Usefulness of Trans-Nasal Ultra-Thin Office Endoscopy in High-Risk Pre-Bariatric Patients

Abstract

Introduction: Esophagogastroduodenoscopy (EGD) is an important tool for evaluating pre-bariatric patients. Obese patients are at high risk for airway complications during conventional sedated endoscopy. It is well known that sedation in obese patients is challenging due to the risks of sleep apnea and airway compromise while performing esophageal intubation. Improvement in technology has led to the use of ultra-thin scopes that can be used trans-nasally with minimal risk, patient discomfort, safety and efficacy. Methods: Thirty-one patients with pre-bariatric screening indications. The variables assessed were the success rate, tolerability and reliability with no use of sedation in the office setting. The endoscope used for all the procedures was the GIF-N180 Olympus 4.9 mm gastroscope. Biopsies were procured with a 2 mm pediatric biopsy forceps. Two percent lidocaine gel was applied to the nasal orifice prior to the procedure. Results: The study looked at 31 patients from June 2011 to June 2014 ( 14 men and 17 women) with an average age of 32 years ( ranging from 21 to 46) and a BMI range of 35 to 55. All 31 patients had successful intubation of the second duodenal portion with no safety concerns or complications. Common pathology was found in all the patients with gastritis (100%), esophagitis (83%), esophageal reflux (50%), hiatial hernia (33%) and gastric ulcer (16%). All of the patients were satisfactorily assessed and cleared for bariatric surgery.After appropriate therapy the pathology specimens were adequately analyzed and satisfactorily in all the patients. Conclusion: Initial data suggests that unsedated ultra-thin endoscopy with 4.9 mm diameter GIFN180 scope is safely feasible in ambulatory office care setting with the majority of pre-bariatric patients tolerating the procedure with no sedation. Alami et al. have done previous studies where they looked at morbidly obese patients in the out patient hospital setting. They showed all 25 patients reported successful endoscopy with no sedation using a 5.9 mm diameter GIF XP 160. Our study was able to show similar efficacy and safety in the ambulatory physician office setting with an even smaller(4.9 mm) scope. In the era of affordable and accountable care, this may prove to be the most effective and appropriate approach in Pre-Bariatric endoscopic screening and assessment of such patients.