Transnasal endoscopy (TNE) is an unsedated alternative to conventional oesophagogastroduodenoscopy (OGD), enabling upper gastrointestinal (UGI) assessment via an ultrathin endoscope under topical anaesthesia. Randomised trials confirm comparable diagnostic accuracy and patient acceptability, yet large-scale real-world data are limited. Rising UK endoscopy demand and the NHS Faster Diagnosis Standard (FDS), requiring cancer diagnosis or exclusion within 28 days, necessitate pathway innovation. We evaluated diagnostic yield, safety, and operational performance of a newly implemented TNE service for patients with UGI symptoms, including urgent suspected cancer (two-week-wait, 2WW) referrals, in a UK tertiary centre.

All patients undergoing TNE between April and August 2025 were included in this prospective observational study. Referrals originated from routine and 2WW suspected UGI cancer pathways. Procedures were performed by JAG-accredited endoscopists in a dedicated TNE suite under topical anaesthesia without sedation. Data collected included demographics, referral indication, completion rate, same-day oral OGD conversion, cancer detection, non-attendance (DNA) rate, incomplete procedure waiting list (IPWL) delay, and complications. Outcomes were compared between Q1 (April–June) and Q2 (July–August) to assess scalability. Benchmarking was performed against UK National Endoscopy Database (NED) OGD data and international TNE cohorts. Statistical analyses used Fisher’s exact test and exact binomial confidence intervals.

A total of 593 TNE procedures were completed (mean age 64.2 ± 12.8 years; 54% female). Indications included 2WW suspected UGI cancer (52%), dyspepsia/reflux (35%), anaemia (9%), and surveillance (4%). UGI cancer was detected in 11/593 (1.9%; 95% CI 0.93–3.29%), exceeding the national OGD benchmark of 1.0% (p=0.03). Cancer yield was 2.6% (8/307; 95% CI 1.13–5.07%) in 2WW referrals versus 1.0% (3/286; 95% CI 0.22–3.03%) in non-2WW pathways (p=0.23; not significant).

Oral conversion was required in 132/593 (22.3%; 95% CI 18.97–25.83%). Same-day conversion without sedation occurred in 35/132 (26.5%), rising from 35.6% (16/45; 95% CI 21.9–51.2%) in Q1 to 73.1% (19/26; 95% CI 52.2–88.4%) in Q2 (p=0.003). Deferred conversions, primarily for sedation preference, incurred minimal IPWL delay (<7 days), maintaining FDS compliance.

DNA rates fell from 7.6% (29/382; 95% CI 5.14–10.72%) in Q1 to 2.6% (9/348; 95% CI 1.19–4.85%) in Q2 (p=0.002), reflecting improved patient engagement and streamlined pathway integration. No procedural complications occurred (0%; 95% CI 0–0.62%). Diagnostic completion and cancer detection rates were equivalent between high- and mid-volume endoscopists.

TNE is a safe (0% complications), effective (cancer yield > OGD benchmark), and scalable diagnostic option for suspected UGI cancer. Integration within 2WW pathways supports FDS compliance and reduces DNA rates, alleviating endoscopy service pressure. These findings provide a strong evidence base for wider NHS adoption and European integration of TNE as a patient-centred innovation in UGI cancer diagnostics.