Elsevier

Gastrointestinal Endoscopy

Volume 44, Issue 3, September 1996, Pages 243-248
Gastrointestinal Endoscopy

Photodocumentation of total colonoscopy: how successful are endoscopists? Do reviewers agree?,☆☆,

https://doi.org/10.1016/S0016-5107(96)70159-1Get rights and content

Abstract

Background: Documentation of total colonoscopy usually rests on a statement in the endoscopy report indicating that cecal landmarks were visualized. We sought to determine whether providing photographs of cecal landmarks provided an objective marker of complete colonoscopy.

Methods: We had 12 outside experienced endoscopists review 120 photographs of cecal landmarks that had been included with colonoscopy reports from our center that included 20 consecutive cases of reported total colonoscopy from each of 6 endoscopists. Reviewers graded whether they believed each set of photographs documented that at least the cecal inlet was reached as definite, probable, or uncertain.

Results: There was considerable disparity among reviewers as to whether individual photographs documented total colonoscopy. The frequency of combined, definite, and probable scores that they gave for the 120 photographs ranged from 97% down to 44% (median 82%). Different endoscopists also seemed to be variably successful in photodocumenting total colonoscopy. Four of the endoscopists received definite and probable scores for their 20 cases at least 80% of the time (86% for the highest ranked endoscopist). The lowest ranked endoscopist received such scores just 64% of the time.

Conclusions: Documenting total colonoscopy with static images of cecal landmarks is only partially successful as an objective measure of the extent of total colonoscopy. (Gastrointest Endosc 1996;44:243-8.)

Section snippets

MATERIALS AND METHODS

We had 12 outside experienced gastroenterologists-endoscopists, half in academic practice and half in private practice, review 120 photographs of cecal landmarks obtained from procedures done between July and October of 1994 that had been included with reports from our Endoscopy Center at the University of Missouri Hospital and Clinics. These included 20 consecutive cases of total colonoscopy from each of five gastroenterologists and one surgeon who regularly used our facilities. The 6

Success of the endoscopists in documenting total colonoscopy

Table 1 shows the cecal landmark views provided by the 6 endoscopists for their 20 consecutive cases and the mean number of views per photograph. The table also shows a summary of the scores they were given for their 20 cases as provided by the 12 reviewers, including the mean score, the frequency of “definite” scores, and the frequency of combined “definite” and “probable” scores (Fig. 2).

. Definite and probable scores (%) for each of the endoscopists (computed for each endoscopist based on the

DISCUSSION

With a barium contrast study of the colon, x-ray films are obtained that provide a permanent objective marker of the extent of the examination. In contrast, documentation that total colonoscopy was performed (i.e., cecum reached) usually rests on a statement in the endoscopy report that cecal landmarks were visualized.

High-quality videoendoscopic images and image management systems are now widely in use that give endoscopists the ability to photodocument pathologic lesions identified during the

Acknowledgements

The authors thank John Hewett, PhD, and Jane Johnson, MA, for statistical support.

References (11)

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    It is expected that endoscopists should be able to intubate the cecum in ≥90% of cases and in ≥95% of patients presenting for screening colonoscopy.35-37 Although differences exist in interpretation of photo documentation of complete colonoscopy among endoscopists,38,39 photo documentation of the cecal landmarks is a quality indicator that should be expected in each colonoscopy report. Reaching and examining the cecum ensures examination of the proximal colon, where a substantial fraction of colorectal neoplasms are located.40,41

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    This discrepancy may be related to the opinion of some endoscopists that a landmark photo has no additional clinical benefit. Studies have in addition showed that reviewers may disagree whether a photograph is representing the cecum.17,18 Apart from cecal intubation, the quality of a colonoscopy depends on the quality of bowel preparation.

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    However, the ASGE concedes that cecal photography “may not be convincing in all cases.” The unreliability of cecal landmarks to document the extent of colonic examination is corroborated by prospective studies.3,4 We prospectively demonstrated that TI photography was an effective means of documenting total colonoscopy.

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    This possibility of bias is inherent in these types of studies, because it is impractical to have a second confirmatory colleague present for the procedure. Still photography is not perfect at allowing later confirmation of cecal intubation.24,25 Although photography was frequently used during our procedures, this was not a requirement, because photodocumentation is a poor criterion standard.

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From the Division of Gastroenterology, University of Missouri School of Medicine, Columbia, Missouri.

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Reprint requests: John B. Marshall, MD, Gastroenterology, MA 421, University of Missouri School of Medicine, Columbia, MO 65212.

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