The Gastroscopy RAte of Cleanliness Evaluation (GRACE) Scale: an international reliability and validation study

Gianluca Esposito, Emanuele Dilaghi, Cristina Costa-Santos, GRACE Investigators, Irene Ligato, Bruno Annibale, Mario Dinis-Ribeiro, Miguel Areia, Vitor N. Arantes, Jacques Bergman, Raf Bisschops, Pieter J. . F. de Jonge, Francesco Di Matteo, Alanna Ebigbo, Monika Ferlitsch, Vanja Giljaca, Cesare Hassan, Tomas Hucl, Roman Kuvaev, Philippe LeclercqTamara Matysiak-Budnik, Yuichi Mori, Alan Moss, Enrique Perez-Cuadrado-Robles, Roos E. Pouw, Douglas K. Rex, Enrique Rodriguez de Santiago, Peter D. Siersema, Tony C. Tham, Konstantinos Triantafyllou, Andrei Voiosu, Bas Weusten, Gianluca Andrisani, Stefano Angeletti, Mousa Ayoub, Simon Bac, Kirsten Boonstra, Nienke Borren, Antonio Capogreco, Irene Chivato Martin Falquina, Jessica Chaves, Nicolo Citterio, Arianna Dal Buono, Elisabetta Dell'Unto, Victor Dragan, Luis Elvas, Ksenia Filimendikova, Adrian Frick, John Guardiola, Berrie Meijer, Steffi van de Ven

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Abstract

Background Muco sal visualization during upper gastrointestinal (UGI) endoscopy can be impaired by the presence of foam, bubbles, and mucus. Some UGI endoscopy visibility scales have been proposed but have not undergone multicenter validation. This study aimed to develop and validate the Gastroscopy RAte of Cleanliness Evaluation (GRACE) scale. Methods A multicenter, international, cross-sectional study was conducted. The GRACE scale is based on a score from 0 (worst) to 3 (excellent) for esophagus, stomach, and duodenum, for a total ranging from 0 to 9. In phase 1, four expert endoscopists evaluated 60 images twice, with a 2week interval between rounds; in phase 2, the same 60 images were scored twice by one expert and one nonexpert endoscopist from 27 endoscopy departments worldwide. For reproducibility assessment and real-time validation, the scale was applied to consecutive patients undergoing gastroscopy at each center. Results On internal validation, interobserver agreement was 0.81 (95 %CI 0.73-0.87) and 0.80 (95 %CI 0.72-0.86), with reliability of 0.73 (95 %CI 0.63-0.82) and 0.72 (95 %CI 0.63-0.81), in the two rounds, respectively. On external validation, overall interobserver agreement was 0.85 (95 %CI 0.82-0.88) and reliability was 0.79 (95 %CI 0.73-0.84). In real-time evaluation, the overall proportion of correct classifications was 0.80 (95 %CI 0.77-0.82). Conclusions The GRACE scale showed good interobserver agreement, reliability, and validity. The widespread use of this scale could enhance quality and standardize the assessment of muco sal cleanliness during UGI endoscopy, pushing endoscopists to strive for excellent visibility and reducing the risk of missed lesions.
Original languageEnglish
Number of pages9
JournalEndoscopy
DOIs
Publication statusE-pub ahead of print - 8 Nov 2024

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