Küçükdemirci Ö, Cagaptay S, Bas B. Diagnostic yield and biopsy practice variability between gastroenterologists and general surgeons performing upper gastrointestinal endoscopy. World J Gastrointest Surg 2026; 18(9): 123344 [DOI: 10.4240/wjgs.123344]
Corresponding Author of This Article
Ömer Küçükdemirci, MD, Chief Physician, Department of Gastroenterology, Hakkari State Hospital, Dağgöl, Gençlik Cd. No. 2, Hakkari 30000, Türkiye. drkucukdemirci@yahoo.com
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Küçükdemirci Ö, Cagaptay S, Bas B. Diagnostic yield and biopsy practice variability between gastroenterologists and general surgeons performing upper gastrointestinal endoscopy. World J Gastrointest Surg 2026; 18(9): 123344 [DOI: 10.4240/wjgs.123344]
Author contributions: Küçükdemirci Ö conceived and designed the study, collected and analyzed the data, interpreted the findings, drafted the manuscript, and performed critical revision of the manuscript for important intellectual content; Cagaptay S and Bas B contributed to data interpretation and critical revision of the manuscript; Cagaptay S contributed to the preparation and revision of the histopathology-related sections of the manuscript; Bas B contributed to literature review. All authors read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.
AI contribution statement: ChatGPT (OpenAI) was used solely for language refinement of selected sections of the manuscript. No part of the main text was generated by artificial intelligence. AI was not involved in the study design, data collection, data analysis, interpretation of the results, or preparation of the figures. No AI-generated images were used in this manuscript. All AI-assisted text was carefully reviewed and verified by the authors, who take full responsibility for the scientific content of the manuscript.
Institutional review board statement: The study protocol was approved by the Hakkari University Scientific Research and Publication Ethics Committee (approval No. 2025/213).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: The datasets generated and/or analyzed during the current study are not publicly available due to institutional, ethical, and legal restrictions related to patient confidentiality. De-identified data may be made available from the corresponding author upon reasonable request and subject to approval by the relevant institutional authorities.
Corresponding author: Ömer Küçükdemirci, MD, Chief Physician, Department of Gastroenterology, Hakkari State Hospital, Dağgöl, Gençlik Cd. No. 2, Hakkari 30000, Türkiye. drkucukdemirci@yahoo.com
Received: May 15, 2026 Revised: June 17, 2026 Accepted: June 29, 2026 Published online: September 27, 2026 Processing time: 123 Days and 13.4 Hours
Abstract
BACKGROUND
To compare biopsy practices, histopathological diagnostic yield, and detection of premalignant gastric lesions between gastroenterologists and general surgeons performing upper gastrointestinal endoscopy in a geographically remote, specialist-limited setting, and to evaluate whether endoscopist specialty remained associated with intestinal metaplasia detection after adjustment for biopsy sampling intensity and temporal factors.
AIM
To compare biopsy practices, histopathological diagnostic yield, and detection of premalignant gastric lesions between gastroenterologists and general surgeons performing upper gastrointestinal endoscopy, and to evaluate whether endoscopist specialty remained associated with intestinal metaplasia detection after adjustment for biopsy sampling intensity and temporal factors.
METHODS
This retrospective observational study included 8825 upper gastrointestinal endoscopy procedures performed from 2015 to 2025 at a secondary-care hospital. Endoscopic findings, biopsy practices, and histopathological outcomes were compared between gastroenterologists and general surgeons. Histopathological analyses were restricted to procedures with at least one pathologically evaluable biopsy specimen. Multivariable logistic regression and temporal sensitivity analyses were performed to identify factors associated with intestinal metaplasia detection.
RESULTS
Of 8825 procedures, 7232 (82.0%) were performed by gastroenterologists and 1593 (18.0%) by general surgeons. Biopsy acquisition was more frequent among gastroenterologists (90.2% vs 79.7%, P < 0.001), who also performed multisite sampling more often. Among biopsied procedures, intestinal metaplasia was detected in 10.3% and 8.8% of procedures, respectively (P = 0.124), whereas Helicobacter pylori infection (62.4% vs 56.6%, P < 0.001) and dysplasia (1.2% vs 0.2%, P = 0.004) were more frequently identified in the gastroenterologist group. In multivariable analysis, increasing age [odds ratio (OR): 1.04, 95% confidence interval (CI): 1.03-1.04, P < 0.001] and Helicobacter pylori infection (OR: 1.48, 95%CI: 1.26-1.74, P < 0.001) were independently associated with intestinal metaplasia. After adjustment for biopsy sampling intensity and study period, endoscopist specialty was not independently associated with intestinal metaplasia detection (OR: 1.08, 95%CI: 0.87-1.33, P = 0.511), whereas biopsy sampling intensity remained significant (OR: 1.13, 95%CI: 1.08-1.18, P < 0.001).
CONCLUSION
Gastroenterologists and general surgeons demonstrated differences in biopsy acquisition practices and histopathological diagnostic yield. However, the attenuation of specialty-related differences after adjustment for biopsy sampling intensity and temporal factors suggests that biopsy strategy and sampling behavior may play a greater role than specialty background alone in the detection of premalignant gastric lesions.
Core Tip: Upper gastrointestinal endoscopy is frequently performed by both gastroenterologists and general surgeons in geographically remote and specialist-limited settings, yet data comparing diagnostic yield between specialties remain limited. In this 10-year real-world study including 8825 procedures, gastroenterologists obtained biopsies more frequently, performed multisite sampling more often, and detected Helicobacter pylori infection and dysplasia more frequently than general surgeons. However, the association between endoscopist specialty and intestinal metaplasia detection was attenuated after adjustment for biopsy sampling intensity and temporal factors. These findings suggest that biopsy strategy and sampling behavior may influence the detection of premalignant gastric lesions more strongly than specialty background alone and highlight the importance of standardized biopsy protocols and quality-focused endoscopy training.
Citation: Küçükdemirci Ö, Cagaptay S, Bas B. Diagnostic yield and biopsy practice variability between gastroenterologists and general surgeons performing upper gastrointestinal endoscopy. World J Gastrointest Surg 2026; 18(9): 123344
Upper gastrointestinal endoscopy is a cornerstone diagnostic procedure in modern gastrointestinal practice and plays a critical role in the detection and surveillance of premalignant lesions and upper gastrointestinal malignancies[1,2]. Because upper gastrointestinal endoscopy is highly operator-dependent, diagnostic yield may be influenced by factors such as procedural experience, mucosal assessment, and biopsy strategy. With the increasing global burden of gastrointestinal diseases, the demand for endoscopic services has grown substantially worldwide. However, access to dedicated gastroenterology services remains uneven, particularly in geographically distant and resource-limited healthcare settings, where upper gastrointestinal endoscopy is frequently performed by physicians from multiple specialties[3,4].
A major challenge in providing adequate gastroenterological care is the limited and uneven distribution of trained specialists. This issue persists globally, including in high-income healthcare systems, where the number of gastroenterologists per 100000 population remains relatively low. Previous reports estimate this number to be approximately 3.9 in the United States, 3.48 in France, 2.1 in Australia, 1.83 in Canada, 1.41 in the United Kingdom, and 1.2 in Türkiye[5-7]. Consequently, access to gastroenterologists may be limited, particularly outside major urban centers. In geographically distant or sparsely populated areas, maintaining tertiary referral centers or a full spectrum of subspecialty services may not always be feasible[8]. As a result, in geographically distant and specialist-limited settings, upper gastrointestinal endoscopy is frequently performed not only by gastroenterologists but also by general surgeons and other physicians involved in multidisciplinary endoscopy practice[9-12].
Limitations in specialist availability and healthcare infrastructure may directly affect the quality and consistency of endoscopic practice[13]. Upper gastrointestinal endoscopy is widely recognized as an operator-dependent procedure in which differences in training background, procedural experience, and biopsy strategy may influence diagnostic interpretation and lesion detection[2,12,13]. However, real-world evidence comparing endoscopic and histopathological outcomes between gastroenterologists and general surgeons remain limited, particularly in geographically distant and specialist-limited healthcare settings[14].
Therefore, using a 10-year endoscopy dataset from a secondary-care hospital located in a geographically remote region, we aimed to evaluate differences in biopsy acquisition rates, biopsy sampling strategies, and histopathological diagnostic yield between gastroenterologists and general surgeons performing upper gastrointestinal endoscopy. Specifically, we aimed to compare biopsy acquisition rates, biopsy sampling strategies, and the detection of intestinal metaplasia, Helicobacter pylori infection, and other premalignant gastric lesions between gastroenterologists and general surgeons. We also evaluated whether the association between endoscopist specialty and intestinal metaplasia detection persisted after adjustment for biopsy sampling intensity.
MATERIALS AND METHODS
This retrospective observational study was conducted at Hakkari State Hospital, a secondary-care center located in eastern Türkiye. All upper gastrointestinal endoscopy procedures performed from January 2015 to October 2025 were retrospectively reviewed. During the study period, upper gastrointestinal endoscopy procedures were performed by both gastroenterologists and general surgeons. Gastroenterologists were available intermittently during the study period (approximately 5.5 years), with periods of overlap between the two groups. A total of six gastroenterologists and seventeen general surgeons performed endoscopic procedures. Endoscopists who performed fewer than 30 procedures during the study period were excluded to reduce operator-level variability. All participating physicians had completed specialty training and independently performed upper gastrointestinal endoscopy procedures as part of routine clinical practice at the study center. Histopathological evaluation of biopsy specimens was performed by 16 different pathologists during the study period.
Patients who underwent upper gastrointestinal endoscopy as outpatients or inpatients and had a complete endoscopy report in the hospital information system were eligible. Additional clinical records were reviewed when available to supplement missing data. Patients were excluded if no formal endoscopy report was available, if clinical or procedural data were inaccessible, or if they were younger than 18 years. After applying these criteria, 8825 upper gastrointestinal endoscopy procedures were included in the final analysis.
Demographic data (age and sex), endoscopic indications, endoscopic findings, biopsy characteristics, and histopathological results were extracted from electronic medical records and endoscopy databases. All study data were independently reviewed and recorded by an experienced endoscopy nurse and a pathologist, both blinded to the study objectives to minimize bias. Endoscopic indications and findings were recorded as documented in the original endoscopy reports. Because multiple endoscopic diagnoses could be reported during a single procedure, more than one finding was allowed per examination. Indication data were not consistently available throughout the study period; therefore, analyses related to endoscopic indications were restricted to procedures with documented information.
Biopsy practices were evaluated according to biopsy acquisition, number of biopsy fragments, and sampling locations. Biopsy sampling sites included the esophagus, gastric antrum, corpus, and duodenum. For histopathological analyses, biopsy acquisition was defined as the presence of at least one pathologically evaluable tissue specimen. Procedures without a pathologically evaluable tissue specimen were excluded from histopathological outcome analyses. Histopathological diagnoses were obtained from pathology reports and included chronic active gastritis, intestinal metaplasia, Helicobacter pylori infection, atrophy, dysplasia, and malignancy.
The primary outcome of the study was the detection of premalignant upper gastrointestinal lesions, particularly intestinal metaplasia and dysplasia. Because intestinal metaplasia was the most frequently detected premalignant lesion and had sufficient events for robust statistical analysis, it was selected as the dependent variable in the multivariable regression models. Secondary outcomes included the detection of Helicobacter pylori infection and malignancy, as well as differences in biopsy acquisition rates, biopsy sampling strategies, and endoscopic diagnostic patterns between gastroenterologists and general surgeons.
To assess the potential impact of temporal confounding, additional analyses according to study period were performed. The study period was divided into three predefined intervals (2015-2018, 2019-2022, and 2023-2025), and temporal changes in biopsy practices and histopathological diagnostic yield were evaluated separately for gastroenterologists and general surgeons. Although gastroenterologists were not continuously available throughout the study period, they performed procedures during each of the predefined intervals. Therefore, temporal analyses were incorporated to better evaluate whether the observed differences between specialties could be explained by calendar-time effects. The study protocol was approved by the Hakkari University Scientific Research and Publication Ethics Committee (approval No. 2025/213).
Statistics analysis
Statistical analyses were performed using SPSS Statistics version 26 (IBM Corp., Armonk, NY, United States). Categorical variables were compared using the χ2 test, and continuous variables were analyzed using the independent samples t-test. Multivariable logistic regression analysis was performed to identify factors associated with intestinal metaplasia detection. A P < 0.05 was considered statistically significant. Temporal changes in biopsy practices and histopathological diagnostic yield across predefined study periods were analyzed separately for gastroenterologists and general surgeons. Categorical variables across study periods were compared using the χ2 test and continuous variables using one-way analysis of variance. In addition, a sensitivity logistic regression analysis including endoscopist specialty, biopsy sampling intensity, and study period was performed to evaluate the potential influence of calendar time on intestinal metaplasia detection.
RESULTS
A total of 8825 upper gastrointestinal endoscopy procedures performed from 2015 to 2025 were included in the study. Of these, 7232 procedures (82.0%) were performed by gastroenterologists, whereas 1593 procedures (18.0%) were performed by general surgeons. Endoscopists with a procedural volume of fewer than 30 procedures were excluded to reduce operator-level variability. The mean age of patients was 43.1 ± 16.3 years in the gastroenterologist group and 42.9 ± 16.9 years in the general surgeon group, with identical median ages of 41 years. Male patients were more frequent in the general surgeon group (55.3% vs 50.3%, P = 0.002). The temporal distribution of procedures differed significantly between specialties (P < 0.001). Gastroenterologists performed procedures across all three study periods, with 2434 procedures in 2015-2018, 2400 in 2019-2022, and 2398 in 2023-2025. General surgeons also performed procedures across the study period, with increasing procedural volume over time. Baseline demographic characteristics and temporal distribution of procedures are summarized in Table 1.
Table 1 Demographic characteristics and temporal distribution of procedures, n (%).
Pre-procedure indications were available for 1371 procedures (15.5%), including 1003 procedures in the gastroenterologist group and 368 procedures in the general surgeon group. Among procedures with documented indications, dyspepsia was the most common indication in the gastroenterologist group (50.2%), followed by screening (12.9%) and upper gastrointestinal bleeding (11.5%). In the general surgeon group, screening (28.3%) and abdominal pain (27.2%) were more frequently reported indications. The distribution of documented indications differed significantly between groups (P < 0.001) (Table 2). To evaluate the potential influence of indication-related referral patterns, an additional sensitivity analysis was performed in the subset of 1371 procedures with documented endoscopic indications. Within this subgroup, intestinal metaplasia was detected in 7.4% of procedures performed by gastroenterologists and 4.6% of those performed by general surgeons (P = 0.090). Helicobacter pylori infection was identified in 54.8% and 53.8% of procedures, respectively (P = 0.781). These findings suggest that differences in endoscopic indications and referral pathways may partially contribute to the observed differences in histopathological outcomes, particularly for intestinal metaplasia.
Table 2 Indications for upper gastrointestinal endoscopy, n (%).
Because multiple diagnoses could be recorded per procedure, the total number of endoscopic findings exceeded the number of procedures. Accordingly, 13292 diagnoses were documented in the gastroenterologist group and 1944 in the general surgery group. Gastritis was the most common finding in both groups but was reported more frequently by non-gastroenterologists (62.0% vs 48.7%, P < 0.001). In contrast, bulbitis, hiatal hernia/Lower esophageal sphincter laxity, and celiac disease were more frequently reported by gastroenterologists (all P < 0.01). Normal findings were also more common in the general surgery group (4.7% vs 1.1%, P < 0.001) (Table 3).
Biopsy was performed in the majority of procedures in both groups and was more frequently obtained in the gastroenterologist group than in the general surgery group (90.2% vs 79.7%, P < 0.001). Among procedures with biopsy, the mean number of biopsy specimens was comparable between groups (2.88 ± 1.94 vs 2.92 ± 2.01, P = 0.588). However, biopsy sampling strategies differed between groups. Gastroenterologists more frequently obtained combined antrum and corpus biopsies, whereas general surgeons more commonly performed antrum-only sampling. Multisite biopsy sampling was also more frequently observed in the gastroenterologist group, while general surgeons tended to rely on more limited sampling strategies. Detailed biopsy acquisition rates and biopsy site distributions are presented in Table 4.
Table 4 Biopsy performance and distribution of biopsy sites, n (%).
Histopathological outcomes were reanalyzed using only procedures in which at least one biopsy specimen was obtained. Among biopsied procedures, intestinal metaplasia was detected in 10.3% of procedures performed by gastroenterologists and 8.8% of those performed by general surgeons, although this difference did not reach statistical significance (P = 0.124). In contrast, Helicobacter pylori infection remained significantly more frequent in the gastroenterologist group, being identified in 62.4% and 56.6% of biopsied procedures, respectively (P < 0.001). Notably, dysplasia was detected six-fold more frequently among biopsied procedures performed by gastroenterologists (1.2% vs 0.2%, P = 0.004). Similarly, chronic active gastritis was more common in the gastroenterologist group, whereas malignancy detection rates remained comparable between specialties. Detailed histopathological findings are presented in Table 5.
Table 5 Histopathological findings among biopsied procedures, n (%).
Multivariable logistic regression analysis identified increasing age and Helicobacter pylori infection as independent predictors of intestinal metaplasia. In the initial model, procedures performed by gastroenterologists showed a borderline association with higher intestinal metaplasia detection [odds ratio (OR): 1.23, 95%CI: 1.00-1.52, P = 0.051]. Increasing age was associated with greater odds of intestinal metaplasia (OR: 1.03 per year, P < 0.001), whereas female sex was associated with lower odds (OR: 0.80, P = 0.003). Helicobacter pylori infection was strongly associated with intestinal metaplasia detection (OR: 2.06, P < 0.001).
After additional adjustment for biopsy sampling intensity, the association between endoscopist specialty and intestinal metaplasia detection was attenuated and no longer statistically significant (OR: 1.14, 95%CI: 0.92-1.41, P = 0.23). In contrast, increasing age and Helicobacter pylori infection remained independent predictors of intestinal metaplasia (Table 6).
Table 6 Multivariable models for predictors of intestinal metaplasia.
Temporal changes in biopsy practice and histopathological diagnostic yield were further evaluated according to specialty and study period. Biopsy performance increased significantly over time in both gastroenterologists and general surgeons (both P < 0.001). The mean number of biopsy fragments also changed significantly across study periods in both groups (both P < 0.001), with the highest biopsy sampling intensity observed during 2023-2025. However, intestinal metaplasia detection did not significantly differ across study periods in either the gastroenterologist group (10.0%, 9.7%, and 8.3%; P = 0.086) or the general surgery group (6.1%, 7.0%, and 7.6%; P = 0.706). In contrast, Helicobacter pylori detection changed significantly over time in both groups. These findings suggest that although biopsy practices changed over the study period, temporal variation alone did not appear to explain the observed differences in intestinal metaplasia detection. Detailed temporal analyses are presented in Table 7.
Table 7 Temporal changes in biopsy practice and histopathological diagnostic yield according to specialty, n (%)/mean ± SD.
To further evaluate the potential influence of temporal confounding, an additional sensitivity logistic regression analysis was performed including endoscopist specialty, biopsy sampling intensity, and study period. Using 2015-2018 as the reference period, endoscopist specialty was not independently associated with intestinal metaplasia detection (OR: 1.08, 95%CI: 0.87-1.33, P = 0.511). In contrast, the number of biopsy fragments remained independently associated with intestinal metaplasia detection (OR: 1.13, 95%CI: 1.08-1.18, P < 0.001). Compared with the 2015-2018 period, intestinal metaplasia detection did not differ during 2019-2022 (OR: 1.03, 95%CI: 0.86-1.23, P = 0.767), whereas procedures performed during 2023-2025 were associated with lower odds of intestinal metaplasia detection (OR: 0.61, 95%CI: 0.50-0.75, P < 0.001). The results of this sensitivity analysis are presented in Table 8.
Table 8 Sensitivity logistic regression analysis for intestinal metaplasia detection including study period.
In this retrospective real-world study, we evaluated whether endoscopist specialty influenced diagnostic yield, biopsy practices, and histopathological outcomes during upper gastrointestinal endoscopy. A total of 8825 procedures were analyzed, enabling comparison between examinations performed by gastroenterologists and general surgeons. Although biopsies were obtained in the majority of procedures regardless of specialty, important differences were observed in biopsy acquisition rates, sampling strategies, and the detection of premalignant gastric lesions.
Baseline demographic characteristics were largely comparable between groups, suggesting that the observed differences in histopathological outcomes were unlikely to be explained by patient demographics alone. Upper gastrointestinal endoscopy is a highly operator-dependent procedure, and previous studies have demonstrated that procedural experience, training background, and adherence to quality indicators may significantly influence diagnostic performance and lesion detection[15]. In addition, higher procedural volume has been associated with improved quality outcomes in endoscopic practice, underscoring the potential impact of operator experience on diagnostic yield[16].
The distribution of documented endoscopic indications differed between groups. However, indication data were available for only a subset of procedures, limiting interpretation of these findings. Dyspepsia was more frequently documented in the gastroenterologist group, whereas screening and abdominal pain were more commonly reported among general surgeons. These differences may reflect variations in referral patterns, clinical documentation, and specialty-related terminology in routine practice[17]. Dyspeptic symptoms and reflux-related complaints remain among the most common indications for upper gastrointestinal endoscopy worldwide[18,19]. Variability in symptom description and documentation may also contribute to differences in recorded indications between specialties[20]. Nevertheless, the indications observed in both groups were consistent with commonly accepted indications for upper gastrointestinal endoscopy, including dyspepsia, upper gastrointestinal bleeding, dysphagia, abdominal pain, and iron deficiency anemia[21,22]. The potential influence of indication-related referral patterns on histopathological outcomes should also be considered. In a sensitivity analysis restricted to procedures with documented indications, the differences in intestinal metaplasia and Helicobacter pylori detection between specialties were substantially attenuated. This finding suggests that variations in referral pathways and patient selection may have contributed, at least in part, to the observed differences in histopathological outcomes.
The distribution of endoscopic diagnoses differed between groups. Gastritis was more frequently reported in examinations performed by general surgeons, whereas bulbitis and hiatal hernia or lower esophageal sphincter laxity were more commonly documented by gastroenterologists. Normal endoscopic findings were also more frequent in the general surgery group. These differences may reflect variability in endoscopic interpretation and lesion characterization, both of which are influenced by procedural experience and training background[23]. In addition, broader diagnostic categories such as gastritis may be used more frequently in routine clinical practice, potentially contributing to interobserver variability between specialties[24]. Because upper gastrointestinal endoscopy remains highly operator-dependent, variability in mucosal assessment may influence reported diagnostic findings. Emerging technologies such as artificial intelligence-assisted endoscopy systems may help reduce diagnostic variability and improve lesion detection in multidisciplinary endoscopy settings[23,25].
Regarding biopsy practices, important differences were observed between the two groups. Gastroenterologists obtained biopsy specimens more frequently than general surgeons and were also more likely to perform multisite sampling. Current guidelines recommend the updated Sydney protocol for systematic gastric mucosal assessment, which involves obtaining at least five biopsy specimens from different anatomical sites. This standardized approach is important for accurate evaluation of gastric pathology, particularly for chronic gastritis, intestinal metaplasia, and Helicobacter pylori infection[26,27]. Despite the higher biopsy acquisition rate among gastroenterologists, the mean number of biopsy specimens remained below the number recommended by current guidelines in both groups, suggesting that adherence to the Sydney protocol was suboptimal regardless of specialty. This finding is particularly noteworthy because one might expect gastroenterologists to adhere more closely to guideline-recommended biopsy strategies. The relatively high proportion of procedures performed without biopsy in both groups may indicate that routine endoscopic practice in geographically distant and specialist-limited settings does not always fully reflect guideline-based recommendations. Practical factors such as time constraints, patient volume, procedural workload, perceived bleeding risk, and operator experience may all contribute to this observation[28,29]. Nevertheless, gastroenterologists more frequently obtained combined antrum and corpus biopsies and performed multisite sampling, both of which may improve the diagnostic yield of gastric mucosal pathology. These differences in sampling behavior may partially explain the higher detection of Helicobacter pylori infection, dysplasia, and other premalignant lesions observed in the gastroenterologist group and further support the notion that biopsy strategy may influence histopathological outcomes more strongly than specialty background alone.
One of the most noteworthy findings of our study is the apparent relationship between histopathological outcomes and biopsy practices. When histopathological analyses were recalculated using only procedures in which pathologically evaluable tissue specimens were available, intestinal metaplasia continued to be detected more frequently in procedures performed by gastroenterologists (10.3% vs 8.8%), although this difference no longer reached statistical significance. In contrast, Helicobacter pylori infection, chronic active gastritis, and particularly dysplasia remained more frequently identified in the gastroenterologist group. The difference in dysplasia detection was especially striking, with dysplasia being detected approximately six times more frequently among biopsied procedures performed by gastroenterologists (1.2% vs 0.2%). Intestinal metaplasia is a well-established premalignant stage in gastric carcinogenesis, and its detection depends on careful mucosal assessment and adequate tissue sampling[30,31]. In our multivariable analyses, increasing age and Helicobacter pylori infection were identified as independent predictors of intestinal metaplasia. Female sex was independently associated with lower odds of intestinal metaplasia in both multivariable models. Although the present study was not designed to investigate sex-specific mechanisms, this finding is in line with previous epidemiological studies demonstrating a higher prevalence of gastric premalignant lesions and gastric cancer among men[32-34]. The observed association may reflect a combination of biological, environmental, and lifestyle-related factors that differ between sexes. Importantly, the association between endoscopist specialty and intestinal metaplasia detection was attenuated after adjustment for biopsy sampling intensity, suggesting that histopathological diagnostic yield may be more closely related to sampling strategy and sampling adequacy than to specialty background itself. This interpretation is also consistent with the observation that gastroenterologists obtained biopsies more frequently and performed multisite sampling more often than general surgeons.
These findings are also important when interpreting Helicobacter pylori detection rates. The diagnosis of Helicobacter pylori depends directly on histopathological sampling and may be influenced by the anatomical location of biopsy acquisition, sampling intensity, and pathological processing. Therefore, the observed differences in Helicobacter pylori detection cannot necessarily be interpreted as reflecting true differences in disease prevalence alone. Rather, they may indicate that more systematic biopsy practices and broader sampling strategies improve diagnostic yield. Indeed, adherence to the Sydney system has previously been shown to increase the detection rates of both Helicobacter pylori infection and intestinal metaplasia in very large biopsy series[27,30]. Our findings regarding biopsy practices further support this interpretation. Gastroenterologists not only obtained biopsies more frequently but also performed multisite sampling more often. Nevertheless, the mean number of biopsy specimens remained below the level recommended by the current Sydney protocol in both groups[26,27]. This observation may indicate that routine endoscopic practice in geographically remote and specialist-limited settings does not always fully adhere to guideline-recommended biopsy strategies. Interestingly, despite the higher biopsy acquisition rates among gastroenterologists, intestinal metaplasia, Helicobacter pylori infection, and particularly dysplasia continued to be detected more frequently in this group. This suggests that diagnostic yield depends not only on whether biopsies are obtained, but also on where and how tissue sampling is performed[35]. Overall, our findings support the notion that biopsy strategy, sampling intensity, and anatomical sampling distribution may play a more important role in the detection of premalignant lesions than specialty background alone. Consequently, the observed differences between gastroenterologists and general surgeons may be more appropriately interpreted in the context of biopsy acquisition habits and sampling behavior rather than specialty training alone.
Malignancy detection rates were similar between groups. This finding is not unexpected, as overt malignant lesions are typically macroscopically apparent during endoscopy and therefore less dependent on subtle differences in mucosal interpretation. In contrast, the detection of premalignant lesions such as intestinal metaplasia and Barrett’s esophagus often requires careful mucosal assessment and targeted biopsy sampling.
Barrett’s esophagus was identified in a small number of patients in our study (0.3%), and all cases were detected during procedures performed by gastroenterologists based on biopsy findings. This low prevalence is consistent with previous reports from Türkiye and neighboring regions, where Barrett’s esophagus has been reported less frequently than in Western populations[36,37]. However, all Barrett-related diagnoses in our cohort were based on histopathological findings suggestive of or compatible with Barrett’s esophagus rather than definitively confirmed diagnoses, indicating that the true prevalence may be even lower. In clinical practice, the detection of Barrett’s esophagus may be challenging even for experienced endoscopists, as careful mucosal assessment and systematic biopsy sampling from the esophagogastric junction are often required[38,39]. Esophageal biopsy may also be technically demanding in routine practice, potentially contributing to hesitancy in biopsy acquisition[40]. The low overall detection rate observed in our cohort, including the absence of Barrett-related diagnoses in the general surgery group, may therefore reflect variability in esophageal inspection, biopsy practices, and clinical suspicion during routine examinations rather than true absence of disease. In addition, factors such as procedural workload and time constraints may also have contributed to reduced detection rates in this real-world setting.
Additional analyses evaluating temporal trends provided further insight into the interpretation of our findings. By dividing the study period into three predefined intervals, we observed that both biopsy performance and biopsy sampling intensity increased significantly over time in gastroenterologists and general surgeons. This finding may reflect improvements in endoscopic technology and image quality, increasing awareness of endoscopy quality indicators, greater adoption of standardized biopsy protocols such as the Sydney system, and changes in operator experience over time[2,13,15,26,27]. Similar temporal changes in upper gastrointestinal endoscopic diagnoses have previously been reported by Caglar et al[41] in a 40-year endoscopy series, where shifts in diagnostic patterns were attributed not only to changes in disease epidemiology but also to improvements in endoscopic technology, differences among endoscopists, and evolving diagnostic definitions. Despite these changes in biopsy practice, intestinal metaplasia detection remained relatively stable across study periods within both specialties. This finding suggests that the higher detection rate of intestinal metaplasia among gastroenterologists cannot be explained solely by calendar time. Nevertheless, sensitivity regression analysis demonstrated lower adjusted odds of intestinal metaplasia detection during the most recent study period compared with 2015-2018. Although this finding may appear counterintuitive given the increase in biopsy sampling intensity over time, it may reflect a combination of unmeasured temporal factors, including changes in patient case-mix, referral patterns, endoscopy indications, Helicobacter pylori prevalence, eradication practices, and pathology reporting habits[27,42]. Therefore, the observed period effect should not be interpreted as a direct consequence of technological progress or operator performance alone, but rather as evidence that long-term retrospective endoscopy cohorts are influenced by multiple time-dependent factors. The importance of biopsy strategy is further supported by studies evaluating premalignant and microscopic lesions in other upper gastrointestinal settings. In Barrett’s esophagus, assessment of additional spatial biopsy levels and temporal samples has been shown to improve diagnostic and predictive performance, emphasizing the contribution of sampling intensity to lesion detection. Likewise, in hereditary diffuse gastric cancer surveillance, systematic random biopsies substantially increased the detection of early malignant lesions, and omission of random biopsies would have resulted in significant underdiagnosis[43-45]. These observations support our main interpretation that detection of premalignant lesions depends not only on endoscopist specialty but also on biopsy strategy, sampling intensity, anatomical sampling distribution, and evolving clinical practice over time. It should also be noted that the temporal analyses were performed at the procedure level and therefore incorporated changes in both biopsy acquisition and histopathological detection over time. As a result, the observed trends likely reflect the combined influence of evolving biopsy practices and pathological findings rather than histopathological outcomes alone.
These findings may have practical implications for endoscopy training in specialist-limited settings. Rather than focusing solely on specialty background, training programs may benefit from emphasizing systematic mucosal assessment, adherence to Sydney biopsy protocols, and standardized biopsy strategies. Such measures may help reduce variability in histopathological diagnostic yield across different provider groups. In line with this approach, recent consensus recommendations on upper gastrointestinal endoscopy training have emphasized that competency should extend beyond technical completion of the procedure and include lesion recognition, pathology assessment, quality indicators, and standardized performance measures. Strengthening these aspects of endoscopy training may contribute to more consistent detection of premalignant upper gastrointestinal lesions across different practice settings[46-48].
The present study should be interpreted within the context of several strengths and limitations. A notable strength is the inclusion of a large number of upper gastrointestinal endoscopy procedures collected over a 10-year period, allowing evaluation of endoscopy practice patterns across different time periods and physician groups. In addition, data originating from geographically remote and specialist-limited settings remain relatively scarce in the literature, despite the fact that a substantial proportion of routine endoscopic practice worldwide is performed under similar circumstances. The availability of detailed biopsy and histopathological data also enabled a comprehensive assessment of biopsy acquisition habits, sampling strategies, and temporal changes in diagnostic yield.
Several limitations should nevertheless be acknowledged. The retrospective design inevitably carries a risk of incomplete documentation and residual confounding. Endoscopic indications were available for only a subset of procedures, although additional sensitivity analyses were performed to explore the potential influence of referral patterns. Temporal confounding also remains an important consideration. Although gastroenterologists performed procedures during each of the predefined study periods and additional temporal analyses, including sensitivity regression models, were undertaken to evaluate the potential impact of calendar time, the influence of temporal factors cannot be completely eliminated. Changes in endoscopic technology, imaging quality, pathology reporting practices, clinical workflows, and operator experience over time may still have affected the observed associations or attenuated specialty-related differences. Another limitation relates to biopsy processing. Because gastric antral and corpus biopsy specimens were frequently submitted in the same pathology container, site-specific analyses of intestinal metaplasia were not possible. Finally, this study reflects the realities of endoscopy practice in a geographically remote setting. While this represents a strength of the study, local healthcare conditions, referral pathways, and workforce characteristics may differ from those of larger tertiary centers, which should be taken into account when extrapolating the findings.
CONCLUSION
Upper gastrointestinal endoscopy performed by gastroenterologists and general surgeons demonstrated differences in biopsy practices and histopathological diagnostic yield. Gastroenterologists obtained biopsies more frequently, performed multisite sampling more often, and detected Helicobacter pylori infection and dysplasia more frequently than general surgeons. Although intestinal metaplasia was also identified more frequently in the gastroenterologist group, this difference was attenuated after adjustment for biopsy sampling intensity and temporal factors. Taken together, these findings suggest that biopsy acquisition habits, sampling intensity, and biopsy strategy may play a greater role than specialty background alone in the detection of premalignant upper gastrointestinal lesions. In geographically remote and specialist-limited settings, greater adherence to standardized biopsy protocols and quality-focused endoscopy training may help improve diagnostic consistency and optimize the detection of clinically relevant gastric pathology.
ACKNOWLEDGEMENTS
The authors would like to thank Professor Dr. Serhat Bor for his valuable guidance and support during the preparation of this manuscript.
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Footnotes
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: Türkiye
Peer-review report’s classification
Scientific quality: Grade B, Grade C
Novelty: Grade B, Grade B
Creativity or innovation: Grade B, Grade C
Scientific significance: Grade B, Grade B
P-Reviewer: Lucas IC, Adjunct Professor, MD, PhD, Professor, Brazil; Peng D, MD, China S-Editor: Hu XY L-Editor: A P-Editor: Zhao S
