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Photographic Documentation during Diagnostic and Operative Colonoscopy: Why and How

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    Colonoscopy is regarded as the ‘gold standard’ in colorectal cancer screening, nonetheless it is not an infallible test, since the literature highlights the risk of “interval cancers”, i.e. any colorectal cancer diagnosed within 3 to 5 years of a previously “negative” colonoscopy. Hence the need to accurately document the endoscopic procedure, not only describing the different findings in the endoscopic report, but also with the aid of endoscopic images or video recording.

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    A recent report from Douglas Rex describes a case of a patient submitted to a total colonoscopy which detected two small polyps in the transverse colon. During the index colonoscopy, both the polyps and the cecum and the rectal retrovision had been photographically documented.

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    A subsequent colonoscopy performed 5 years later again showed two small sessile polyps in the sigmoid colon, while the remaining segments showed no abnormality.

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    A further follow-up examination 5 years later showed a normal colonoscopy except for the presence of a 2 cm ulcerated lesion located adjacent to the dentate line, an area in which the previous photographic documentation ruled out any lesion. Given the accurate documentation obtained at previous examinations, the author was able to exclude the possibility of an interval cancer, highlighting the pivotal role of a systematic and accurate documentation of the endoscopic procedures.

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    During the colonoscopy, the endoscopist should perform a punctual description of the procedure and take pictures in the various segments explored, both in case of normal and pathological colon.

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    In particular, a colon can be described as “normal” in the endoscopic report only if the exploration is complete and devoid of any disease. Otherwise, all the abnormalities of the lumen, its content, the mucosal surface, the presence of protruding or non-protruding lesions, diffuse or localized, should be photographically documented in addition to an accurate description.

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    The contribution of the endoscopic images to the endoscopic description is self-evident.

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    The standard landmarks that the endoscopist should photographically document are recommended by the ESGE. Besides, the endoscopic report will document the lesions(s) detected and their location

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    The scheme of photo-documentation recommended by the ESGE is summarized in the slide

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    This a model of an endoscopic report form including data of the patient, the endoscopic procedure, photos and video recordings.

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    It is essential that the report allows to link the image(s) to the presumed site of the lesion within the explored colon.

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    Beside description of the endoscopic findings, in case of detection of a lesion along the colon, the operator should express his/her opinion regarding the indication to endoscopic or surgical treatment.

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    In the first case, if the therapeutic maneuver is simultaneously performed, it should be photographically documented in its procedural steps, including possible adverse events. If the endoscopist chooses to delay the therapeutic procedure, the lesion should be documented in details.

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    Should the endoscopist deem the lesion fit for surgery, he/she will precisely indicate the site, and will proceed to mark the healthy mucosa distal to the lesion with carbon particles or india ink. Sometimes, in view of a possible laparoscopic approach, it may be useful to position metal clips that can be fluoroscopically located to orient he surgeon to the abdominal quadrant involved. The drawback of clip application is the risk of their distal dislodgement from the mucosa, with inappropriate resection. To obviate this risk, the endoscopist should always place two or three clips, ideally on a mucosal fold.

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    The use of routine photography, and of high quality videotaping, during diagnostic and therapeutic colonoscopies, witnesses the accuracy of the procedure and reduces medical-legal risk (D. Rex)