FASGE, FACG, FACP, AGAF
Director of Endoscopic Research & Development
The University of Texas MD Anderson Cancer Center
Houston, Texas
In this month’s column, I highlight articles related to training and quality in endoscopic ultrasound. EUS indications have rapidly evolved with more complex interventions. Therefore, it is important that we look at the quality of what we do and how we train the next generation of endosonographers. Training in one EUS procedure does not imply competence in another.
The first featured article is the EUS quality indicator statement published by the American College of Gastroenterology and American Society for Gastrointestinal Endoscopy. I recently spoke with Girish Mishra, MD, the lead author of the ACG/ASGE statement. Dr. Mishra commented, “Our writing group felt compelled to tackle many of the newer EUS-guided interventions and address the success rates that should be obtained, along with the acceptable adverse events, based on the published literature and expert opinion. We lack … thresholds right now, as so many interventional endoscopists are performing these procedures.”
This month’s second featured article is a review on the state of EUS training that discusses resources available worldwide, different training models, limitations, and challenges.
ACG and ASGE EUS Quality Indicators
Am J Gastroenterol 2025;120(5):973-992; Gastrointest Endosc 2025;101(5):928-949.e1
The ACG and ASGE have updated their quality indicators for EUS in response to new evidence and innovations in EUS use, including the growth of interventional EUS, over the past decade.
The quality indicators, which were selected due to their implications for endoscopist practice and patient outcomes, based on clinical studies and expert consensus, span the pre-, intra-, and post-procedure periods. Each indicator was given a rating for strength of recommendation, ranging from 1A, “strong recommendations” based on “randomized trials without important limitations,” to 3, “weak recommendations” based on “expert opinions only.”
In total, there are 20 quality indicators, including four pre-procedure, 12 intra-procedure, and four post-procedure indicators. Indicators that were scored 1C or higher on strength of recommendation targeted the following:
- more than 90% frequency of performing EUS for an indication included in a published standard list of appropriate indications and documenting the indication;
- more than 98% frequency of administering prophylactic antibiotics for appropriate indications;
–The recommendations indicate that prophylactic antibiotics should be administered for pancreatic necrosis, should be strongly considered for EUS-guided biliary drainage, gallbladder drainage, gastroenterostomy, pancreatic fluid collection, and trans-gastric endoscopic retrograde cholangiopancreatography, should be considered on a case-by-case basis for pancreatic pseudocyst, are not routinely indicated for pancreatic cystic lesion, and are not indicated for pancreatic solid lesions.
- more than 85% frequency of obtaining a diagnostically accurate EUS-guided liver biopsy;
- at least 87% frequency of obtaining a diagnostic specimen by EUS-guided sampling of malignant pancreatic masses;
- at least 92% frequency of achieving technical success in EUS-guided pancreatic fluid collection drainage;
- at least 85% frequency of achieving technical success in EUS-guided biliary drainage;
- more than 92% frequency of achieving technical success in EUS-directed trans-gastric ERCP; and
- less than 0.5% frequency of perforation, less than 1% frequency of infection, less than 1% frequency of acute pancreatitis, less than 1% frequency of clinically significant bleeding (in general), and less than 5% frequency of clinically significant bleeding after EUS-guided liver biopsy sampling.
The authors emphasized that the quality indicators should be used “as a framework for quality improvement efforts,” with these efforts initially focused on the priority indicators.
The State of EUS Training
World J Gastrointest Endosc 2025;17(8):107458
An international team of investigators has outlined the current state of EUS training and highlighted strengths and limitations of current training models. Given the technical challenges of EUS and expansion of its use from diagnostic to interventional applications, the authors emphasized the need for training centers and standards that promote expertise in “both theoretical knowledge and practical procedures.”
The authors noted that recommendations for the number of supervised EUS procedures a trainee should perform have been put forth by the ASGE (n=225) and the European Society of Gastrointestinal Endoscopy (n=250). In addition, the authors described the utility of several training approaches that can foster theoretical understanding and technical proficiency (e.g., computer-based simulators, phantoms, ex vivo animal models, and live animal models).
With access to society-sponsored training programs geographically limited, some countries and universities have developed certified EUS training courses. For example, the EUS diploma in France is a two-year program that involves three weeks of theoretical instruction, including video sessions, and a week of practical training in diagnostic EUS and some interventional EUS procedures. The course is organized by the Club Francophone d’Echo-endoscopie and the French Society of Digestive Endoscopy. Trainees are required to have at least two years of experience before entering the course, and completion of the course is not required to practice EUS in France.
Another well-regarded course is the Digestive EUS University Diploma, offered by the Mohammed VI International Center for Sciences and Health and University of Health Sciences, in Casablanca, Morocco. The course involves four modules:
- Normal echoanatomy of the upper GI tract, including the pancreatobiliary system and lower GI tract;
- Upper and lower digestive tract diseases;
- Pancreatobiliary diseases; and
- Liver, mediastinal, and other organ pathologies, with training in EUS-guided fine-needle aspiration/FNB.
Each module comprises three days of lectures, case videos, hands-on training, and live demonstrations. Participants must complete four weeks of training at an expert center and are monitored for one year after the course to evaluate EUS quality.
The World Endoscopy Organization has also developed the WEO International School of EUS (WISE), initially in collaboration with the Asian EUS Group Korea but more recently with an Egyptian group. In addition, numerous other societies and organizations hold workshops and conferences and have developed websites to facilitate EUS training.
The authors emphasize the need for a greater number of comprehensive EUS training programs that “encompass theoretical instruction, hands-on training using simulators and animal models, live demonstrations of EUS cases in endoscopy rooms, and, most critically, supervised performance of EUS procedures under expert guidance.” However, they acknowledge that a challenge to establishing more comprehensive programs is the limited number of facilities equipped with simulators, EUS experts, and the high volume of procedures needed for adequate training. This is even more of a challenge for interventional EUS, they noted, given that “each procedure has a distinct learning curve, necessitating specialized training programs to mitigate associated risks.”
This article is from the November 2025 print issue.