The causes of Post Endoscopy Upper Gastrointestinal Cancer: results from the English national root cause analysis project

Aims Post endoscopy upper gastrointestinal cancers (PEUGIC) are often missed opportunities to diagnose earlier or even prevent cancer. PEUGIC in patients undergoing surveillance for pre-malignant conditions (e.g. Barrett’s oesophagus) are a potentially important surveillance quality metric. A national process for identifying all PEUGIC in the English National Health Service and performing root cause analysis was developed. Methods Potential PEUGIC occurring 3-36 months after an index endoscopy without a cancer diagnosis between 2017 and 2023 were identified from National Cancer Registration and Hospital Episode Statistics Datasets held by the National Cancer Registration and Analysis Service. Data from local root cause analysis were uploaded onto a secure portal for national analysis. Only PEUGIC following surveillance endoscopy were included in this analysis. Logistic regression was used to analyse for associations. Results 3151 potential PEUGIC were examined by local reviewers in 144 English hospitals. 635 were excluded and data were available for 2516 PEUGIC. 618 PEUGIC (24.6%) were undergoing surveillance for Barrett’s oesophagus (83%), chronic atrophic gastritis (7%) or other premalignant conditions (10%). PEUGIC sites were oesophagus 85%, stomach 13% and duodenum 1%. 5% of PEUGIC were not related to the condition under surveillance. PEUGIC categorisation of the index endoscopy was as follows: A) lesion detected with adequate management 61%; B) lesion detected with inadequate management 26%; C) possible missed lesion with adequate endoscopy 9%; and D) possible missed lesion with inadequate endoscopy 4%. Inadequate endoscopy or decision making was found in 30% of PEUGIC and associated with patient harm OR 2.61 (95% CI 1.74 -3.92). Compliance with the Seattle biopsy protocol was only 58% in Barrett’s PEUGIC. Additional focal or cancer associated lesions (e.g. ulcer) were present in the PEUGIC segment in 23%. Oesophageal surveillance PEUGIC tended to present with more advanced stage 2 cancers or greater (48% vs 43% gastric) suggesting failures of surveillance. 45.2% of oesophageal and 47.0% of gastric PEUGIC were considered at least possibly avoidable by reviewers. Treatment was adversely affected with palliative treatment in 22% of oesophageal and 30% of gastric PEUGIC. Reviewers considered that 6% of PEUGIC led to premature death [ 1 ]. Endoscopy practices associated with stage 2 PEUGIC or greater were, sedation without opioids OR 1.75 (95% CI 1.03-2.97), lack of image enhancement OR 1.78 (95% CI 1.18-2.70) and lack of dedicated surveillance endoscopy sessions OR 2.08 (95% CI 1.46-2.98). Conclusions Inadequate assessment or decision making was noted in 30% of surveillance PEUGIC, which adversely affected treatment outcomes in 20% of oesophageal and 30% of gastric PEUGIC. 48% of oesophageal patients presented with stage 2 cancer or greater suggesting failures of surveillance. Good sedation practice, image enhancement and dedicated surveillance sessions were associated with stage 1 PEUGIC and good outcomes. Publication History Article published online: 27 March 2025 © 2025. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany