The Gastroscopy RAte of Cleanliness Evaluation (GRACE) scale: an international reliability and validation study
Esposito, Gianluca Dilaghi, Emanuele Costa-Santos, Cristina Ligato, Irene Annibale, Bruno Dinis-Ribeiro, Mário Areia, Miguel
Esposito, Gianluca
Dilaghi, Emanuele
Costa-Santos, Cristina
Ligato, Irene
Annibale, Bruno
Dinis-Ribeiro, Mário
Areia, Miguel
Abstract
Background: Mucosal 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 2-week 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 mucosal cleanliness during UGI endoscopy, pushing endoscopists to strive for excellent visibility and reducing the risk of missed lesions.
MIDER Authors
Affiliations
Sapienza University of Rome; University of Porto; Portuguese Oncology Institute of Porto; Portuguese Oncology Institute of Coimbra; Mater Dei Contorno Hospital; University of Amsterdam; UZ Leuven; TARGID KU Leuven; University Medical Center Rotterdam; Fondazione Policlinico Universitario Campus Bio-Medico; University Hospital Augsburg; Medical University of Vienna; University Hospitals Birmingham NHS Foundation Trust; IRCCS Humanitas Research Hospital; Institute for Clinical and Experimental Medicine, Prague; Yaroslavl Regional Cancer Hospital; University Hospital of Nantes; University of Oslo; Western Health, Melbourne; Georges-Pompidou European Hospital; Amsterdam University Medical Centers; Indiana University School of Medicine; Universidad de Alcalá; Radboud Institute for Health Sciences; Ulster Hospital; National and Kapodistrian University of Athens; Attikon University General Hospital; Colentina Clinical Hospital; University Medical Centre Utrecht; Carol Davila University of Medicine and Pharmacy; Hospital Universitario Infanta Elena; University Hospital Center; IMT School for Advanced Studies Lucca; Clinique MontLegia
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Date
2024-11-08
Type
Article
Subject
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Citation
Esposito G, Dilaghi E, Costa-Santos C, Ligato I, Annibale B, Dinis-Ribeiro M, Areia M; GRACE Investigators. The Gastroscopy RAte of Cleanliness Evaluation (GRACE) Scale: an international reliability and validation study. Endoscopy. 2025 Apr;57(4):312-320. doi: 10.1055/a-2422-0856. Epub 2024 Sep 25. Erratum in: Endoscopy. 2025 Apr;57(4):C2. doi: 10.1055/a-2545-0228