The Toronto Upper Gastrointestinal Cleaning Score: a prospective validation study

Abstract

Background and aims: Assessment of mucosal visualization during esophagogastroduodenoscopy (EGD) can be improved with a standardized scoring system. To address this gap, we created the Toronto Upper Gastrointestinal Cleaning Score (TUGCS). Methods: We developed the TUGCS using Delphi methodology, whereby an international group of endoscopy experts iteratively rated their agreement with proposed TUGCS items and anchors on a 5-point Likert scale. After each Delphi round, we analyzed responses and refined the TUGCS using an 80% agreement threshold for consensus. We used the intra-class correlation coefficient (ICC) to assess inter-rater and test-retest reliability. We assessed internal consistency with Cronbach’s alpha and item-total and inter-item correlations with Pearson’s Correlation Coefficient. We compared TUGCS ratings with an independent endoscopist’s global rating of mucosal visualization using Spearman’s rho. Results: We achieved consensus with 14 Delphi participants after three Delphi rounds. Inter-rater reliability was high at 0.79 (95% CI [0.64-0.88]). Test-retest reliability was excellent at 0.83 (95% CI [0.77-0.87]). Cronbach’s α was 0.81, item-total correlations ranged from 0.52-0.69, and inter-item correlations ranged from 0.38-0.74. There was a positive correlation between TUGCS ratings and a global rating of visualization (r = 0.41, p=0.002). TUGCS ratings for EGDs with global ratings of excellent were significantly higher than EGDs with global ratings of fair (p=0.010). Conclusion: The TUGCS has strong evidence of validity in the clinical setting. The international group of assessors, broad variety of EGD indications, and minimal assessor training improves generalizability and potential for dissemination.

Global trends in training and credentialing guidelines for gastrointestinal endoscopy: a systematic review

“…In contrast to colonoscopy and ERCP, EGD has sparse data on clinically relevant KPIs, with the duodenal (D2) intubation rate being the only consistent indicator in most guidelines 3 16 20 28 . Moving forward, credentialing guidelines may consider the addition of measures such as EGD duration 38 and mucosal visualization 39 , akin to withdrawal time and bowel preparation in colonoscopy respectively, which are being explored for their relevance to clinical outcomes.…”

“…In contrast to colonoscopy and ERCP, EGD has sparse data on clinically relevant KPIs, with the duodenal (D2) intubation rate being the only consistent indicator in most guidelines [3,16,20,28]. Moving forward, credentialing guidelines may consider the addition of measures such as EGD duration [38] and mucosal visualization [39], akin to withdrawal time and bowel preparation in colonoscopy respectively, which are being explored for their relevance to clinical outcomes. The JAG, NZCCRTGE, CCRTGE, and ESGE recommended the use of validated observational assessment tools in addition to procedural volume and KPIs [16,17,30,31], wherein an endoscopist is observed and graded on a set of items specific to the procedure by an expert assessor.…”

Current status of quality control in screening esophagogastroduodenoscopy and the emerging role of artificial intelligence

“…21,32 The visualization of the esophagus, stomach, and duodenum should be evaluated using verified scales, such as the Toronto Upper Gastrointestinal Cleaning Score, which assesses bubbles, blood, mucus or other contents, and the need for washing during observation. [65][66][67][68] Adequate mucosal visibility is essential for ensuring high-quality examination.…”

The Approach to Performance of Quality Upper Endoscopy in Lynch Syndrome (QUELS)

“…The utility of using any mucosal visualization scoring scales, such as the Toronto Upper Gastrointestinal Cleaning Score (TUGCS), a newly validated scoring system, has not been proven. 20 Virtual or traditional chromoendoscopy should be used for interrogation of focal abnormalities detected on EGD. It is optimal that superficial neoplastic lesions in the stomach and duodenum are described using the Paris classification.…”

“…19 We suggest the quality of visualization should be reported for the esophagus, stomach, and duodenum and recommend inadequate visualization of any organ be specifically reported. The utility of using any mucosal visualization scoring scales, such as the Toronto Upper Gastrointestinal Cleaning Score (TUGCS), a newly validated scoring system, has not been proven 20. Virtual or traditional chromoendoscopy should be used for interrogation of focal abnormalities detected on EGD.…”