title: Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data.
abstract: BACKGROUND
  Simple endoscopic retrograde cholangiopancreatography (ERCP) outcome measures such as success and complication rates may not allow direct comparisons among endoscopists or centers because procedure degree of difficulty can vary tremendously from case to case. We propose a new grading scale designed to objectively quantify ERCP degree of difficulty.
  
  
  METHODS
  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 according to difficulty grade. The scale was then prospectively applied to all ERCPs during a 1-year period.
  
  
  RESULTS
  In the pilot study, 209 of 231 (90%) ERCPs were technically successful, and 8 (3%) were followed by complications. Grade 1 to 4 procedures were more likely to succeed (94% vs. 74%, p< 0.05) and less likely to have associated complications (2% vs. 10%, p< 0.05) than grade 5/5B ERCPs. Of 187 ERCPs assessed prospectively, 166 (89%) were successful and 10 (5%) were followed by complications; 132 of 138 (96%) grade 1 to 4 procedures succeeded compared with 30 of 46 grade 5 to 5B ERCPs (65%, p<0.001), but complications were not significantly more frequent in grade 5 to 5B ERCPs (8.7% vs. 4.3%, p = not significant).
  
  
  CONCLUSIONS
  Technical success was dependent on ERCP degree of difficulty, but complications were not. Outcome data that incorporate degree of difficulty information may be more meaningful, allowing endoscopist-to-endoscopist and center-to-center comparisons.
authors.affiliation: Department of Gastroenterology and Radiology, Wilford Hall Medical Center, San Antonio, Texas, USA.
authors.forename: S M
authors.initials: SM
authors.lastname: Schutz
authors.forename: R M
authors.initials: RM
authors.lastname: Abbott
mesh_terms: D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000145:classification*; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D010865:Pilot Projects; D011446:Prospective Studies; D012189:Retrospective Studies; D018570:Risk Assessment