ESGE and its publications

Significant variability in the technical performance of gastrointestinal (GI) endoscopy, overuse of endoscopy for surveillance, an underuse of more advanced endoscopic interventions, such as endoscopic submucosal dissection or endoscopic ultrasound-guided biliary drainage, are only a few of the challenges that the European Society of Gastrointestinal Endoscopy (ESGE) has sought to address through society publications. Over the past decade, ESGE has developed a rigorous, evidence-based, and reproducible standard for ESGE publications. ESGE is an amalgam of 41 national gastroenterology/endoscopy member societies; thus, ESGE publications must be of sufficiently high quality to be either directly accepted as the equivalent to the local standards of our member societies or to influence the local standard of care and thereby standardize practice within our large and diverse ESGE community.

ESGE has strived to advance and improve the methodology of its publications to keep up with the technological advancements and innovations in GI endoscopy. For example, when the ESGE Guideline Committee was first established, its focus was exclusively on producing clinical guidelines as guidance on whether and when GI endoscopy was indicated. Later, quality standards in endoscopy were introduced and a more rigorous methodology for ESGE publications was created. Most recently, technology innovations, such as bariatric endoscopy, third-space endoscopy, and therapeutic endoscopic ultrasound, have resulted in additional training challenges for advanced endoscopy procedures; thus, ESGE has created procedure-specific curricula.

Today, ESGE publications cover the entire spectrum of guidance and training in GI endoscopy ([Fig. 1]), addressing the following fundamental questions.

Fig. 1 European Society of Gastrointestinal Endoscopy (ESGE) publications on the ESGE website.

1. When is an endoscopic diagnostic evaluation and/or therapeutic intervention recommended?

2. What is the level of competence required for the endoscopist undertaking such intervention(s)?

3. How can we train an endoscopist to achieve such a level of competence?

4. How can we measure and improve quality of GI endoscopy performance?

These questions deserve to be addressed by specific methodologies for two main reasons: 1) the amount of published high level evidence is much lower for the level of competence and training required for endoscopic procedures than for clinically oriented issues; and 2) the output of such information has been primarily qualitative in the case of clinical recommendations (to do vs. not to do endoscopy) and quantitative for defining the level of endoscopist competence required and its acquisition. Thus, ESGE publications are currently divided into 1) clinical guidelines, 2) performance (quality) measures, and 3) curricula.

Clinical guidelines

The ESGE Guideline Committee was set up to develop documents providing guidance to endoscopists. Moreover, ESGE develops Cascade Guidelines to adapt ESGE guidelines for use in developing countries [1]. The first ESGE guidelines were based on anecdotal observational evidence. Following the adoption of more rigorous guideline methodology, ESGE guidelines are now based on an evidence-based approach using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE), which aim to weigh the benefits and harm of any possible endoscopic intervention [2]. Owing to the hierarchy between controlled and observational studies, most endoscopic interventions that are relevant in the preventive and clinical fields are nowadays often supported by randomized studies [1] [3]. Thus, there has been an improvement between the quality of evidence and the level of certainty of ESGE recommendations. This represents a remarkable difference from the past and is in the best interest not only of our members but also of patients undergoing an endoscopic procedure.

One of the main pitfalls of evidence-based guidelines is the time lag between new evidence and the update of a guideline. ESGE updates each guideline every 5 years. However, new evidence that may alter the recommendations and/or the level of certainty of one or more recommendations may become available during this interval period. Thus, ESGE has adopted a modular platform that will allow guidelines to be updated using an easily accessible application, ensuring continuous provision of up-to-date guidance. This is in line with the approach taken by other scientific societies, such as the World Health Organization during the COVID-19 pandemic.

Quality measures

The inverse relationship between the neoplasia detection rate and the risk of post-colonoscopy interval colorectal cancer forced the endoscopy community to accept an association between technical factors of colonoscopy and clinical outcomes of patients. Such technical factors were primarily related to the competence of the operator and the organization of the endoscopy service. Thus, the ESGE Quality Improvement Committee was launched with the aim of producing publications that provide a definition of the minimum level of competence required for both diagnostic and interventional endoscopic procedures (including colonoscopy), and for discriminating between a minimum and desirable level of operator competence [4]. Moreover, the ESGE Quality Improvement Committee also set the minimum levels required for the endoscopy unit itself, as well as developing and launching an interactive tool to measure key performance indicators for endoscopic procedures. These publications on quality in endoscopy have generated an impressive number of educational events and quality assurance programs that distinctly characterize the evolution of GI endoscopy over the past 20 years.

Curricula

Despite the availability of GI endoscopy training programs in all member society countries, ESGE was compelled to develop more specific curricula for training in advanced endoscopy procedures [5]. These advanced techniques require more structured, long-lasting training programs involving animal laboratories, simulation models, observation of an expert(s), initial training under expert supervision, and finally autonomy. These documents are being produced by the ESGE Curricula Working Group.

What is common across all these ESGE publication methodologies is technical orientation, meaning the role of endoscopy in the management of a specific disease, mainly addressing the fields of upper, lower, and pancreaticobiliary endoscopy. This allows a synergistic interaction across the documents as all have the same goal: to generate a core of knowledge for each endoscopy technique that should drive the performance of each individual endoscopist to improve patient outcomes.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Hassan C, Aabakken L, Ebigbo A. et al. Partnership with African countries: European Society of Gastrointestinal Endoscopy (ESGE) – Position Statement. Endosc Int Open 2018; 06: E1247-E1255
• 2 Hassan C, Ponchon T, Bisschops R. et al. European Society of Gastrointestinal Endoscopy (ESGE) Publications Policy – Update 2020. Endoscopy 2020; 52: 123-126 DOI: 10.1055/a-1067-4657. (PMID: 31847009)
• 3 Bretthauer M, Løberg M, Wieszczy P. et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med 2022; 387: 1547-1556 DOI: 10.1056/NEJMoa2208375. (PMID: 36214590)
• 4 Rutter MD, Senore C, Bisschops R. et al. The European Society of Gastrointestinal Endoscopy Quality Improvement Initiative: developing performance measures. Endoscopy 2016; 48: 81-89 DOI: 10.1055/s-0035-1569580. (PMID: 26662057)
• 5 Dekker E, Houwen BBSL, Puig I. et al. Curriculum for optical diagnosis training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2020; 52: 899-923

Publication History

Article published online:
30 January 2024