Background
EPD is vital for quality control and communication between providers, patients, and family members. Effective EPD can prevent repeat endoscopies and can be useful for medicolegal needs. Multiple societies including the European Society of Gastrointestinal Endoscopy (ESGE) have recommendations to standardize EPD. We examined the role of EPD education in improvement of endoscopic image documentation by gastroenterology fellows.

Methods
We performed a retrospective observational study over a four-month period (July to October 2023). Endoscopic images and landmarks were reviewed for Esophagogastroduodenoscopy (EGD) and colonoscopy examinations performed over 2-months PRE education. Subsequently, all nine fellows were educated on endoscopic photo documentation as per ESGE 2012 and 2016 guidelines. Reference cards with images were distributed and posted on monitor screens in all procedure rooms. A review of procedures was conducted over 2 months POST education.
10 EGD image landmarks as per 2016 ESGE recommendations and 9 colonoscopy as per 2012 ESGE recommendations were included (Tables 1 and 2).
The mean number of total images and each image landmark was analyzed using Welch’s t-test between PRE and POST education. A p value <0.05 was significant. Aborted and any other gastrointestinal procedures were excluded.
Results
A total of 1,527 procedures were analyzed. 520 EGD procedures were analyzed (250 PRE education and 270 POST education). The mean total number of images obtained was statistically significant (PRE 10.16 + 3.79 vs POST 11.59 + 3.76, p-value 0.0001)
All but two of the 10 image categories for EGD showed statistically significant improvement between PRE and POST analysis. These included Z-line (0.73 + 0.44 vs 0.74 + 0.43, p value 0.74) and Cardia/fundus on retroflexed view (0.71+ 0.45 vs 0.78+ 0.41, p value 0.06) respectively.
781 colonoscopy procedures were analyzed (339 PRE education and 442 POST education). The mean total number of images obtained was statistically significant (PRE 10.82 + 4.15 vs POST 12.69 + 4.50, p value 0.0001). All but two image categories had a statistically significant improvement between PRE and POST analysis. This included cecum and appendiceal orifice (0.81 + 0.39 vs 0.80 + 0.39, p value 0.85) and Lower part of rectum in retroflexion (0.81 + 0.39 vs 0.79 + 0.40, p value 0.67).
Conclusion
Our findings suggest that education on EPD is an effective measure to exercise quality control in endoscopy. The lack of improvement in the four respective image categories can be attributed to the distinct appearance, baseline sufficient education and clinical importance of these landmarks. Limitations of our study include single center study, potential of intervention bias and small sample size. Future directions include cost benefit and patient care outcome analysis because of effective endoscopic photo documentation.

Farhan Mohiuddin

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