Transnasal Small-Caliber Videoendoscopy Improves Safety of EGD for Elderly and Bedridden Patients

Abstract

Background and Aims: Un-sedated transnasal small-caliber esophagogastroduodenoscopy (EGD) has been used to examine the upper gastrointestinal tract. Its efficacy for elderly or critically ill patients, however, has not been fully evaluated. Thus, this study evaluated the tolerability of transnasal EGD for elderly and critically ill bedridden patients. Patients and Methods: One prospective randomized study and one crossover study were done to compare transnasal small-caliber (TN) EGD and transoral conventional (TO) EGD. Study 1: Comparative study of the tolerability. We enrolled 240 elderly patients older than 65 years. TN or TO endoscopy was randomly selected for EGD. Study 2: Crossover analysis. We examined 30 bedridden patients using percutaneous endoscopic gastrostomy (PEG). We periodically exchanged PEG tubes during endoscopic observation. During exchanges, TN or TO was randomly selected for each patient, and one endoscopic method was switched to the other at the next exchange. We evaluated cardiopulmonary effects by measuring arterial oxygen saturation (SpO2) and calculating the rate-pressure product (RPP: pulse rate x systolic blood pressure/100). To assess the risk for endoscopy-related aspiration pneumonia during EGD, we also measured blood leukocyte counts (WBC) and serum C-reactive protein (CRP) levels before and after EGD. Results: In Study 1, we observed significant decreases in SpO2 during TO-EGD, but not during TN-EGD (P<0.05). Significant differences of the RPP were not found between TO- and TN-EGD. This showed that TO-EGD more severely affected pulmonary function than TN-EGD for the elderly patients. In Study 2, crossover analysis showed statistically significant increases of the RPP during and at the end of endoscopy (P<0.05), and decreases of SpO2 during endoscopy (P<0.05) for TO-EGD. Thus, for bedridden patients with PEG feeding who were examined in the supine position, TO-EGD more severely suppressed cardiopulmonary function than TN-EGD. In addition, the WBC and CRP values, markers of inflammation, showed statistically significant increases for bedridden patients after TO-EGD. WBC increased from 6053 ± 1975 to 6900 ± 3392 (P<0.001) and CRP values increased from 0.93 ± 0.24 to 2.49 ± 0.91 mg/dl (P<0.001) at 3 days after TO-EGD. The changes of WBC and CRP were not significantly different after TN-EGD. Conclusions: For elderly patients, TO-EGD induced pulmonary rather than hemodynamic effects, while TN-EGD did not. TN-EGD may decrease the risk of endoscopy-related aspiration pneumonia for elderly or critically ill patients when the patient is in the supine position.