Minimal standard terminology for digestive endoscopy: results of prospective testing and validation in the GASTER project.

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 6,232 reports were analyzed, including 3,447 gastroscopies, 1,743 colonoscopies, and 1,042 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.