Discussion

This is the first survey of paediatric endoscopic provision in the UK and the data are vital in order to plan services, including the transition of care from paediatric to adult services, as well as training for the future. The need for endoscopy in children has gone up in line with the change in epidemiology of coeliac disease and inflammatory bowel disease.2 ,3 Unlike adult practice, most endoscopies undertaken were diagnostic with only a small number involving therapeutic procedures. It is clear that there is a wide variation in practice throughout the UK in terms of the number of endoscopies performed, and whether the procedures are performed under sedation or general anaesthetic. This variation in the number of endoscopies performed could be interpreted as some centres doing more investigations compared to others, but it is difficult to come to any firm conclusions based on our study, because we have not collected the data on catchment population of each centres. Some centres also provide services supra regionally for endoscopy for conditions such as colonic polyposis and this could increase the number of endoscopies compared to the others. Similar variation in admission rates for children for upper and/or lower GI endoscopy by Primary Care Trusts in England was also published recently.4 We acknowledge that paediatric endoscopy practice may change in the future because of changes in the diagnostic pathway of coeliac disease and the emerging trend to achieve and document mucosal healing in patients with inflammatory bowel disease. It is clear that there is a wide variation also in the number of procedures performed by trainees in each of the centres and it is thus vital that a trainee is able to rotate between accredited training centres in order to gain wide experience.

There was variation in the location of paediatric endoscopy services in different hospitals. Most centres rely on operating theatres or adult endoscopy suites and this may be due to the fact that there is not enough volume of paediatric endoscopies in each centre to justify a separate paediatric endoscopy suite. Since most of the paediatric endoscopies were done under GA, anaesthetic service availability also was a factor.

Many centres perform all endoscopies under GA, and there has been an interesting trend over the previous 4 years. Some 25% of paediatric gastroenterology centres who responded, used sedation for a proportion of endoscopic procedures in 2007, and this number had fallen to 16% in 2011. There has been a striking increase in the proportion of endoscopies carried out after the administration of Propofol, which should correctly be regarded as an anaesthetic procedure rather than sedation. Recent guidelines produced by NICE5 have suggested safe alternatives for endoscopic procedures in children (the use of Midazolam and Pethidine with the ability of staff trained in resuscitation) but it seems there is gradual drift away from sedation for GI endoscopic procedures in children. This may have implications for the future as fewer gastroenterologists will have been trained in the use of sedation techniques and there is an issue in the transitional care of adolescents and young people requiring endoscopy as adult gastroenterologists perform almost all procedures under sedation. There is a strong argument that, prior to handover to adult gastroenterology care it is important that final endoscopy performed on the paediatric unit is performed under sedation, rather than general anaesthetic, although there is no evidence base for this practice. However this is an important point to consider as it has been raised by many adolescents in the Transition clinics which are run in several centres (personal information). It is clear that a number of factors influence the way endoscopies are performed, including cultural norms, endoscopic experience and procedural training.6–8 It is also apparent that the provision of adequate paediatric anaesthetists (and operating-theatre time) is an important factor in how services are organised in each unit. There are no firm data from the UK regarding complications following procedures performed under sedation or anaesthesia, and the personal experience from one of the authors (HJ) over 20 years of more than 1000 endoscopies done under sedation and under GA (unpublished data), suggests that there is little evidence that endoscopies performed under sedation are more unsafe than those performed under GA, at least in older children. Reports of paediatric procedural sedation from North America in more than 100 000 procedures show that major complications are rare and there are not statistically significant differences in complication rates between anaesthetists and other providers of sedation.9 ,10 Indeed, it could be argued that providing both techniques in each unit is important and that older children and young adults should undergo these procedures using sedation which will be their experience after transition to adult units.

There was a wide variation in the provision of PEG and in most centres this service was provided by the paediatric surgical team. It is clear that some paediatric gastroenterology trainees are not exposed to PEG insertion and the opportunities for such training should be available to those who wish to avail themselves of it. In the current endoscopy curriculum for paediatric gastroenterology training in the UK, PEG insertion skills are considered as additional optional skills, not needed for all trainees.

There was also a wide variation in the number of out-of-hours endoscopies performed in each unit. The majority of units do not offer a dedicated out-of-hours service and this is in large part because many paediatric gastroenterologists continue to take part in general paediatric rotas (and indeed there is not enough numbers of specialists per unit to undertake a separate Paediatric Gastroenterology rota). Perhaps the best approach to provide out-of-hours endoscopy support would be through the development of managed clinical networks to provide regional solutions.

It should be emphasised that at the time of the survey in 2007 there had been little formal organisation and assessment of paediatric endoscopy services in the UK and, indeed, little involvement with JAG processes. Since then (and in part prompted by this survey) there has been much closer cooperation with JAG and now more robust arrangements for training and assessment of units are being developed which will be helpful in prompting commissioners to follow standards for the future designation of such services. The focus for this drive is the British Society of Paediatric Gastroenterology, Hepatology and Nutrition Endoscopy Working Group which is collaborating with JAG to provide a paediatric curriculum for paediatric endoscopy as well as providing a Directly Observed Procedural Skills assessment. This group will continue to work to provide specific standards for paediatric endoscopy services in the UK, which will need to reflect the needs of the particular childhood population.

In conclusion, we have shown that there is a wide variation in the provision of paediatric endoscopy services across the UK. To the best of our knowledge, there is no similar study published comparing paediatric endoscopy provision and these data will be invaluable in helping to plan for a robust and equitable UK-wide service and in providing the optimum arrangements for transition of young people to adult units.