TAKING BIOPSIES IN MACROSCOPICALLY NORMAL ENDOSCOPIES - IS THERE INTER-OPERATOR VARIABILITY AND NEED FOR STRINGENT GUIDELINES AND TRAINING?

Aims Numerous studies have questioned the value of taking biopsies in macroscopically-normal mucosa. Inappropriate biopsies increase financial and time pressures on the increasingly-strained endoscopy, pathology and NHS services. We hypothesized that non-physician endoscopists have greater uptake on performing biopsies in macroscopically normal endoscopies.

Methods We conducted a retrospective study of diagnostic gastroscopies and colonoscopies performed across 3 district-general hospitals (January-November 2018) in United Lincolnshire Hospitals NHS Trust. Endoscopic reports were examined for age, sex, indication, endoscopic diagnosis, biopsies taken (yes/no), and operator (gastroenterologist/surgeon/nurse endoscopist {NE}). We classified ‘biopsy not indicated’ when mucosa was described as ‘normal’ in the endoscopic report, where indication for endoscopy was anaemia, rectal bleeding, or weight-loss in colonoscopies, and dyspepsia, vomiting or abdominal pain in gastroscopies.

Results A total of 326 gastroscopies and 355 colonoscopies were included. 170 procedures fulfilled the ‘biopsy not indicated’ classification, of which 59% had multiple biopsies taken. Biopsy rates among gastroenterologists, surgeons, and NEs in ‘biopsy not indicated’ were 53% (39/73), 60% (42/70) and 70% (19/27) respectively. Using Chi-square, there was no statistically significant difference between various groups: surgeons and NEs (p= 0.34), surgeons and gastroenterologists (p= 0.42), and gastroenterologists and NEs (p= 0.12). This rejects our hypothesis.

Conclusions Our study showed that a significant number of biopsies are performed without good indication, with no significant inter-operator variability. Both the British Society of Gastroenterology and National Institute for Health and Care Excellence have published guidance on when biopsy is indicated, but there are few high-level recommendations on when not to biopsy. Findings from our study mandate development of such guidance, followed by training of all endoscopists and UK-wide audit of local practice to ensure compliance with guidelines. The implementation of such strategies has been proven effective at a local level, and if adopted nationally can significantly optimise financial burden of endoscopy services on the NHS.