endoscopy News that because the field of interventional EUS has emerged only within the last decade, the new quality indicators reflect the current state of the field while building on the foundation of diagnostic EUS knowledge (Am J Gastroenterol 2025;120[5]:973-992).
“Almost half of this document is new compared to the one from 10 years ago, because the technology has evolved so much, especially in the last five years,” Dr. Mishra said.
In particular, Dr. Mishra noted that nine out of 12 indications given for interventional EUS are completely new. Of the 20 quality indicators, nine pertain to interventional EUS. Five indicators define the frequency with which technical success ought to be achieved in EUS-guided interventional procedures, two indicators pertain to the occurrence and documentation of adverse events (AEs), and another pertains to the frequency with which a complete report is created.
“There are many endosonographers at academic centers and in community practice who are performing interventional EUS procedures without any sort of guidelines or targets for how successful one should be, because the data are still emerging,” Dr. Mishra said. “Prospective randomized studies are lacking. So, we based our recommendations on the latest available literature and came up with numbers that are stringent but achievable if one performs high-quality procedures.”
Among the 20 quality indicators, five are identified as priority indicators. They include:
- indicator 1, which pertains to the frequency with which EUS is performed for an indication identified as appropriate in a published list and documented accordingly;
- indicator 7, which pertains to the frequency of documentation of the echogenicity and wall layer of origin of subepithelial masses;
- indicator 11, which defines the frequency with which EUS-guided sampling of a malignant pancreatic mass obtains a diagnostic specimen;
- indicator 12, which defines the frequency of technical success in EUS-guided pancreatic fluid collection; and
- indicator 18, which prescribes the frequency of documentation of AE incidence after both diagnostic and interventional EUS.
The more “stringent and granular” documentation of subepithelial masses based on wall layers is a significant update, as is the inclusion of an indicator on the frequency of obtaining an adequate EUS-guided liver biopsy sample, Dr. Mishra said.
Defining an acceptable frequency of AEs in both diagnostic and interventional EUS presented a challenge, he added. “There will always be AEs, and with high-risk interventional EUS procedures, there will be complications, but the people performing these procedures should be held to reasonable, acceptable standards,” Dr. Mishra said. “This document is not a guideline because we don’t have Level 1 data and didn’t apply a grade methodology, but we felt a responsibility to give people something they can reference that’s based on the best available evidence.”
| Selected Established and Evolving Indications for EUS |
| Diagnostic indications |
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| Therapeutic (interventional) indications |
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| ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound. Based on Am J Gastroenterol 2025;120(5):973-992. |
Dr. Mishra emphasized that the document is not only for endosonographers but also merits a close look from gastroenterologists who want to learn about the implications of EUS for their own practices and patients.
“For instance, there are GIs who practice high-quality care who may not know that with interventional EUS, it’s possible to access the bile duct after a Roux-en-Y bypass,” he explained. “The conventional wisdom is that it’s not possible, but it’s being done routinely with a good success rate. So, there’s lots of great knowledge in this document for practicing GIs who may not be aware that this field exists.”
A Solid Framework
Todd Baron, MD, the director of advanced therapeutic endoscopy at the University of North Carolina at Chapel Hill School of Medicine, said the document is “good and timely” and deserves to be widely read.
“I think it’s as comprehensive as it can be in most respects, and what really struck me is that the authors are trying to get ahead of the curve in terms of where the field of EUS is headed,” Dr. Baron said. “I applaud them for trying to provide as solid a framework as is possible given the state of the evidence, acknowledging that this is a rapidly evolving area.”
Dr. Baron singled out the AE-related indicators as worthy of close attention, given the wide range of skill levels and complication risks encompassed by interventional EUS procedures.
“It’s important to emphasize that a lot of the data on interventional EUS comes from academic centers that have high volumes and a lot of experience, and so can’t be extrapolated to community practices,” he said.
He likened the relatively sudden emergence of interventional EUS in recent years to the advent of laparoscopic cholecystectomy in the late 1980s. “For over 100 years, cholecystectomy was performed as an open surgery. Then a famous pelvic surgeon in Europe described the first laparoscopic procedure, and it quickly became obvious that it was superior to open cholecystectomy in many respects,” Dr. Baron said. “A lot of practitioners in the U.S. who were only trained in open surgery realized they had to adopt the laparoscopic method to keep up with the field, and there were a lot of adverse events as a result.
“If we don’t want history to repeat itself, we need to ensure that community practitioners are properly trained on the procedures they’re performing and that they understand the downsides and risks,” he added. “This document will help promote that level of awareness.”
—Ajai Srinivas
Drs. Baron and Mishra reported no relevant financial disclosures.
This article is from the June 2025 print issue.