Background and Study Aims: Standardization of the endoscopic report is a key issue
for future research in the field of digestive endoscopy. The Minimal Standard Terminology
(MST) has been proposed by the European Society for Gastrointestinal Endoscopy (ESGE)
as a structured language for production of computerized endoscopic reports. The aim
of this study was to validate version 1.0 of this terminology prospectively, by collecting
cases in a multicenter, multilingual trial.
Methods: Endoscopic cases (esophagogastroduodenoscopy [EGD], colonoscopy, endoscopic
retrograde cholangiopancreatography [ERCP]) were prospectively collected in nine university
hospitals in Europe, using the same software. Reports were produced in the local language,
but the software allowed comparison of reports between languages, and global analysis
of the database. Outcome measures were the adequacy of terms proposed in the MST to
describe “reasons for performing an endoscopy”, “findings”, and “endoscopic diagnoses”,
frequency of use and content of free-text fields, and types of lesions described.
Results: A total of 6232 reports were analyzed, including 3447 gastroscopies, 1743
colonoscopies, and 1042 ERCPs. Overall, terms originally contained in the MST were
adequate to describe fully 91.0 % of all examinations where “reasons for endoscopy”
were described, 99.5 % of examinations where “findings” were described, 95.8 % of
all examinations containing descriptions of “endoscopic diagnosis”, 98.9 % of examinations
containing descriptions of “additional diagnostic procedures”, and 94.8 % of examinations
containing descriptions of “additional therapeutic procedures”. Free-text fields were
only used in the other cases (less than 5 % of cases in average).
Conclusions: The MST appeared adequate to cover a large part of routine endoscopy
reports, and could thus be used as a tool for standardization of endoscopic reports
in clinical practice. The latter could be significantly improved by the use of a structured
and standardized terminology for the production of endoscopic reports.
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M.D. M. Delvaux
Gastroenterology Unit CHU Rangueil
31403 Toulouse Cédex 04
France
Telefon: + 33-561-322229
eMail: 106521.3337@compuserve.com
