Original article
Clinical endoscopy
Grading the complexity of endoscopic procedures: results of an ASGE working party

https://doi.org/10.1016/j.gie.2010.12.036Get rights and content

Background

Working parties of the American Society for Gastrointestinal Endoscopy (ASGE) Quality Committee recently published a proposed new lexicon for adverse events and a separate extensive review of risk factors. The complexity of procedures also affects outcomes.

Objective

To establish a system for grading the complexity of endoscopic procedures.

Design

Voting on levels 1 (easiest) to 4 (most difficult) on a list of possible procedures and contexts.

Setting

Community and academic gastroenterologists in the United States, Canada, and Britain.

Main Outcome Measurements

Median scores of votes cast.

Results

Consensus list of levels 1 through 4 contexts and procedures.

Limitations

Eminence rather than evidence based.

Conclusions

A consensus list was developed for comments and testing to complement the proposed lexicons for adverse events and risk factors.

Section snippets

Defining complexity

Any procedure can turn out to be difficult technically (eg, cannulation in a diverticulum at ERCP or colonoscopy with multiple loops). However, these challenges are somewhat subjective and may reflect levels of expertise rather than generic and reproducible issues. Our goal was to focus primarily on those circumstances in which difficulty is predictable before the procedure starts (eg, performing ERCP in a patient with known Billroth II anatomy, EGD for the treatment of malignant esophageal

Methods

We made comprehensive lists of specific endoscopic techniques, clinical contexts in which they are used, and some anatomical/pathological challenges that may be encountered during their use. These were sent to the 17 members of the ASGE Adverse Events Working Party to review. Their comments resulted in a final list, with a total of 20 items for EGD, 13 for EUS, 26 for ERCP, and 15 for colonoscopy. The resulting voting sheet was distributed to the 10 members of the ASGE Quality Committee, the 7

Results

Votes were received from 76 endoscopists, 60% of whom were in academic centers and 40% in private practice. Some did not score all of the items because not all endoscopists felt comfortable scoring procedures with which they were not familiar or of that they did not perform in adequate volume. Overall data are shown in TABLE 1, TABLE 2, TABLE 3, TABLE 4, with votes in more than 50% agreement highlighted in black and the few with less than 50% in gray. The procedures and contexts are segregated

Discussion

This is the first attempt to provide rankings for the complexity of all major endoscopic procedures. We did not include capsule endoscopy, which is very simple to perform and virtually without risk. There will be additional endoscopic techniques in the future, eg, bariatric procedures, fundoplication, and full-thickness resections. Those are likely to justify fourth level rankings.

Our listings for ERCP differ substantially from those first proposed by Schutz and Abbott.2 The scope of ERCP has

References (9)

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

See CME section; p. 1015

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