Objective evaluation of ERCP procedures: a simple grading scale for evaluating technical difficulty

Abstract

Background and objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding endoscopic procedure that varies from a simple diagnostic to a highly complex therapeutic procedure. Simple outcome measures such as success and complication rates do not reflect the competence of the operator or endoscopy unit, as case mix is not taken into account. A grading scale to assess the technical difficulty of ERCP can improve the objectivity of outcome data. Methods: A I to IV technical difficulty grading scale was constructed and applied prospectively to all ERCPs over a 12 month period at a single centre. The procedures were performed by two senior trainees and two experienced consultants (trainers). The grading scale was validated for construct validity and inter-rater reliability at the end of the study using the χ 2 test and κ statistics. Results: There were 305 ERCPs in 259 patients over the 12 months study period (males: 112, females: 147, age range 17-97, mean 70.3 years). There was overall success in 244 (80%) procedures with complications in 13 (4%): bleeding in five (1.6%), cholangitis in one (0.3%), pancreatitis in five (1.6%), and perforation in two (0.7%). Success rate was highest for grade I, 49/55 (89%), compared with grade IV procedures, 8/11 (73%). There was a significant linear trend towards a lower success rate from grade I to IV (p=0.021) for trainees, but not for trainers. Complications were low in grade I, II, and III procedures, 12/295(4%), compared with grade IV procedures, 1/11(9%). The inter-rater reliability for the grading scale was good with a substantial agreement between the raters (κ=0.68, p<0.001). Conclusion: Success and complications of ERCP by trainees are influenced by the technical difficulty of the procedure. Outcome data incorporating a grading scale can give accurate information when auditing the qualitative outcomes. This can provide a platform for structured objective evaluation. E ndoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is not only technically challenging, but also associated with a risk of serious complications. The procedure itself varies from a simple, straightforward diagnostic ERCP to a highly specialised therapeutic ERCP. A recent survey in the UK showed wide differences between endoscopists in success rates (from 76% to 95%) and serious complications (0% to 16%).1 It is far from acceptable to have such a variation in practice and outcomes in any health care system. Studies have shown that skill and experience have a huge impact on the outcomes of ERCP. 3Success and complications depend not only on the endoscopist's experience, but also on the technical difficulty. Auditing ERCP procedures by simple outcome measures such as complication and success, without taking into account the experience and technical difficulty, does not reflect the actual competence of the unit or an individual endoscopist. Units dealing with advanced, therapeutic ERCP procedures may not be achieving the same success rat...

Quantitative assessment of technical proficiency in performing needle-knife precut papillotomy

“…Although technical proficiency may depend on an endoscopist's ability to complete a particular procedure successfully regardless how many procedures he or she has performed, the number of NKPP procedures performed is highly relevant because it is a very advanced ERCP procedure performed by experienced endoscopists [18,30,32,33].…”

Assessment of the endoscopic retrograde cholangiopancreatography grading system: A prospective study from a tertiary care center

“…Therefore, no practical use in the field of clinical practice was found. In the study conducted by Ragunath et al (12), which included 259 patients, the ERCP procedures were divided into four degrees, and the success and complication rates between experienced endoscopists and trainee endoscopists were compared. Eventually, discordant results were found between the technical difficulty of the procedures and the success and complication rates.…”

Identification of significant difficulty of selective deep cannulation by a simple predictive model: an endoscopic scale for teaching ERCP

“…This high level of confidence for discharging significant DSDC has not been obtained with any proposed model. Previous reports have focused on validating a technical complexity grading scale for ERCP procedures, using variables obtained at the end of the procedure [7,8], or on studying the impact of a hands-on ERCP workshop on clinical practice [19]. In our series, significant DSDC was present in 26% of the cases.…”

“…In addition, Jowell et al [6] have developed a system to assess technical competence and experience in ERCP procedures. To allow endoscopist-to-endoscopist and center-to-center comparisons, Schutz et al [7] and Ragunath et al [8] have developed simple grading scales for evaluating technical complexity in ERCP.…”