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Introduction Sustainability has been a key initiative to improve endoscopy services and an aspirational goal of the National Health Service (NHS). There is growing pressure from all stakeholders to deliver greater quality and quantity of service whilst reducing costs.Our primary aim was to assess the cost of discarding unused vial medications in routine endoscopy practices across endoscopy units in London, identify factors in a procedure influencing cost and to highlight a hidden cost saving that can be further evaluated by endoscopy services.Methods This is a retrospective service evaluation across 10 endoscopy units in London between 1 December 2025 to 14 December 2025. Patients aged 18 or over during this period who underwent a GI endoscopic intervention in an endoscopy unit were included. All non-GI procedures e.g. bronchoscopy and procedures requiring anaesthetic support and not requiring intra-venous sedation were excluded. Procedures that took place outside of the endoscopy unit were also excluded. The drugs recorded for this project were Fentanyl and Midazolam. For each drug the volume vial used, dose given, and dose discarded was recorded. The costing of sedation used was £1.36 per Midazolam 5mg/5ml ampoule and £1.62 per Fentanyl 100Mcg/2ml ampoule based on NHS drug tariff reimbursement pricing.Data was extracted from controlled drugs books located within the endoscopy unit and from endoscopic reports. Procedural demographics such as procedure type, day of endoscopy and endoscopist role were recorded also.Results 2532 (Mean 253 procedures per site) GI endoscopy procedures were performed over the 10 endoscopy units in 2weeks.The mean Midazolam dose administered per procedure is 1.99mg (Range 1.58-2.65). The mean Midazolam dose discarded per procedure is 2.21mg (Range 1.75-3.19). The mean Fentanyl dose administered per procedure is 48.48micrograms (Range 46.08-59.43). The mean Fentanyl dose discarded per procedure is 37.75micrograms (Range 26.4-53.49).The cost burden of discarded Midazolam is £0.601 per procedure and discarded Fentanyl is £0.612 per procedure which equates to a total cost of £1521.73 for Midazolam and £1549.58 for Fentanyl over the 2week period evaluated for the 10 London endoscopy sites. This translates to on average £3956.50 Midazolam and £4028.92 Fentanyl discard cost per endoscopy site per year.Conclusions This service evaluation has highlighted the hidden cost implications of discarded medication during endoscopy. A key finding is the cost of drug discard is greater than the cost of dose administered for Midazolam on average per patient. With a total estimated drug discard loss of £7985.42 per year per London endoscopy site it raises the important question on how this can be improved to increase sustainability in UK endoscopy practice.