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Research
Standardising assessment and documentation of pouchoscopy
  1. Valerie Annerijn van der Ploeg,
  2. Yasuko Maeda,
  3. Omar D Faiz,
  4. Ailsa L Hart,
  5. Susan K Clark
  1. Department of Surgery, St Mark’s Hospital, Harrow, UK
  1. Correspondence to Susan K Clark, Department of Surgery, St. Mark’s Hospital, London HA1 3UJ, UK; s.clark8{at}nhs.net

Abstract

Background/aims Variation in quality of reporting on endoscopic procedures is a common clinical problem. Findings are not documented in a standardised manner and there is a tendency towards reporting abnormal findings only. This study aimed to review quality of flexible pouchoscopy reports and to develop a standardised reporting template.

Methods Ileo-anal-pouch experts (n=5) compiled a list of items that should be documented at flexible pouchoscopy. Reports were reviewed retrospectively for their completeness compared with the template. The template was then introduced and quality of reports was analysed prospectively.

Results One hundred and twenty-one reports produced between March 2015 and June 2015 were reviewed. Between August 2015 and November 2015, the template was introduced and reports were analysed. There was significant improvement in documentation of anus and perianal area (before template (B) 12% to after template (A) 51%, p<0.0001), rectal cuff (B: 55% to A: 75%, p=0.01), pouch-anal anastomosis (B: 37% to A: 67%, p=0.0002) and pouch inlet (B: 13% to A: 41%, p<0.0001). Pouch body was described in high percentage regardless of introduction of the template (B: 98% to A: 97%, p=0.61).

Conclusions Documentation of pouchoscopy findings was suboptimal and introduction of a template improved documentation of flexible pouchoscopy significantly.

  • pouchoscopy
  • ileoanal pouch
  • pouchitis

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Footnotes

  • Contributors VAvdP performed and managed the study, collected and analysed the data, wrote the paper and submitted the study. YM assisted with performing the study, analysing the data and writing the paper. ODF, ALH and SKC were the clinical experts and contributed to the design of the study, the content of the pouchoscopy reporting template and revised the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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