ORIGINAL ARTICLE: Clinical Endoscopy Grading the complexity of endoscopic procedures: results of an ASGE working party Peter B. Cotton, MD, FRCS, FRCP, Glenn Eisen, MD, MPH, Joseph Romagnuolo, MD, MScEpid, FRCPC, John Vargo, MD, MPH, Todd Baron, MD, Paul Tarnasky, MD, Steve Schutz, MD, Brian Jacobson, MD, MPH, Chris Bott, BS, Bret Petersen, MD Charleston, South Carolina; Portland, Oregon; Cleveland, Ohio; Rochester, Minnesota; Dallas, Texas; Boise, Idaho; Boston, Massachusetts, USA Background: Working parties of the American Society for Gastrointestinal Endoscopy (ASGE) Quality Commit- tee 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. ( Gastrointest Endosc 2011;73:868-74.) A working party of the American Society for Gastroin- testinal Endoscopy (ASGE) recently published a lexicon for defining and classifying adverse events and their se- verity. 1 This should facilitate the important task of stan- dardizing the reporting of “complication rates.” However, the authors recognized that some endoscopic procedures are more difficult and risky than others. As a result, reports of rates of adverse events cannot be interpreted or com- pared meaningfully unless the complexity spectrum of the procedures is known. Thus, a perforation rate for a series of upper endoscopies is uninterpretable unless it is known how many esophageal strictures were managed. Likewise, the pancreatitis rate after ERCP is markedly influenced by the precise clinical context, indication, and interventions performed or attempted. Recording the complexity spec- trum of an endoscopic series would allow rates of adverse events and procedural success to be presented in a mean- ingful way so that endoscopists performing more complex procedures do not appear to be more dangerous and/or less successful than their less adventurous peers. Schutz and Abbott 2 first addressed the complexity issue for ERCP and suggested a 5-point scale for “difficulty,” which has been used extensively in a simplified form. 3 Use of that scale in an analysis of data from 7 different centers confirmed that technical success rates were much higher in level 1 ERCP procedures. 4 Raganath et al 5 drew similar Abbreviation: ASGE, American Society for Gastrointestinal Endoscopy. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. See CME section; p. 1015 Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.12.036 Received November 5, 2010. December 29, 2010. Current affiliations: Medical University of South Carolina (P.B.C., J.R., C.B.), Charleston, South Carolina, Oregon Health Sciences University (G.E.), Portland, Oregon, Cleveland Clinic Foundation (J.V.), Cleveland, Ohio, Mayo Clinic (T.B., B.P.), Rochester, Minnesota, Digestive Health Associates of Texas (P.T.), Dallas, Texas, Boise Digestive Health Clinic (S.S.), Boise, Idaho, Boston University Medical Center (B.J.), Boston, Massachusetts, USA. Reprint requests: Peter B. Cotton, MD, FRCP, FRCS, Digestive Disease Center, Medical University of South Carolina, 25 Courtenay, ART 7100A, MSC 290, Charleston, SC 29425-2900. If you would like to chat with an author of this article, you may contact Dr. Cotton at cottonp@musc.edu. 868 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 5 : 2011 www.giejournal.org