ESGE Recommendations for Quality Control in Gastrointestinal Endoscopy: Guidelines for Image Documentation in Upper and Lower GI Endoscopy

Rationale

The demand for quality control in endoscopic procedures is gaining force in most European countries, and this justifies the preparation of good practice guidelines for such procedures.

In any endoscopic procedure, the following questions should be asked:

Has there been a complete exploration of the relevant section of the digestive tract (the esophagus, stomach and upper duodenum, the full length of the colon or rectum, and the full length of the sigmoid (in flexible sig-moidoscopy)? If the exploration has been incomplete, what is the reason for this? Is there an anatomical justification for it (stenosis, etc.)? Was the patient unable to tolerate the examination (colonoscopy and pain without sedation)? Was the digestive tract not empty (food in the stomach, bowel insufficiently prepared)? If the procedure is classified as negative, is the negative finding reliable? If there is a positive finding, is the morphological description of the lesion reliable?

The demand for quality control is of course growing among academic teams involved in the training of young endoscopists, but it is also a matter of concern for experienced endoscopists, for the following reasons:

Patients expect to receive and in accordance with national legal requirements, to sign a form providing their informed consent to the procedure, and they consequently require more precise information beforehand. Gastrointestinal assistants and other colleagues concerned in the care of the patient also require such information. Health-care providers, whether these are public health systems or insurance companies, require at the very least proof that the procedure has been performed and performed in a satisfactory manner. In many countries, there is already a trend toward requesting proof of completeness of a colonoscopy in relation to the reimbursement of fees. There is no doubt that recorded images are the only way of proving the completeness of a colonos-copy procedure or the length of the segment of sigmoid explored during flexible sigmoidoscopy The trend toward an increased number of legal actions being brought after interventional procedures in itself already justifies the need for the operator to collect some objective evidence of his or her performance during an endoscopic procedure.

In the past, the series of films taken during barium radiography of the stomach or colon was maintained in the patient's file and made available for interpretation by other practitioners. However, the use of gastrointestinal endoscopy has spread in most countries without any guidelines being prepared for a systematic list of images suitable for the procedure. Video recordings have often been made in Western countries, but these have focused on images of a detected lesion or the various steps of a therapeutic procedure, without being related to systematic recording of all procedures (including negative ones). However, in Japan, the practice of recording images has developed following a rigorous method: first with gastrocamera exploration, and then with fiberoptic and video electronic endoscopy. Some 20-40 images are collected for an upper gastrointestinal endoscopy. Nowadays, keeping records of endoscopic images is easy using a video printer, but direct capture on the computer hardware linked to the processor is also possible, allowing classification of images and patients, as well as allowing images to be included in the patient's records. Endoscopists must get back into the habit of recording images using a systematic protocol. Printing out large numbers of photos could give rise to financial difficulties and could become a source of further debate with health-care providers; a major advantage of storing digital images in the computer is that it can be done at no cost once the computer has been installed.

The objective of the European Society of Gastrointestinal Endoscopy (ESGE) is to promote this practice in European countries and to make the images available for communication to the patient or to the endoscopist's colleagues (general practitioners or surgeons). The ESGE is now recommending that a minimal checklist of images should be introduced into the code of good practice; this list is being mailed to all European endoscopy societies, and the ESGE is requesting the boards of the national societies to promote the communication of these recommendations to their members.