As for many medical procedures,ERCP outcomesare reported in terms of procedural success andcomplication rates.In general,technical successshould be defined on an intention-to-diagnose andintention-to-treat basis,and a consensus conferencehas standardized ERCP complication definitions.
Although technical success and complication dataare useful in assessing procedure quality,taken bythemselves they are relatively crude measures ofoutcome.A large multicenter prospective study by Freemanet al.
found that numerous patient-specific andendoscopist-specific factors significantly impact therisk of complications after biliary sphincterotomy.Similarly,technical success may vary markedlydepending on many factors,particularly the type ofintervention being attempted.When biliary sphinc-terotomy is attempted or when the goal is to removesingle small stones from the bile duct,for example,ERCP is almost always successful.
Extracting cal-culi from intrahepatic bile ducts or the pancreas,onthe other hand,is much more likely to result in atechnical failure.
Although interventional cardiologists have devel-oped a system to grade the technical difficulty ofcoronary artery lesions prior to angioplasty,
thereis presently no objective way to quantify ERCPdegree of difficulty.In an attempt to give technicalsuccess information from our center additional con-text,a relatively simple ERCP degree of difficultygrading scale was developed,pilot tested by apply-ing it retrospectively to our 1997 outcome data,andthen used to prospectively grade ERCPs at our cen-ter during 1998.
Demographic and procedural information for allERCPs done at our center is entered into a database(GITrac;Akron Systems Development,Charleston,S.C.)immediately after each procedure.In addition,all ERCPsperformed during the previous week are reviewed at anafternoon conference attended by a majority of gastroen-terology fellows and attending physicians at our center,aswell as a radiologist (R.A.) with expertise in ERCP inter-pretation.At this conference,technical success and com-plication determinations are made for each scheduled pro-cedure,and any additional details about earlier ERCPs(e.g.,late complications) are noted.Although patientswere not contacted routinely after ERCP to capture com-plications,it is unlikely that they would have occurred
Grading ERCPs by degree of difficulty:a new concept toproduce more meaningful outcome data
Stephen M.Schutz,MD,Robert M.Abbott,MD
San Antonio, Texas
Simple endoscopic retrograde cholangiopancreatography (ERCP) outcome mea-sures such as success and complication rates may not allow direct comparisons among endos-copists or centers because procedure degree of difficulty can vary tremendously from case tocase.We propose a new grading scale designed to objectively quantify ERCP degree of difficulty.
A 1 to 5 scale was devised to grade ERCPs according to their level of technical difficulty.A retrospective pilot study was performed to assess ERCP outcomes at our institution accordingto difficulty grade.The scale was then prospectively applied to all ERCPs during a 1-year period.
In the pilot study,209 of 231 (90%) ERCPs were technically successful,and 8 (3%) werefollowed by complications.Grade 1 to 4 procedures were more likely to succeed (94% vs.74%,
< 0.05) and less likely to have associated complications (2% vs.10%,
< 0.05) than grade 5/5BERCPs.Of 187 ERCPs assessed prospectively,166 (89%) were successful and 10 (5%) were fol-lowed by complications;132 of 138 (96%) grade 1 to 4 procedures succeeded compared with 30of 46 grade 5 to 5B ERCPs (65%,
< 0.001),but complications were not significantly more frequentin grade 5 to 5B ERCPs (8.7% vs.4.3%,
= not significant).
Technical success was dependent on ERCP degree of difficulty,but complicationswere not.Outcome data that incorporate degree of difficulty information may be more meaningful,allowing endoscopist-to-endoscopist and center-to-center comparisons.(Gastrointest Endosc2000;51:535-9.)
VOLUME 51,NO.5,2000GASTROINTESTINAL ENDOSCOPY
Received May 25,1999.For revision August 30,1999.Accepted December 9,1999.From the Departments of Gastroenterology and Radiology,Wilford Hall Medical Center,San Antonio,Texas.Presented in part at the annual ASGE meeting May 18,1999,Orlando,Florida.Reprint requests:Stephen M.Schutz,MD,Chief,Division of Gastroenterology,David Grant Medical Center,101 Bodin Ci,Travis AFB,CA 94535.