Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.
Faculty of Medicine, University of Basel, Basel, Switzerland.
J Crohns Colitis. 2021 Jul 5;15(7):1089-1105. doi: 10.1093/ecco-jcc/jjab011.
Diagnosis and management of inflammatory bowel diseases [IBD] requires a lifelong multidisciplinary approach. The quality of medical reporting is crucial in this context. The present topical review addresses the need for optimised reporting in endoscopy, surgery, and histopathology.
A consensus expert panel consisting of gastroenterologists, surgeons, and pathologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. The following topics were covered: in endoscopy: [i] general IBD endoscopy; [ii] disease activity and surveillance; [iii] endoscopy treatment in IBD; in surgery: [iv] medical history with surgical relevance, surgical indication, and strategy; [v] operative approach; [vi] intraoperative disease description; [vii] operative steps; in pathology: [viii] macroscopic assessment and interpretation of resection specimens; [ix] IBD histology, including biopsies, surgical resections, and neoplasia; [x] IBD histology conclusion and report. Statements were developed using a Delphi methodology incorporating two consecutive rounds. Current practice positions were set when ≥ 80% of participants agreed on a recommendation.
Thirty practice positions established a standard terminology for optimal reporting in endoscopy, surgery, and histopathology. Assessment of disease activity, surveillance recommendations, advice to surgeons for operative indication and strategies, including margins and extent of resection, and diagnostic criteria of IBD, as well as guidance for the interpretation of dysplasia and cancer, were handled. A standardised report including a core set of items to include in each specialty report, was defined.
Interdisciplinary high-quality care requires thorough and standardised reporting across specialties. This topical review offers an actionable framework and practice recommendations to optimise reporting in endoscopy, surgery, and histopathology.
炎症性肠病（IBD）的诊断和治疗需要终身多学科方法。在这种情况下，医学报告的质量至关重要。本专题述评旨在探讨内镜、手术和组织病理学报告中优化报告的必要性。
由欧洲克罗恩病和结肠炎组织召集的一个由胃肠病学家、外科医生和病理学家组成的共识专家小组，对文献进行了系统回顾。涵盖了以下主题：内镜方面：[i]一般 IBD 内镜检查；[ii]疾病活动度和监测；[iii]IBD 的内镜治疗；手术方面：[iv]具有手术相关性的病史、手术适应证和策略；[v]手术方法；[vi]术中疾病描述；[vii]手术步骤；组织病理学方面：[viii]切除标本的大体评估和解释；[ix]IBD 组织学，包括活检、手术切除和肿瘤；[x]IBD 组织学结论和报告。陈述的制定采用德尔菲法，包括两轮连续投票。当≥80%的参与者对建议达成一致时，就会确定当前的实践立场。
30 项实践立场为内镜、手术和组织病理学的最佳报告制定了标准术语。评估疾病活动度、监测建议、为手术适应证和策略提供给外科医生的建议，包括边缘和切除范围，以及 IBD 的诊断标准，以及对发育不良和癌症的解释指导，都得到了处理。定义了一个标准化报告，包括在每个专业报告中包含的核心项目集。
跨专业的高质量护理需要在各专业领域进行全面和标准化的报告。本专题述评提供了一个可操作的框架和实践建议，以优化内镜、手术和组织病理学的报告。
