# Expansion of interventional endoscopy and day-case procedures: A nationwide longitudinal study of gastrointestinal endoscopy in France

Hervé-Pierre Toudic, Marie Morvan, Noémi Reboux, Stanislas Chaussade, Olivier Gronier, Stéphane Koch, David Bernardini, Emmanuel Coron, Michel Robaszkiewicz, Lucille Quénéhervé

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Hervé-Pierre Toudic, Marie Morvan, Noémi Reboux, Stanislas Chaussade, Olivier Gronier, et al. Expansion of interventional endoscopy and day-case procedures: A nationwide longitudinal study of gastrointestinal endoscopy in France. Clinics and Research in Hepatology and Gastroenterology, 2025, 49 (1), pp.102505. 10.1016/j.clinre.2024.102505. hal-05288051

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# Expansion of interventional endoscopy and day-case procedures: A nationwide longitudinal study of gastrointestinal endoscopy in France

Hervé-Pierre Toudic<sup>a</sup>, Marie Morvan<sup>b,c</sup>, Noémi Reboux<sup>a,b</sup>, Stanislas Chaussade<sup>d</sup>, Olivier Gronier<sup>e</sup>, Stéphane Koch<sup>f</sup>, David Bernardini<sup>g</sup>, Emmanuel Coron<sup>h</sup>, Michel Robaszkiewicz<sup>a,b,c,1</sup>, Lucille Quénéhervé<sup>a,i,1,*</sup>

## ARTICLE INFO

**Key words:**

Epidemiology

ERCP

Colonoscopy

EUS

## ABSTRACT

**Background:** An accurate assessment of the evolution of GI endoscopy volumes is warranted to identify long-term trends and to help anticipate training, infrastructure and human resource needs. The main objective of this longitudinal study was to evaluate the evolution of GI endoscopy in France.

**Methods:** This retrospective study consisted of a cross-sectional analysis repeated each year from 2008 to 2018 using data from a national health database related to hospital admissions. All day-case and hospital stays presenting at least one of the 119 GI endoscopy procedures were extracted.

**Results:** This study showed an increase in day-case and hospital stays including a GI endoscopy procedure of 18.4 %. In addition, day-case endoscopy increased from 67.8 % to 76.9 % of hospital admissions. There was a 19.6 % increase in lower GI endoscopy, with in particular a 247 % increase in endoscopic mucosal resection. EUS and pancreaticobiliary and duodenal endoscopy have seen the most significant increases, 63 % and 70.2 % respectively; notably, therapeutic EUS increased by 476 %.

**Conclusion:** This study shows the good dynamics of GI endoscopy in a European country with a sustained increase over 11 years in day-case and hospital stays of patients undergoing a GI endoscopy while day-case endoscopy is taking on an increasingly important role.

## Introduction

Gastrointestinal (GI) endoscopy has developed significantly since 1957, when Basil Hirschowitz, an American physician, performed the first flexible gastroscopy [1]. Initially, GI endoscopy was mainly limited to non-invasive procedures performed during short hospital stays. However, the scope of endoscopy has recently widened with the development of day-case endoscopy on one hand, and interventional endoscopy on the other. An accurate assessment of the evolution of GI endoscopy volumes is warranted to identify long-term trends and to help

anticipate training, infrastructure and human resource needs. However, no direct method is available to estimate the exact number of GI endoscopy procedures performed over a long period of time on a national scale in France.

In France, the cost of hospital admission, either hospital stays or day-case, for patients undergoing an endoscopy procedure is determined according to a code, assigned to each endoscopy procedure grouped in the French common classification of procedures (CCAM) [2]. Several types of healthcare facilities provide GI endoscopy in France, all using the same codes. By collecting health data related to each hospital

<footnote><sup>a</sup> Gastroenterology Department, Brest University Hospital, Brest, France</footnote>

<footnote><sup>b</sup> Digestive tumour registry of Finistère, Brest University Hospital, Brest, France</footnote>

<footnote><sup>c</sup> EA 7479 SPURBO, Brest University Hospital, Brest, France</footnote>

<footnote><sup>d</sup> Gastroenterology Department, Hôpital Cochin, Assistance publique des hópitaux de Paris, Paris, France</footnote>

<footnote><sup>e</sup> Centre d'Endoscopie Digestive Ambulatoire, Strasbourg, France</footnote>

<footnote><sup>f</sup> Gastroenterology Department, Besançon University hospital, Besançon, France</footnote>

<footnote><sup>g</sup> Gastroenterology office, Aubagne, France</footnote>

<footnote><sup>h</sup> IMAD, Department of Gastroenterology and Hepatology, University Hospital, Nantes, France</footnote>

<footnote><sup>i</sup> LaTIM, UMR 1101, Brest University Hospital, Brest, France</footnote>

<footnote>* Correspondence author at: Service de gastroentérologie, CHU de La Cavale Blanche, bd Tanguy Prigent, 29200, Brest.
E-mail address: lucille.queneherve@chu-brest.fr (L. Quénéhervé).</footnote>

<footnote n="1">¹ contributed equally to this work</footnote>
admission including GI endoscopy from a national database named PMSI MCO, it is possible to estimate the incidence of each GI endoscopy procedure, the rate of day-case endoscopy and the average length of stay for inpatient endoscopy.

The aim of this national study was to provide an accurate assessment of the evolution of GI endoscopy over a 11-year period (2008–2018) in France.

## Methods

### Study design

This retrospective study consisted of a repeated cross-sectional analysis each year from January 2008 to December 2018 using health data from the national database that collects data on hospital admissions (PMSI MCO), i.e., both day-cases and hospital stays. All hospital admissions with at least one of the 119 GI endoscopy procedures described by the CCAM were extracted. All healthcare facilities were considered, i. e., public hospitals and private for-profit and non-profit structures. In case of hospital stay, patients in the study admitted for any reason were included as long as they underwent at least one GI endoscopy during their stay.

The ENDOCOST study received a favorable opinion from the institutional council in charge of expertise in research, studies, and evaluations in the field of health (CEREES) on 17/01/2020 (n° INDS: TPS 1028871bis) and has been authorized by the National Commission for Information Technology and Civil Liberties (CNIL) (n°920,035).

### Objectives

The primary objective of this study was to evaluate the evolution over 11 years of the number of GI endoscopy procedures in France.

The secondary objectives were to analyze the evolution of day-case endoscopy and of the average length of stay (ALOS) of inpatient endoscopy, all procedures combined and by groups.

### Data collection

The different endoscopy procedures were divided into the following groups:

- **Upper GI endoscopy:** diagnostic and therapeutic esophagogastroduodenoscopy, including endoscopic resection of upper GI lesions, endoscopic hemostasis, placement, change or removal of esophageal or duodenal stents, per-endoscopic gastrostomy;

- **Lower GI endoscopy:** rectosigmoidoscopy, partial and complete diagnostic colonoscopy, endoscopic resection and hemostasis of colonic lesions, colonic stent placement, endoscopic decompression;

- **Endoscopic ultra-sound (EUS):** diagnostic EUS of the upper and lower GI tract, including EUS-guided sampling, and therapeutic EUS, including EUS-guided transmural drainage of pancreatic collection (CCAM procedure HNCJ001);

- **Pancreaticobiliary and duodenal endoscopy:** endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage, including stent placement, biliary stone extraction, lithotripsy, etc., and duodenoscopy using a side-viewing endoscope;

- **Small-bowel endoscopy:** diagnostic and therapeutic enteroscopy, the examination by endoscopic videocapsule being excluded.

It should be noted that some procedures that were new at the time but are now widely performed, such as peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and EUS-guided biliary drainage, had not received specific coding, so their evolution could not be directly assessed in this study. Indeed, physicians had to code them with the codes of procedures deemed to be similar, which may vary between healthcare facilities.

The numbers of hospital admissions were sorted by year of procedure. Available demographic data were age and proportion of male patients. The rate of day-case procedures, and the ALOS for inpatient endoscopy were also collected.

Hospital admissions could include one or more endoscopy procedures and therefore be counted in multiple groups. As a result, the total of hospital admissions was inferior to the sum of the different endoscopy procedure groups. Conversely, patients undergoing several times the same type of endoscopy were only counted once.

### Statistical analysis

Since the number of hospital admissions were provided as time series, the evolution of each variable was analyzed over time. To avoid assumptions of normalization, it was decided to use the Mann-Kendall test, a non-parametric test, which tests whether a trend is statistically identifiable in a series of data, at a fixed threshold. Crude incidence was computed for each endoscopy procedure group, expressed per 100.000 inhabitants per year, with a French population of 63,961,859 in 2008 and of 66,992,159 in 2018. Categorical variables were described by their number and percentage frequency in the study population. Age was described by median and interquartile range. The significance threshold was set at 0.05. Analyses were performed using R software, version 4.1.2 (R Core Team 2021).

## Results

### All hospital admissions including a GI endoscopy procedure

An absolute 18.4 % increase in the pooled number of day-cases and hospital stays that included at least one GI endoscopy procedure was observed over 11 years, from approximately 1,9 million in 2008 to 2,2 million in 2018 (Fig. 1) (*p* < 0.001). As the French population increased, the incidence of day-cases and hospital stays including at least one GI endoscopy increased significantly, from 5141 to 5908 per 100,000 inhabitants in 11 years (*p* < 0.001) (Table 1). In particular, the incidence of day-case endoscopy increased from 3485 to 4542 per 100,000 inhabitants (*p* < 0.001), while the incidence of inpatient hospital stays decreased from 1656 to 1366 per 100,000 inhabitants (*p* < 0.001). In 2008, 67.8 % of GI endoscopies were performed as day-cases compared with 76.9 % in 2018 (*p* < 0.001) (Fig. 2). The ALOS of inpatient endoscopy remained stable: 8.88 in 2008 and 8.48 days in 2018 (*p* = 0.12) (Fig. 3).

Detailed times series for some GI endoscopy procedures of interest are presented in Table 2.

The median age of patients undergoing GI endoscopy in France, increased slightly from 58.2 (48–71) years in 2008 to 59.1 (50–70) years in 2018 (*p* = 0.001). The median age in the upper GI endoscopy and EUS groups increased from 61.2 to 62.5 (*p* = 0.033) and from 61.2 to 61.6 (*p* = 0.01), respectively. The median age in the lower GI endoscopy group decreased from 67.3 to 66.8 (*p* = 0.018). Conversely, there were no statistically significant changes in median age in the pancreaticobiliary and duodenal endoscopy or small bowel endoscopy groups.

No significant variation was observed in the sex ratio of patients undergoing endoscopy procedures, with the proportion of male patients remaining stable at 48.0 % (*p* = 0.88).

### Upper GI endoscopy

Admissions that included upper GI endoscopy increased by 26.1 % (*p* < 0.001), from approximately 970,000 to 1,2 million between 2008 and 2018 with a crude incidence rising from 1516 to 1824 per 100,000 inhabitants (*p* < 0.001). In particular, diagnostic endoscopy, endoscopic resection of upper GI lesions, endoscopic hemostasis, and esophageal or duodenal stent placement, change or removal increased by 25.0 %, 93.1 %, 37.1 % and 76.4 %, respectively (all *p* < 0.001).
<figure><img src="image_3.png" /><figcaption>**Fig. 1.** Number of hospital admissions that included at least one GI endoscopy procedure in France from 2008 to 2018. The same hospital stay may include several endoscopy procedures.</figcaption></figure>

<table><caption>**Table 1**
Evolution of the annual crude incidence rates of GI endoscopy procedures over time (per 100.000 inhabitants).</caption><thead><tr><th></th><th>2008</th><th>2009</th><th>2010</th><th>2011</th><th>2012</th><th>2013</th><th>2014</th><th>2015</th><th>2016</th><th>2017</th><th>2018</th><th>p-value</th></tr></thead><tbody><tr><td>Overall</td><td>5141</td><td>5329</td><td>5353</td><td>5382</td><td>5427</td><td>5476</td><td>5507</td><td>5,58</td><td>5941</td><td>5876</td><td>5908</td><td>&lt;0.001</td></tr><tr><td>Upper GI endoscopy</td><td>1516</td><td>1554</td><td>1602</td><td>1627</td><td>1685</td><td>1694</td><td>1716</td><td>1744</td><td>1786</td><td>1797</td><td>1824</td><td>&lt;0.001</td></tr><tr><td>Lower GI endoscopy</td><td>2071</td><td>2154</td><td>2153</td><td>2152</td><td>2156</td><td>2174</td><td>2182</td><td>2219</td><td>2395</td><td>2354</td><td>2365</td><td>&lt;0.001</td></tr><tr><td>EUS</td><td>95</td><td>101</td><td>107</td><td>114</td><td>119</td><td>125</td><td>132</td><td>134</td><td>138</td><td>145</td><td>147</td><td>&lt;0.001</td></tr><tr><td>Pancreaticobiliary and duodenal endoscopy</td><td>63</td><td>67</td><td>70</td><td>76</td><td>80</td><td>83</td><td>87</td><td>91</td><td>95</td><td>99</td><td>103</td><td>&lt;0.001</td></tr><tr><td>Small-bowel endoscopy</td><td>8</td><td>8</td><td>10</td><td>13</td><td>14</td><td>14</td><td>15</td><td>13</td><td>9</td><td>9</td><td>9</td><td>0.64</td></tr></tbody></table>

<figure><img src="image_4.png" /><figcaption>**Fig. 2.** Rate of day-case GI endoscopy from 2008 to 2018.</figcaption></figure>
<figure><img src="image_5.png" /><figcaption>Fig. 3. Average length of stay of patients undergoing an inpatient endoscopy from 2008 to 2018.</figcaption></figure>

Day-case upper GI endoscopy increased from 61.1 % to 73.4 % during the study period (p < 0.001) and the ALOS of inpatient upper GI endoscopy tended to decrease from 11.06 to 10.44 days (p = 0.02).

### Lower GI endoscopy

There was a 19.6 % increase in day-cases and hospital stays that included lower GI endoscopy (p < 0.001), from approximately 1,3 million to 1,6 million, with a crude incidence rising from 2071 to 2365 per 100,000 inhabitants. In particular, a large increase was seen in the 2015–2016 period with an 8.2 % increase in lower GI endoscopy over 1 year. While diagnostic lower GI endoscopy increased by only 9.3 % (p < 0.001), a 39.3 % increase in endoscopic resection of colonic lesions was observed (p < 0.001), from 410,000 to 580,000 approx., including a 247.0 % increase in endoscopic mucosal resection (EMR), from 30,000 to 104,000 approx. (Table 2). In comparison endoscopic hemostasis of colonic lesions increased from 158 to 244 (+284.6 %; p < 0.001). Day-case lower GI endoscopy increased from 74.5 % to 84.0 % (p < 0.001) over the study period. ALOS of inpatient lower GI endoscopy remained stable, from 3.83 to 3.77 (p = 1).

### Endoscopic ultrasound

A steady increase of 63.0 % over 11 years in the number of day-cases and hospital stays including EUS was observed (p < 0.001), from approximately 60,000 to 99,000, with a crude incidence rising from 95 to 147 per 100,000 inhabitants. In particular, pancreaticobiliary EUS increased by 77.9 % (p < 0.001) versus 11.0 % for esophageal and rectal EUS (p < 0.01). EUS-guided transmural drainage of pancreatic collection, increased from 171 in 2008 to 985 in 2018 (+476.0 %) (p < 0.001). Day-case EUS increased from 52.9 % to 55.7 % (p < 0.001) over the study period and ALOS of inpatient EUS decreased from 6.72 to 6.33 (p = 0.003).

### Pancreaticobiliary and duodenal endoscopy

The number of hospital admissions that included a pancreaticobiliary and duodenal endoscopy increased by 70.2 % (p <

0.001), from approximately 40,000 to 69,000. Both endoscopic management of biliary stones (extraction or lithotripsy) and biliary stent placement, change, or removal increased dramatically, by 69.8 % (p < 0.001) and 111.6 % (p < 0.001), respectively. Day-case pancreaticobiliary and duodenal endoscopy increased but accounted for a limited number of patients (12.5 % in 2008, 16.3 % in 2018; p < 0.0001). ALOS of inpatient pancreaticobiliary and duodenal endoscopy decreased from 8.47 to 7.54 during the study period (p = 0.001).

### Small bowel endoscopy

An absolute 91 % increase in hospital admissions that included a small bowel endoscopy procedure was observed between 2008 and 2014 (p = 0.003), followed by a gradual decrease between 2014 and 2018 (38.7 % decrease). The crude incidence rose from 8 per 100,000 inhabitants in 2008 to 15 in 2014 and then decreased to 9 in 2018. Day-case enteroscopy increased from 48.2 % to 64.3 % during the study period.

## Discussion

This study highlights the important dynamics of GI endoscopy in France with an increase in hospital admissions (day-case and inpatient) including a GI endoscopy procedure of 18.4 % over a 11-year period. In addition, a significant increase in day-case endoscopy was observed. Analysis of the evolution of endoscopic procedure is largely used in the United States [3–5]. In Europe, initiatives have led to large-scale collection of endoscopy data; in the Netherlands GI endoscopy data from 20 centers have been prospectively collected in a national database from 2012 to 2020 [6–8], and in the UK, a registry has been implemented to automatically capture patient-level data from the approximately 520 UK endoscopy units [9]. The two databases have been used to measure the impact of the COVID-19 pandemic on GI endoscopy [6, 10]. On the other hand, national registries dedicated to specific procedures [11–14] have enabled large-scale analyses to be carried out.

The increase in upper GI endoscopy was mainly due to the development of diagnostic endoscopy (+25.0 %, or 226 000 patients in 11 years). This increase can be explained by the population aging and the
<table><caption>**Table 2**
Evolution of hospital stays between 2008 and 2018: a selection of GI endoscopy procedures.</caption><thead><tr><th></th><th>2008</th><th>2009</th><th>2010</th><th>2011</th><th>2012</th><th>2013</th><th>2014</th><th>2015</th><th>2016</th><th>2017</th><th>2018</th><th>%</th><th>p-value</th></tr></thead><tbody><tr><td>Upper GI endoscopy</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Diagnostic upper GI endoscopy</td><td>905,041</td><td>930,966</td><td>963,128</td><td>982,635</td><td>1022,719</td><td>1030,814</td><td>1052,941</td><td>1072,260</td><td>1103,354</td><td>1111,458</td><td>1130,783</td><td>24.9</td><td>&lt;0.0001</td></tr><tr><td>Endoscopic band ligation</td><td>12,142</td><td>12,747</td><td>12,734</td><td>12,820</td><td>13,239</td><td>13,961</td><td>13,735</td><td>13,882</td><td>14,071</td><td>14,169</td><td>13,944</td><td>14.8</td><td>0.001</td></tr><tr><td>Esophageal dilation</td><td>6367</td><td>6296</td><td>6325</td><td>6585</td><td>6794</td><td>7111</td><td>7342</td><td>7967</td><td>7878</td><td>8198</td><td>8400</td><td>31.9</td><td>0.0002</td></tr><tr><td>Esophageal stenting</td><td>2595</td><td>2965</td><td>3355</td><td>3490</td><td>3416</td><td>3555</td><td>3401</td><td>3397</td><td>3294</td><td>3259</td><td>3334</td><td>28.5</td><td>1</td></tr><tr><td>Upper GI endoscopic resection</td><td>12,965</td><td>14,123</td><td>15,261</td><td>15,405</td><td>17,059</td><td>18,206</td><td>19,963</td><td>21,892</td><td>22,414</td><td>23,226</td><td>25,041</td><td>93.1</td><td>0.01</td></tr><tr><td>Lower GI endoscopy</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Diagnostic colonoscopy</td><td>828,371</td><td>856,633</td><td>866,792</td><td>874,840</td><td>882,424</td><td>885,355</td><td>890,506</td><td>891,469</td><td>927,553</td><td>919,669</td><td>917,062</td><td>10.7</td><td>0.0002</td></tr><tr><td>Resection of colonic lesions (except EMR)</td><td>383,697</td><td>406,854</td><td>401,126</td><td>395,680</td><td>394,822</td><td>403,524</td><td>408,575</td><td>423,797</td><td>478,168</td><td>464,250</td><td>471,986</td><td>23.0</td><td>0.005</td></tr><tr><td>Colonic EMR</td><td>30,044</td><td>38,506</td><td>41,023</td><td>44,609</td><td>48,058</td><td>54,054</td><td>60,846</td><td>72,531</td><td>97,876</td><td>97,447</td><td>104,333</td><td>247.3</td><td>&lt;0.0001</td></tr><tr><td>Hemostasis of colonic lesions</td><td>158</td><td>178</td><td>177</td><td>177</td><td>193</td><td>191</td><td>215</td><td>219</td><td>220</td><td>225</td><td>244</td><td>284.6</td><td>&lt;0.001</td></tr><tr><td>EUS</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Esophageal and gastric EUS</td><td>7616</td><td>7978</td><td>8471</td><td>8491</td><td>9013</td><td>8912</td><td>9093</td><td>9134</td><td>8955</td><td>9250</td><td>8959</td><td>17.6</td><td>0.003</td></tr><tr><td>Pancreaticobiliary EUS without biopsy</td><td>38,835</td><td>41,099</td><td>44,344</td><td>47,798</td><td>49,767</td><td>52,675</td><td>56,592</td><td>57,566</td><td>58,669</td><td>61,818</td><td>63,165</td><td>63.6</td><td>&lt;0.0001</td></tr><tr><td>Pancreaticobiliary EUS with biopsy</td><td>5969</td><td>7088</td><td>7917</td><td>8965</td><td>10,183</td><td>11,291</td><td>11,877</td><td>12,983</td><td>13,998</td><td>15,432</td><td>16,557</td><td>177.4</td><td>&lt;0.0001</td></tr><tr><td>Anorectal EUS</td><td>6645</td><td>6916</td><td>6826</td><td>6927</td><td>6597</td><td>7044</td><td>7040</td><td>6823</td><td>7329</td><td>7063</td><td>6866</td><td>3.3</td><td>0.16</td></tr><tr><td>Therapeutic EUS</td><td>171</td><td>219</td><td>269</td><td>332</td><td>419</td><td>462</td><td>562</td><td>625</td><td>734</td><td>816</td><td>985</td><td>476.0</td><td>&lt;0.0001</td></tr><tr><td>Pancreaticobiliary and duodenal endoscopy</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Biliary stone removal and lithotripsy during ERCP</td><td>14,869</td><td>15,769</td><td>16,899</td><td>18,332</td><td>19,190</td><td>19,945</td><td>21,071</td><td>21,880</td><td>22,885</td><td>23,860</td><td>25,244</td><td>69.8</td><td>&lt;0.0001</td></tr><tr><td>Biliary stent placement/change/removal</td><td>12,430</td><td>13,528</td><td>14,494</td><td>15,959</td><td>17,452</td><td>19,019</td><td>20,394</td><td>22,109</td><td>23,717</td><td>25,212</td><td>26,307</td><td>111.6</td><td>&lt;0.0001</td></tr><tr><td>Cholangioscopy</td><td>337</td><td>291</td><td>315</td><td>288</td><td>269</td><td>267</td><td>265</td><td>303</td><td>335</td><td>428</td><td>495</td><td>46.9</td><td>0.5</td></tr><tr><td>Endoscopic sphincterotomy</td><td>5206</td><td>5172</td><td>5158</td><td>5421</td><td>5684</td><td>5417</td><td>5542</td><td>5424</td><td>5615</td><td>5890</td><td>5970</td><td>14.7</td><td>0.005</td></tr><tr><td>Small-bowel endoscopy</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Diagnostic small bowel endoscopy</td><td>4350</td><td>4529</td><td>5725</td><td>7144</td><td>7759</td><td>8244</td><td>8648</td><td>7446</td><td>5221</td><td>5060</td><td>4848</td><td>11.4</td><td>0.64</td></tr><tr><td>Endoscopic resection during enteroscopy</td><td>292</td><td>249</td><td>318</td><td>367</td><td>403</td><td>385</td><td>370</td><td>418</td><td>323</td><td>379</td><td>369</td><td>26.4</td><td>0.1</td></tr><tr><td>Hemostasis of intestinal lesion during enteroscopy</td><td>311</td><td>400</td><td>437</td><td>481</td><td>485</td><td>441</td><td>513</td><td>500</td><td>464</td><td>475</td><td>510</td><td>64.0</td><td>0.02</td></tr></tbody></table>

EMR: endoscopic mucosal resection; ERCP: endoscopic retrograde cholangio pancreatography; EUS: endoscopic ultrasound.

Corresponding CCAM procedures are detailed in Supplementary material.
rising incidence of gastroesophageal reflux disease, for instance, but it is also in line with the increase in lower GI endoscopy. Indeed, in France, upper GI endoscopy is often performed in unsedated patients whereas colonoscopy is mainly performed in sedated patients, so physicians may be inclined to perform upper GI endoscopy during the same session, in order to increase patient acceptance of the examination. This approach has recently been shown to be more cost-effective [4]. A significant increase in therapeutic upper GI endoscopy was also observed, from tumor resection to esophageal and duodenal stenting. The latter was probably influenced in part by the rising incidence of pancreatic cancer. Indeed, between 2010 and 2018, the incidence of pancreatic cancer in France rose by an average of 2.6% in men and 3.2% in women each year [15]. To note, the median age of upper GI endoscopy increased slightly during the study period and remained in the sixth decade. Regarding lower GI procedures, we observed an increase of almost 40% in endoscopic resection of colonic lesions. Changes in polyp resection modalities were also evident, with a dramatic increase in EMR and an increasing number of day-case endoscopic resections of colonic lesions. This growing number of EMRs is probably not due to an increase in the incidence of polyps in France but - at least in part - to improved detection thanks to the introduction of the fecal immunochemical testing for colorectal cancer screening in 2015 [16], better endoscope resolution and post-graduate training on EMR. Furthermore, the high number of EMRs performed in France can be explained by the fact that the same code is applied for small (<10 mm) and large (≥10 mm) resections [17]. The diffusion of cold snare polypectomy, that replaced EMR, hot snare-, hot forceps- and cold forceps- polypectomy in most small polyps, began during the 2010 decade and was probably not implemented in all centers before the end of the study period. An English study describing polypectomy practices between 2010 and 2012 observed changes in endoscopic techniques despite a shorter study period [18]. Details of the techniques could not be investigated in our study because the type of instrument used is not taken into account in the code. It is also important to note that, over this period, another French study confirmed an increase in the rate of large benign polyps and superficial colorectal cancers resected by endoscopy rather than by surgery [17]. Interestingly, while endoscopic colonic resection increased dramatically, endoscopic colonic hemostasis remained at a low level, suggesting that reinterventions for post-resection hemorrhage were rare, thus confirming the low risk of hemorrhage after endoscopic resection.

European guidelines recommending reduced post-polypectomy surveillance were updated after the study period [19], suggesting that the number of colonoscopies would stabilize or even decrease in the future. Finally, it is worth noting that the median age of patients undergoing colonoscopy slightly decreased over the study period, perhaps due to the spread of colorectal cancer mass screening.

Our results also confirm the progression of pancreaticobiliary endoscopy, with EUS and pancreaticobiliary and duodenal endoscopy showing the most significant increases, 63 % and 70.2 %, respectively, over 11 years. At least two hypotheses can be discussed to explain this development. First, the aging of the French population is leading to an increase in the number of choledocholithiasis and pancreatic cancers detected every year [15]. ERCP for biliary stones rose from 15,000 to 25,000/year over the study period, while endoscopic biliary stent management increased from 12,000 to 26,000/year. Second, the fact that a new generation of endoscopists is combining EUS and ERCP in the same session could help to diagnose and treat more pancreato-biliary lesions endoscopically. In particular, when a pancreatic neoplasm is diagnosed in the context of biliary obstruction, an EUS-guided biopsy is performed first, followed by an ERCP and, if technically unsuccessful, EUS-guided lumen-apposing metal stent placement. It is striking to note that EUS-guided biopsy has risen from 6000 to 16,000/year over the study period.

After an increase during the first part of the study period, small-bowel endoscopy declined, probably due to an increase in the use of video capsule endoscopy, which has become the preferred method for

small bowel examination [20].

At the national level and including all endoscopy procedures, a significant increase in day-case activity has been demonstrated. Indeed, approximately 2/3 of hospital admissions including a GI endoscopy were day-cases in 2008, compared with more than 3/4 of hospital admissions in 2018. Simultaneously, ALOS of inpatient endoscopy remained roughly stable from 8.88 days in 2008 to 8.48 days in 2018, despite the aging of the French population [21]. Inpatient endoscopy covers an important spectrum of situations. On the one hand, some patients spend one night in hospital to undergo a therapeutic endoscopy such as ERCP, or because they live alone and cannot be discharged the same day. These situations are decreasing as the safety of interventional endoscopy increases and efforts are made to provide convenient ambulatory care. On the other hand, patients hospitalized for GI or non-GI reasons may undergo GI endoscopy during their stay. The types of endoscopy procedures with the longer ALOS are upper GI endoscopy, small bowel endoscopy, and pancreatic and duodenal endoscopy.

As part of the 2018–2022 national health strategy, the importance of continuing the ambulatory shift and developing alternatives to so-called conventional hospitalization has been stressed. This national strategy aims to increase the rate of ambulatory surgery to 70 % by 2022. Interestingly, there is growing evidence of the feasibility and safety of day-case endoscopy procedures, such as submucosal dissection, despite their reputation as high-risk procedures [22].

This study has inherent limitations, such as the lack of precision in the indications for endoscopy and the absence of details on how procedures that do not have their own CCAM wording were coded. For instance, in this study, therapeutic EUS was represented by only one code which does not reflect the variety of underlying indications. Overall, minimally invasive endoscopy procedures are progressing, finding new indications that were previously managed by surgery, such as POEM for achalasia, EMR and ESD for large benign colorectal lesions and superficial colorectal tumors, endoscopic necrectomy for infected pancreatic necrosis, EUS-guided gastroenterostomy for gastric outlet obstruction, and endoscopic sleeve gastroplasty, or by interventional radiology, such as therapeutic EUS for difficult biliary drainage, as the next evaluation of endoscopic activity will likely show. However, these new procedures had no specific CCAM wording at the time of this study, making it difficult to obtain a clear picture of their evolution. In addition, the database did not allow us to assess the rate of coding errors or the variation in coding between institutions, which may introduce a significant risk of bias. Furthermore, this method for recording the evolution of GI endoscopy is indirect and does not provide the exact number of endoscopies, in particular when several endoscopy procedures were performed during the same stay, for instance upper GI endoscopy in the case of refractory hemorrhage, or necrectomy in the case of complicated pancreatic collection. However, this method makes it possible to consider the whole country, and its scope provides an original and valuable picture of the practice of GI endoscopy in a European country. Finally, we did not assess the appropriateness of endoscopy during this period, which can vary considerably by country and situation [23], nor the complications rates of day-case and inpatient procedures [24]. However, previous studies demonstrated that the risk of day-case endoscopy is low, but underestimated, especially if the distance between the endoscopy site and patient's home is important [25]. Data on the increase in endoscopy procedures are also needed to plan the transition to green endoscopy [26]. Another limitation of this study is that it is taking place in a single country, which may hamper the generalizability of its results. For example, France has a specific healthcare system, encompassing both public and private health establishments, but the cost of endoscopic procedures is largely covered by the social security system to which all citizens contribute. Furthermore, the prescription of anesthetic drugs, and hence sedation, is carried out only by anesthetists, and GI endoscopy is performed in the overwhelming majority of cases by gastroenterologists. However, French endoscopists use and participate in the development of European
recommendations, which increases the external validity of these results. Finally, when transposing these data to another population, it is important to bear in mind the composition of the French population, that of an ageing Western European country [21].

This study highlights the growing need for endoscopy training in a large country. Indeed, as indications for surgical removal of benign recto-colonic lesions have declined considerably, more GI endoscopists need to be trained in advanced endoscopic resections such as complex EMR and ESD. Another example is the increasing need for EUS and ERCP due to the rising incidence of pancreatic adenocarcinoma. Thus, training in therapeutic endoscopy requires trainers, adequate and often expensive simulation models, and more generally an organization that allows residents, fellows and more experienced endoscopists to learn and repeat procedures in order to gain experience and promote excellence in endoscopy. Health authorities must also consider medical demographics [27] and increase the number of gastroenterology residents in order to promote high-quality GI endoscopy, in a context where it is replacing many surgical procedures because of their less-invasive nature.

## Conclusion

This study shows the progression of GI endoscopy in France, with a sustained increase over 11 years in the number hospital admissions for patients undergoing GI endoscopy and, in particular, the progression of pancreaticobiliary interventional endoscopy and endoscopic resection of colonic lesions. Simultaneously, day-case endoscopy is taking on an increasingly important role. In this context, efforts must be made to improve the training of endoscopists and plan the transition toward green endoscopy.

## Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

## Funding statement

This study was funded by the French Society of Digestive Endoscopy (SFED) and the main medical device manufacturers in the sector, members of the National Union of the Medical Technology Industry (Syndicat National de l'Industrie des Technologies Médicales - SNITEM).

The digestive tumour registry of Finistère is funded by the National Public Health Institute (Santé publique France), the National Cancer Institute (INCa) and the French League Against Cancer (CD29).

## CRediT authorship contribution statement

**Hervé-Pierre Toudic:** Writing – original draft, Investigation, Formal analysis, Data curation. **Marie Morvan:** Software, Resources, Formal analysis. **Noémi Reboux:** Writing – review & editing. **Stanislas Chaussade:** Writing – review & editing. **Olivier Gronier:** Writing – review & editing, Funding acquisition. **Stéphane Koch:** Writing – review & editing, Methodology, Funding acquisition. **David Bernardini:** Writing – review & editing, Funding acquisition. **Emmanuel Coron:** Writing – review & editing. **Michel Robaszkiewicz:** Writing – review & editing, Supervision, Methodology, Funding acquisition, Conceptualization. **Lucille Quénéhervé:** Writing – original draft, Supervision, Investigation, Formal analysis.

## Declaration of competing interest

The authors declare that they have no conflict of interest related to this work.

## Acknowledgment

The authors thank the French Society of Digestive Endoscopy (SFED) and the main medical device manufacturers in the sector, members of the National Union of the Medical Technology Industry (Syndicat National de l'Industrie des Technologies Médicales - SNITEM) for funding this study. The authors would also like to thank Mr Ludovic Lamarsalle and his team at HEVA for carrying out the study and extracting PMSI data from the database of the Agence Technique de l'Information sur l'Hospitalisation (ATIH).

## Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.clinre.2024.102505.

## References

[1] Hirschowitz BI, Curtiss LE, Peters CW, Pollard HM. Demonstration of a new gastroscope, the fiberscope. Gastroenterology 1958;35(1):50. Jul discussion 51-53.

[2] Inscription sur la liste des actes et prestations [Internet]. [cited 22 Nov 30]. Available from: https://www.ameli.fr/medecin/textes-reference/inscription-liste-actes-prestations.

[3] Sonnenberg A, Turner KO, Genta RM. Trends of colonic neoplasia in US outpatient endoscopy centers. Dig Dis Sci 2022;67(10):4702-7. Oct.

[4] Wang P, Hutfless SM, Shin EJ, Hartman C, Disney S, Fain CC, et al. Same-day vs different-day elective upper and lower endoscopic procedures by setting. JAMA Intern Med 2019;179(7):953-63. Jul 1.

[5] Huang RJ, Thosani NC, Barakat MT, Choudhary A, Mithal A, Singh G, et al. Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013. Gastrointest Endosc 2017;86(2): 319-26. Auge5.

[6] Lantinga MA, Theunissen F, Ter Borg PCJ, Bruno MJ, Ouwendijk RJT, Siersema PD, et al. Impact of the COVID-19 pandemic on gastrointestinal endoscopy in the Netherlands: analysis of a prospective endoscopy database. Endoscopy 2021;53(2): 166-70. Feb.

[7] Theunissen F, Lantinga MA, Borg PCJT, Ouwendijk RJT, Bruno MJ, Siersema PD, et al. The yield of upper gastrointestinal endoscopy in patients below 60 years and without alarm symptoms presenting with dyspepsia. Scand J Gastroenterol 2021; 56(6):740-6. Jun.

[8] Theunissen F, Lantinga MA, ter Borg PCJ, Ouwendijk RJT, Siersema PD, Bruno MJ. Efficacy of different bowel preparation regimen volumes for colorectal cancer screening and compliance with European Society of Gastrointestinal Endoscopy performance measures. United Eur Gastroenterol J 2023;11(5):448-57. May 15.

[9] Lee TJ, Siau K, Esmaily S, Docherty J, Stebbing J, Brookes MJ, et al. Development of a national automated endoscopy database: the United Kingdom National Endoscopy Database (NED). United Eur Gastroenterol J 2019;7(6):798-806. Jul.

[10] Rutter MD, Brookes M, Lee TJ, Rogers P, Sharp L. Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis. Gut 2021;70(3):537-43. Mar.

[11] Rodríguez de Santiago E, Herreros-de-Tejada A, Albéniz E, Ramos Zabala F, Fernández-Esparrach G, Nogales O, et al. Implementation of esophageal endoscopic submucosal dissection in Spain: results from the nationwide registry. Gastroenterol Hepatol 2024;47(2):119-29. Feb.

[12] Zwager LW, Bastiaansen BAJ, van der Spek BW, Heine DN, Schreuder RM, Perk LE, et al. Endoscopic full-thickness resection of T1 colorectal cancers: a retrospective analysis from a multicenter Dutch eFTR registry. Endoscopy 2022;54(5):475-85. May.

[13] Albuys J, Montori Pina S, Boukechiche S, Albéniz E, Vidal G, Legros R, et al. Risk of delayed bleeding after colorectal endoscopic submucosal dissection: the Limoges Bleeding Score. Endoscopy 2024;56(2):110-8. Feb.

[14] Alfarone L, Schaefer M, Wallenhorst T, Lepilliez V, Degand T, Le Baleur Y, et al. Impact of annual case volume on colorectal endoscopic submucosal dissection outcomes in a large prospective cohort study. Am J Gastroenterol 2024;11. Jul.

[15] Defossez G., Le Guyader-Peyrou S., Uhry Z., Grosclaude P., Colonna M., Dantony E., et al. Estimations nationales de l'incidence et de la mortalité par cancer en France métropolitaine entre 1990 et 2018. Volume 1 – Tumeurs solides [Internet]. Santé publique France; 2019 [cited 2020 Apr 7] p. 372. Available from: https://www.santepubliquefrance.fr/; https://geodes.santepubliquefrance.fr; http://lesdonnees.e-cancer.fr/; https://www.e-cancer.fr/.

[16] Cariou M, El Fettouhi A, Kermarrec T, Bommelaere F, Foll Y, Nousbaum JB, et al. Comparative evaluation of two colorectal cancer screening campaigns using different faecal occult blood tests in a French area. Cancer Epidemiol 2020;69: 101839. Dec.

[17] Le Roy F, Manfredi S, Hamonic S, Piette C, Bouguen G, Riou F, et al. Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: a population-based study. Endoscopy 2016;48(3):263-70. Mar.

[18] Din S, Ball AJ, Taylor E, Rutter M, Riley SA, Johal S. Polypectomy practices of sub-centimeter polyps in the English Bowel Cancer Screening Programme. Surg Endosc 2015;29(11):3224-30. Nov.
[19] Hassan C, Antonelli G, Dumonceau JM, Regula J, Bretthauer M, Chaussade S, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2020. Endoscopy 2020;52(8):687-700. Aug.

[20] Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature 2000;405(6785):417. May 25.

[21] Bilan démographique 2018 - Insee Première - 1730 [Internet]. [cited 2022 May 11]. Available from: https://www.insee.fr/fr/statistiques/3692693.

[22] Maselli R, Galtieri PA, Di Leo M, Ferrara EC, Anderloni A, Carrara S, et al. Cost analysis and outcome of endoscopic submucosal dissection for colorectal lesions in an outpatient setting. Dig Liver Dis 2019;51(3):391-6. Mar.

[23] Rodríguez-Alonso L, Rodríguez-Moranta F, Maisterra S, Botargues JM, Berrozpe A, Ruíz-Cerulla A, et al. The EPAGE guidelines are not an effective strategy for managing colonoscopies during the COVID-19 pandemic. Gastroenterol Hepatol 2022;45(1):9-17. Jan.

[24] Wang L, Mannalithara A, Singh G, Ladabaum U. Low rates of gastrointestinal and non-gastrointestinal complications for screening or surveillance colonoscopies in a population-based study. Gastroenterology 2018;154(3):540-55. Febe8.

[25] Jackson KL, Goel S, Kho AN, Keswani RN. Distance from hospital impacts adverse event detection after outpatient endoscopy. Gastrointest Endosc 2017;85(2):380-6. Feb.

[26] Sebastian S, Dhar A, Baddeley R, Donnelly L, Haddock R, Arasaradnam R, et al. Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy. Gut 2023;72(1):12-26. Jan.

[27] Zerbib F, Sylvain C, Thabut D, Marteau P, Robaszkiewicz M. White book of gastroenterology and hepatology in france. Conseil National Professionnel d'Hépato-Gastroentérologie; 2020.