Objective Clinical guidelines provide evidence-based recommendations on common bile duct (CBD) stone management, though there is little guidance on best practice for sphincterotomy or X-ray acquisitions. Little is known about adherence to these guidelines. Design/method A national survey was distributed to endoscopic retrograde cholangiopancreatography (ERCP) practitioners (British Society of Gastroenterology (BSG) Endoscopy Quality Improvement Programme). Responses to four clinical scenarios were graded as correct or incorrect in relation to guidelines. These related to the decision to proceed to ERCP based on initial imaging (question 1), management of large CBD stones (question 2), irretrievable stones (question 3) and prophylactic pancreatic duct stent placement (question 4). Adherence to guidelines was evaluated according to practitioner characteristics. Variation in sphincterotomy technique and intraprocedural imaging was analysed. Results Responses were received from 389 ERCP practitioners (74% response rate). Most were consultant physicians (84%), 37% aged >= 55 years and 4% female. Endoscopic ultrasound (EUS) was performed by 31%. Regular attendance at >= 2 ERCP-related continued professional development (CPD) activities/year was reported by 58%. Responses aligned with BSG/European Society of Gastrointestinal Endoscopy guidelines in 90.3% (q1), 72.1% (q2), 89.7% (q3) and 75.8% (q4). Greater adherence was noted in q2 with physician specialty (p=0.002); in q3 in physicians (p=0.026) that practise EUS (p=0.006); in q4 in physicians (p<0.001), younger age (p<0.001), EUS practise (p<0.001), fewer years of experience (p=0.003) and more recent CPD attendance (p=0.003). Sphincterotomy size was most commonly based on papillary anatomy and stone size (57%). 58% described sphincterotomy size by the balloon that passes. Most captured an occlusion cholangiogram balloon-at-papilla image (92%), fewer routinely obtained control films (55%) or final postprocedure imaging (45%). Conclusion Despite broad alignment with core clinical guidelines, adherence is variable.

Background National root cause analysis of post-endoscopy upper gastrointestinal (UGI) cancer in England has found wide variations in UGI endoscopy quality. This guidance aims to provide a practical UGI endoscopy guide to improve procedural quality, optimise early malignant and pre-malignant lesion detection and common pathology managment. Methods An initial consensus document was drafted in 2023 by the Scottish National Endoscopy Training Programme. A Guidance Development Group including endoscopy academy and regional endoscopy leads, devolved nation, JAG, AUGIS and BSG representatives was subsequently convened to adapt the document for UK-wide use. Targeted literature reviews were undertaken to provide evidence where available and recommendations were refined through expert consensus. Results High quality UGI examination is facilitated by closed mouth local anaesthetic spray application and combined sedation with opioids and benzodiazepines when sedation is needed. Mucosal cleansing with Simethicone and N-Acetyl Cysteine is recommended. Systematic inspection is recommended during diagnostic UGI endoscopy: first full oesophageal assessment using both white light and digital chromoendoscopy (facilitates squamous neoplasia detection); then complete gastric examination with white light in retroflexion and antegrade, with virtual chromendoscopy for any focal abnormality; and finally duodenal examination. In Barrett's oesophagus, following mucosal cleansing and white light examination, virtual chromoendoscopy and acetic acid enhance dysplasia detection. When gastric atrophy or intestinal metaplasia are suspected, virtual chromoendoscopy with targeted biopsies, if a focal lesion is present, and Sydney protocol biopsies to establish the extent of atrophy/metaplasia are recommended. Conclusions Optimising mucosal visualisation through sedation when appropriate, mucosal cleansing and chromoendoscopy enhances recognition of pre-malignant and early maligant lesions in the oesophagus and stomach and is recommended.

Objective While capsule sponge testing for Barrett's surveillance has garnered increasing popularity, its ongoing use has been hindered by lack of long-term follow-up data. This study aims to analyse results of patients' subsequent follow-up with either upper gastrointestinal (UGI) endoscopy or repeat capsule sponge testing in the lower risk patient cohort undergoing Barrett's surveillance with capsule sponge testing within the CytoSCOT programme.Design/Method Patients with a previous capsule sponge test for Barrett's surveillance demonstrating trefoil factor 3 (TFF3) positivity or negativity only between 14 September 2020 and 31 December 2021 were highlighted from the national CytoSCOT database. Electronic records were analysed to compare endoscopic biopsy results and outcomes in those undergoing follow-up with endoscopy versus repeat capsule sponge testing (+/- subsequent UGI endoscopy). All insufficient tests with missing biomarker data were excluded.Results 680 patients were included. 330/680 (48.5%) had endoscopic follow-up only. 350/680 (51.5%) had repeat capsule sponge testing; 67 of these patients (19.1%) subsequently proceeded to endoscopy. Of the 397 patients with confirmatory endoscopic biopsies, the incidence rates of low-grade dysplasia, high-grade dysplasia, intramucosal adenocarcinoma and oesophageal adenocarcinoma were 3.6%, 1.8%, 0.3% and 0.3% within the endoscopy only cohort and 4.5%, 4.5%, 1.5% and 0% within the repeat capsule sponge test cohort, respectively. There were no significant differences in the rates of detection of dysplasia or cancer between the two cohorts.Conclusion While long-term follow-up results are promising for patients previously undergoing Barrett's surveillance with capsule sponge testing, further robust evidence is required to ensure dysplasia is not missed.

Objective In May 2021 we implemented a locally developed gastric ulcer protocol. Patients with low Edinburgh Gastric Ulcer Scores (EGUS) and benign biopsy results at index oesophagogastroduodenoscopy (OGD1) were recommended to not undergo follow-up OGD (OGD2). We aimed to validate the EGUS and identify any gastric cancer diagnoses since protocol adoption.Design Patients diagnosed with a gastric ulcer at OGD1 in NHS Lothian from 24 May 2021 to 24 June 2023 were identified. Data regarding the EGUS and biopsy rates were gathered and compared with the protocol. Electronic patient records were reviewed for subsequent diagnoses of gastric cancer.Results In total, 236 patients were diagnosed with a gastric ulcer; 9.7% (n=23) were diagnosed with gastric cancer at OGD1. The EGUS produced a negative predictive value of 95.7%. OGD2s were performed in 46.0% (n=98/213) of patients; in 61.2% (n=60/98) this was in accordance with the protocol. No new pathology was identified at follow-up for OGD2s performed contrary to the protocol (median follow-up time 22 months (IQR 17-27)). OGD2s were not performed in 54.0% (n=115/213) of patients; in 83.5% (n=96/115) this was in accordance with the protocol. At follow-up (median 22 months, IQR 17-29), there were no gastric cancer diagnoses in these patients.Results In total, 236 patients were diagnosed with a gastric ulcer; 9.7% (n=23) were diagnosed with gastric cancer at OGD1. The EGUS produced a negative predictive value of 95.7%. OGD2s were performed in 46.0% (n=98/213) of patients; in 61.2% (n=60/98) this was in accordance with the protocol. No new pathology was identified at follow-up for OGD2s performed contrary to the protocol (median follow-up time 22 months (IQR 17-27)). OGD2s were not performed in 54.0% (n=115/213) of patients; in 83.5% (n=96/115) this was in accordance with the protocol. At follow-up (median 22 months, IQR 17-29), there were no gastric cancer diagnoses in these patients.Results In total, 236 patients were diagnosed with a gastric ulcer; 9.7% (n=23) were diagnosed with gastric cancer at OGD1. The EGUS produced a negative predictive value of 95.7%. OGD2s were performed in 46.0% (n=98/213) of patients; in 61.2% (n=60/98) this was in accordance with the protocol. No new pathology was identified at follow-up for OGD2s performed contrary to the protocol (median follow-up time 22 months (IQR 17-27)). OGD2s were not performed in 54.0% (n=115/213) of patients; in 83.5% (n=96/115) this was in accordance with the protocol. At follow-up (median 22 months, IQR 17-29), there were no gastric cancer diagnoses in these patients.Conclusion The protocol is a safe and effective method to reduce the burden of repeat OGDs. Crucially, protocol adherence has demonstrated no missed gastric cancer diagnoses. Continued monitoring of patient outcomes is essential.

High quality Barrett's esophagus surveillance is crucial to detect early neoplastic changes. An esophageal cell collection device (OCCD) was introduced as a triage tool for Barrett's surveillance. This study aims to evaluate whether the Scottish OCCD program (CytoSCOT) has reduced delays to Barrett's surveillance, and whether delayed surveillance negatively impacts endoscopic pathology. All patients undergoing OCCD testing for Barrett's surveillance across 11 Scottish health boards between 14/9/2020 and 13/9/2022 were identified. Patients were dichotomised into two groups (Year 1 vs. Year 2), with individual records interrogated to record demographics, recommended surveillance interval, time from last endoscopy to OCCD test, and OCCD result. Patients were deemed high-risk if the OCCD demonstrated atypia and/or p53 positivity. Further analysis was performed on patients who underwent endoscopy within 12 months of OCCD testing. A total of 3223 OCCD tests were included in the analysis (1478 in Year 1; 1745 in Year 2). In Year 1 versus Year 2, there was a longer median delay to surveillance (9 vs. 5 months; P < 0.001), increased proportion of patients with delayed surveillance (72.6% vs. 57.0%; P < 0.001), and more high-risk patients (12.0% vs. 5.3%; P < 0.001). 425/3223 patients (13.2%) were further investigated with upper gastrointestinal endoscopy, 57.9% of which were high-risk. As surveillance delay increased beyond 24 months, high-risk patients were significantly more likely to develop dysplasia or malignancy (P = 0.004). Delayed Barrett's esophagus surveillance beyond 24 months is associated with increased risk of pre-cancerous pathology. The CytoSCOT program has reduced delays in surveillance, promoting earlier detection of dysplasia and reducing burden on endoscopy services.

Background Barrett's oesophagus surveillance places significant burden on endoscopy services yet is vital to detect early cancerous change. Oesophageal cell collection device (OCCD) testing was introduced across Scotland for Barrett's surveillance in response to the COVID-19 pandemic. This national pragmatic retrospective study presents the CytoSCOT programme results and evaluates whether OCCD testing is successfully identifying high-risk Barrett's patients requiring urgent endoscopy. Methods All patients undergoing OCCD testing for Barrett's surveillance across 11 Scottish health boards over a 32-month period were identified. Patients who underwent endoscopy within 12 months of OCCD test were included. Individual patient records were interrogated to record clinical information and OCCD test result to categorize patients into risk groups. Endoscopic histopathology results were analysed according to risk group and segment length. Patients were deemed high risk if the OCCD test demonstrated atypia and/or p53 positivity. Results 4204 OCCD tests were performed in 3745 patients: 608 patients underwent endoscopy within 12 months and were included in this analysis. Patients with longer Barrett's segments were significantly more likely to have an abnormal OCCD test. 50/608 patients (8.2%) had high-grade dysplasia or cancer on endoscopic biopsies: this equates to 1.3% of the total group (50/3745). 46/50 patients (92.0%) were deemed high risk, triggering urgent endoscopy: this rose to 100% with insufficient tests removed. There were no cancers diagnosed within 12 months post-OCCD in the low-risk group. Conclusion OCCD testing is an effective triage tool to identify high-risk patients with Barrett's oesophagus requiring further investigation with endoscopy within the real-world setting.

Capsule sponge testing, using an oesophageal cell collection device with biomarkers, was implemented nationally across Scotland in 2020 for symptomatic reflux patients referred to secondary care for non-urgent endoscopy. The aim was to use capsule sponge testing as a triage tool to reduce pressures on the endoscopy service during COVID-19, focus endoscopy resources on those most likely to have pathology and streamline the patient pathway. This prospective cohort study presents the first real-world results and evaluates the clinical application of capsule sponge testing in symptomatic reflux disease based on endoscopic biopsy results. Over a 32-month period, all patients undergoing capsule sponge testing for investigation of reflux symptoms across 11 Scottish health boards were identified from prospectively maintained databases. Individual patient records were interrogated to collect baseline demographics, capsule sponge test result (TFF3/atypia/p53) and ongoing clinical management. Further analysis was performed on patients who subsequently underwent upper gastrointestinal (UGI) endoscopy. 1385 tests were performed for reflux symptoms in 1305 patients. The median follow-up time was 20 months (IQR 12–27). 1103/1385 tests (79.6

BACKGROUND AND AIMS:International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK. METHODS:Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved. RESULTS:39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers. CONCLUSIONS:An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.

Abstract Background Oesophageal cell collection device (OCCD) and biomarker testing was implemented nationally across Scotland in 2020 following the COVID-19 pandemic for symptomatic reflux patients referred to secondary care. Collected cells undergo biomarker testing for the presence of trefoil factor 3 (TFF3), an indicator of intestinal metaplasia (IM), in addition to atypia and p53. This national retrospective cohort study is the first to evaluate the clinical application of OCCD testing in symptomatic reflux patients and aims to assess whether OCCD and biomarker testing can safely be used as a triage tool for upper gastrointestinal (UGI) endoscopy in this cohort within secondary care. Methods Over a 32-month period, all patients undergoing OCCD testing with Cytosponge™ for investigation of reflux symptoms across 11 Scottish health boards were identified from prospectively maintained databases. In addition to OCCD testing, all patients also underwent clinical assessment either by UGI specialist nurses or consultants in secondary care. Individual patient records were interrogated to collect baseline demographics, OCCD test result and ongoing clinical management. Further analysis was performed on patients who subsequently underwent UGI endoscopy. All OCCD tests for Barrett’s surveillance were excluded from analysis. Results 1385 OCCD tests were performed for reflux symptoms in 1305 patients. 1103/1385 tests (79.6%) were TFF3 negative: 912/1305 (69.9%) patients discharged with no additional investigations. 355/1305 patients (27.2%) subsequently underwent UGI endoscopy. When insufficient tests with missing biomarker data were excluded, 50/314 patients (15.9%) had biopsies demonstrating IM: biomarkers were significantly more likely to be positive in this group (35.5% vs. 3.2%, p<0.001) (Table 1). 10/1103 patients with a TFF3 negative result (0.9%) had biopsies showing IM, dysplasia or malignancy. 1 patient had a TFF3 negative result but was diagnosed with oesophageal adenocarcinoma 27 months later. Conclusion OCCD and biomarker testing is effectively identifying those symptomatic reflux patients requiring further investigation with UGI endoscopy within the real-world setting. Biomarker testing is clearly aiding the diagnosis of Barrett’s oesophagus within this patient cohort. However, clinical assessment remains crucial to identify those with red flag symptoms and judicious follow-up of the discharged group will be critical to validate the ongoing use of OCCD testing in the long-term.

In 2014, the British Society of Gastroenterology (BSG) published a standards framework outlining key performance indicators for ERCP practitioners and services. In the last 10 years there have been numerous changes to clinical practice yet there remains considerable variation in service delivery in the UK. In 2021 the BSG commissioned an ERCP endoscopy quality improvement project (EQIP) comprising members from all relevant stakeholding groups. This document draws from the results of a national survey of ERCP practitioners and units performed in 2022/23 supported by detailed stakeholder interviews. These results informed a draft document and series of statements that were revised at 2 group meetings and through several iterations. Each statement was included only after achieving 100% consensus from all participants. This service specification has set out 70 consensus statements covering the patient journey from booking to discharge and follow up, the members of the ERCP team, requirements for continued professional development and clinical governance, equipment and facilities and network provision and MDT working. This document describes the key components of a high quality and safe ERCP Service, seen from the patient’s perspective. It provides a detailed template for service delivery that should now be implemented by ERCP practitioners and units through the UK and should be used by ERCP providers and commissioners to benchmark services and guide continuous quality improvement.

Introduction In 2014, the BSG standards framework set out key performance indicators for endoscopic retrograde cholangiopancreatography (ERCP). Recent JAG Census from ERCP units and Getting It Right First Time reports have identified significant variation. As part of the BSG Endoscopy Quality Improvement Programme, BSG have launched a national survey of ERCP practice with individual and organisational components. Here we report the initial findings from the individual survey. Methods Independent ERCP practitioners in the UK were identified via BSG regional leads, NHSE endoscopy leads and the gastroenterology trainee network. An anonymised survey link was emailed to practitioners. Multiple reminders, and individual contacts, were used to maximise the response rate. Clinical questions were aligned with published guidelines and covered a range of ERCP scenarios. Results 491 ERCP practitioners were identified, of whom 386 (78%) responded to the survey. Responses were received from all four nations and all regions in England. The majority of those performing ERCPs are physicians (84%), followed by surgeons (14%) and radiologists (1%). Only 4% of respondents were female. 37% of respondents were over 55 years, and 29% were under 44 years. Of responders, 25% have been practising ERCP for up to 5 years, 21% for 6–10 years, 13 for 11–15 years, 12% for 16 to 20 years and 30% for more than 20 years. 21% reported they were very likely to stop doing ERCP in the next 5 years. One-third report performing between 101 and 150 ERCPs a year (table 1). 59% had attended online CPD within the last year, and 36% had face-to-face CPD within the last year. 49% felt the CPD they received for ERCP was not adequate, and 66% felt the time allocated to ERCP governance was inadequate. 95% of respondents enjoy their ERCP lists most of the time, and 97% felt confident performing ERCP most of the time. 88% felt supported by their clinical colleagues in the hospital and broader network. 87% felt adequately supported by specialist GI radiologists. 86% felt there was a learning culture in their team or department. Conclusion In the UK, a fifth of ERCP practitioners are likely to stop performing ERCP within the next 5 years, which is a clear concern for workforce planning. More than 10% of ERCPists perform fewer than 75 procedures per year. Women are significantly underrepresented in the ERCP workforce. ERCP practitioners report enjoyment with their job, but there is a need for more time dedicated to ERCP CPD and governance.

Introduction Significant variation in outcomes related to stone disease was highlighted in the recent Getting It Right First Time review. As part of the BSG endoscopy quality improvement programme, national surveys of ERCP practice have been undertaken. Here we highlight results in relation to clinical practice and operational resources. Methods Independent ERCP practitioners in the UK were identified via BSG regional leads, NHSE endoscopy leads and the gastroenterology trainee network. An anonymised survey link was emailed to practitioners. Multiple reminders, and individual contacts, were used to maximise the response rate. Clinical questions were aligned with published guidelines and covered a range of ERCP scenarios. Results 491 ERCP practitioners were identified, and 386 (78%) responded to the survey. In patients with an intermediate likelihood of common bile duct stones (CBDS), three-quarters (76%) of responders request magnetic resonance cholangiopancreatography first; 9%of responders would proceed directly to ERCP. In patients with normal anatomy and large or difficult to extract stones, 68% perform sphincterotomy followed by sphincteroplasty and further attempts at duct clearance at the index procedure. There is variation in image acquisition during ERCP, with 55% obtaining a control film at the onset and 45% after endoscope removal. Almost two-thirds (62%) of practitioners stated a preference to perform all ERCPs under deep sedation or general anaesthetic (GA), 84% felt that their unit required more access to deep sedation/GA lists, and 55% felt that procedure outcomes in the preceding month were compromised by lack of deep sedation/GA. Most responders rated their endoscopes and accessories as 'perfectly' (39%) or 'mostly' adequate (54%). Similarly, most rated their endoscopy or radiology room as 'perfectly' (35%) or 'mostly' adequate (50%). 17% work in more than one unit. of these practitioners/respondents, 15% rated the facilities as 'somewhat' or 'completely' inadequate in their base hospitals compared to 31% in their secondary hospitals. Conclusion Despite clear guidance, a quarter of ERCP practitioners still proceed directly to ERCP for indeterminate CBDS, which may put patients at unnecessary risk of adverse events. There is variation in operational resources and facilities in different centres around the UK.

Background The lack of comprehensive national data on endoscopy activity and workforce hampers strategic planning. The National Endoscopy Database (NED) provides a unique opportunity to address this in the UK. We evaluated NED to inform service planning, exploring opportunities to expand capacity to meet service demands. Design Data on all procedures between 1 March 2019 and 29 February 2020 were extracted from NED. Endoscopy activity and endoscopist workforce were analysed. Results 1 639 640 procedures were analysed (oesophagogastroduodenoscopy (OGD) 693 663, colonoscopy 586 464, flexible sigmoidoscopy 335 439 and endoscopic retrograde cholangiopancreatography 23 074) from 407 sites by 4990 endoscopists. 89% of procedures were performed in NHS sites. 17% took place each weekday, 10% on Saturdays and 6% on Sundays. Training procedures accounted for 6% of total activity, over 99% of which took place in NHS sites. Median patient age was younger in the independent sector (IS) (51 vs 60 years, p<0.001). 74% of endoscopists were male. Gastroenterologists and surgeons each comprised one-third of the endoscopist workforce; non-medical endoscopists (NMEs) comprised 12% yet undertook 23% of procedures. Approximately half of endoscopists performing OGD (52%) or colonoscopies (48%) did not meet minimum annual procedure numbers. Conclusion This comprehensive analysis reveals endoscopy workload and workforce patterns for the first time across both the NHS and the IS in all four UK nations. Half of all endoscopists perform fewer than the recommended minimum annual procedure numbers: a national strategy to address this, along with expansion of the NME workforce, would increase endoscopy capacity, which could be used to exploit latent weekend capacity.

The COVID-19 pandemic has had profound implications across the breadth of national healthcare services. Inflammatory bowel disease (IBD) continues to carry an increased risk of colon cancer and national protocols for endoscopic surveillance are in place. Elective procedures such as IBD surveillance were stopped during the COVID-19 pandemic and have been slow to be re-started. We are acutely aware of the pressures on endoscopy services at the present time which is unlikely to improve at the pace needed for services to fully recover. At such times, we need to target this scarce resource to those who need it most, aligned to the principles of ethical healthcare which state that when resources are limited, they should be used to provide the most benefit for as great a number of people as possible. With this in mind, we propose an optional interim framework to aid risk stratification of patients on the IBD surveillance waiting lists where delays to timely surveillance occur. These measures could help address the backlog until a time when clinical services are able to fully recover. Finally, we propose the patient factors to consider when withdrawal of surveillance may be contemplated.

BACKGROUND AND AIMS:Greenhouse gases (GHGs) that trap heat in the atmosphere are composed of carbon dioxide (CO2), methane, nitrous oxide and fluorinated gases (synthetic hydrofluorocarbons, perfluorocarbons and nitrogen trifluoride). In the USA, the health sector accounts for 8.5% of total GHG emissions. The primary objective of this systematic review was to critically analyse the carbon emissions data from GI endoscopic activity.DESIGN:The GI endoscopy carbon cycle was evaluated at preprocedural, intraprocedural and postprocedural levels. We performed a systematic literature search of articles published on these issues until 30 June 2022 and discussed these available data on endoscopy unit GHG carbon cycle, barriers to reduce GHG emissions and potential solutions. The inclusion criteria were any full-text articles (observational, clinical trials, brief communications, case series and editorials) reporting waste generation from GI endoscopy. Abstracts, news articles and conference proceedings were excluded.RESULTS:Our search yielded 393 records in PubMed, 1708 in Embase and 24 in Google Scholar. After application of inclusion and exclusion factors, we focused on 9 fulllength articles in detail, only 3 of them were cross-sectional studies (all from the USA), the others reviews or position statements. Therefore, the quality of the studies could not be assessed due to heterogeneity in definitions and amount of emissions.CONCLUSIONS:Recognition of carbon emissions generated by GI endoscopy activity is critical. Although multiple limitations exists for quantification of these emission, there is an urgent need for collecting proper data as well as examining novel methods for reduction of these emissions for a sustainable endoscopic practices in the future.

In 2016, the British Society of Gastroenterology (BSG) published comprehensive guidelines for obtaining consent for endoscopic procedures. In November 2020, the General Medical Council (GMC) introduced updated guidelines on shared decision making and consent. These guidelines followed the Montgomery ruling in 2015, which changed the legal doctrine determining what information should be given to a patient before a medical intervention. The GMC guidance and Montgomery ruling expand on the role of shared decision making between the clinician and patient, explicitly highlighting the importance of understanding the values of the patient. In November 2021, the BSG President's Bulletin highlighted the 2020 GMC guidance and the need to incorporate patient -related factors into decision making.Here, we make formal recommendations in support of this communication, and update the 2016 BSG endoscopy consent guidelines. The BSG guideline refers to the Montgomery legislation, but this document expands on the findings and gives proposals for how to incorporate it into the consent process. The document is to accompany, not replace the recent GMC and BSG guidelines.The recommendations are made in the understanding that there is not a single solution to the consent process, but that medical practitioners and services must work together to ensure that the principles and recommendations laid out below are deliverable at a local level. The 2020 GMC and 2016 BSG guidance had patient representatives involved throughout the process. Further patient involvement was not sought here as this update is to give practical advice on how to incorporate these guidelines into clinical practice and the consent process. This document should be read by endoscopists and referrers from primary and secondary care.

ObjectiveWe aimed to investigate the clinical utility of follow-up oesophagogastroduodenoscopy (OGD2) in patients with severe oesophagitis (Los Angeles grades C or D) through evaluating the yield of Barrett’s oesophagus (BO), cancer, dysplasia and strictures. Second, we aimed to determine if the Clinical Frailty Scale (CFS) may be used to identify patients to undergo OGD2s.Design/methodPatients in NHS Lothian with an index OGD (OGD1) diagnosis of severe oesophagitis between 1 January 2014 and 31 December 2015 were identified. Univariate analysis identified factors associated with grade. Patients were stratified by frailty and a diagnosis of stricture, cancer, dysplasia and BO.ResultsIn total 964 patients were diagnosed with severe oesophagitis, 61.7% grade C and 38.3% grade D. The diagnostic yield of new pathology at OGD2 was 13.2% (n=51), new strictures (2.3%), dysplasia (0.5%), cancer (0.3%) and BO (10.1%). A total of 140 patients had clinical frailty (CFS score ≥5), 88.6% of which were deceased at review (median of 76 months). In total 16.4% of frail patients underwent OGD2s and five new pathologies were diagnosed, none of which were significantly associated with grade. Among non-frail patients at OGD2, BO was the only pathology more common (p=0.010) in patients with grade D. Rates of cancer, dysplasia and strictures did not vary significantly between grades.ConclusionOur data demonstrate that OGD2s in patients with severe oesophagitis may be tailored according to clinical frailty and only be offered to non-frail patients. In non-frail patients OGD2s have similar pick-up rates of sinister pathology in both grades of severe oesophagitis.

Before the COVID-19 pandemic, approximately 2 million diagnostic gastrointestinal endoscopies were performed annually in the UK. In addition to the growing number of increasingly complex interventional procedures such as endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, device-assisted small bowel endoscopy, endoscopic mucosal resections, and endoscopic submucosal dissection, increasing demand was also being driven by the needs of an ageing population, increasing numbers of patients requiring surveillance, and the need to expand capacity for bowel cancer screening, both by flexible sigmoidoscopy and faecal occult blood testing.