Thin Endoscope Research Articles

Endoscopic treatment of Zenker's diverticulum by harmonic scalpel

Zenker's diverticulum (ZD) is a rare condition with a reported prevalence of 0.01% to 0.11% in the general population. Endoscopic treatment consists of the division of the septum between the diverticulum and the esophagus, within which the cricopharyngeal muscle is contained. Diathermic monopolar current, argon plasma coagulation, and laser have been used to incise the muscular septum with satisfactory results. The main limitation of endoscopic treatment is the occurrence of complications. Perforation and hemorrhage are reported in as many as 23% and 10% of patients, respectively. The aim of this study was to use the technique of endoscopic diverticulotomy by using a harmonic scalpel in patients with ZD and to demonstrate the feasibility of using flexible and rigid devices in ZD treatment. Case series study. Standard protocol was used for patient management, endoscopic procedure, and data collection. Single endoscopist demonstrating preliminary results. Five patients (4 men; median ± standard deviation [SD] age 69.6 ± 9.06 years, range 59-83 years) with ZD were treated with this technique. All patients reported dysphagia and halitosis. The diagnosis was based on clinical, endoscopic, and radiographic findings. All patients received general anesthesia and were placed in the left lateral position. A standard videogastroscope (9.8 mm) and a stiff guidewire were used to insert and achieve an adequate exposure of the ZD septum. The septum was divided using a harmonic scalpel under thin endoscope (5.2 mm) visualization through a soft diverticuloscope. Feasibility of an endoscopic technique by using rigid and flexible devices to treat ZD. Four patients (80%) were successfully treated in 1 session. The median ± SD size of the diverticulum was 3.6 ± 0.89 cm (range 3-5 cm). Median ± SD procedure time was 17.33 ± 2.33 minutes (range 15-20 minutes) in 6 procedures. No hemorrhage or perforation occurred. One patient (20%) required a second session to complete dissection of the ZD septum. All patients demonstrated improvement of dysphagia score after treatment. Small case series design. Endoscopic treatment of ZD by harmonic scalpel through a soft diverticuloscope was feasible and effective in this small case series. Larger studies are warranted to further evaluate this technique.

Biomedical Super-resolved Imaging Using Special Micro-probe

In this paper, we present a design proposal as well as a preliminary experimental validation of special multi-functional biomedical probe. The probe acts as a very thin endoscope (diameter of 100–200 μm), while maintaining high imaging resolution. This micro-probe was made out of polymers, while the core is made out of polystyrene and the cladding is made out of poly(methyl methacrylate). The micro-probe consists from combining hollow regions (capillaries) of a holey structure together with nonhollow regions to form multiple cores. Experimental results for constructing and imaging a resolution target as well as of Fe micro-beads that are embedded into an agar solution are reported. Two very thin tips with external diameters of 100 and 200 μm have been fabricated. The tip provides localization at which its functionalities can be applied. The high imaging resolution capability of 5,000–10,000 imaged pixels and the fact that the edge of the micro-probe is very thin allows localized biomedical inspection, visualization, and treatment with minimal invasive damage. The proposed probe does not provide only spatial resolution that is as good as the one obtained in common endoscopes but it may also enable medical treatment-related multi-functionalities.

880 Endoscopic Treatment of Zenker's Diverticulum by Harmonic Scalpel: Experimental and Human Results

Zenker's diverticulum, also known as cricopharyngeal or pharyngoesophageal diverticulum, is the most common type of diverticulum in the upper GI tract. Open diverticulectomy and cricopharyngeal myotomy is usually indicated with good results. Considering that this condition affects mostly the elderly population, less invasive treatment might be useful. Diathermic monopolar current, argon plasma coagulation and laser have already been employed to incise the muscular septum with satisfactory results. Complications are still the main limitation of endoscopic treatment, Perforation and hemorrhage have been reported in up to 23% and 10% of the patients respectively.The harmonic scalpel or ultracision has been used in laparoscopic surgeries providing adequate and accurate hemostasis. The aim of this study was to present the technique for endoscopic diverticulotomy with harmonic scalpel in suine model and patients with Zenker's diverticulum and the short-term clinical results obtained with this technique. First of all, endoscopic diverticulotomy was performed in 20 pigs, comparing standard technique (Group M - needle knife and monopolar current) to harmonic scalpel technique (Group U). After, in a human model, 20 patients were submitted to endoscopic diverticulotomy by harmonic scalpel technique5 patients. Endoscopic technique: A videogastroscope was used to evaluate the pharyngoesophageal diverticulum and the esophagus. With the endoscope in the esophagus, a soft diverticuloscope was positioned. A shear-type harmonic scalpel was introduced through the soft diverticuloscope along with a thin endoscope. The septum was divided between the diverticulum and the esophagus up to approximately 5mm above the bottom of the diverticular pouch. In experimental model (Table 1), the time of incision and total time were less in group U (p<0,0001). The size of border were 1,92 ±0,38 cm in group M and 2,38 ±0,25 cm in group U (p=0,00047). Regarding about microscopic parameters, only the extension of damage caused by the devices had difference (p<0,0001), in group M was 3,20 ± 0,9 mm and group U was 0,69 ± 0,25 mm. In group M, had more cases of hemorrhage (six suines - p=0,0108). In human trial, 20 cases were done, average age 73,4 ±9,75, range from 52 to 86 years. Complete resection in one session were possible in 19 (95%) patients. The average time of procedure was 14,8 ± 3,58 minutes. Any case of bleeding, one (5%) case of perforation, treated by clinical management. Improvement of dysphagia were possible in all cases after one months. Despite swallowing improvement, four (20%) patients still complain of dysphagia to solid food (Table 2).Table 1Comparative results of experimental modelPARAMETERSGROUP MGROUP Up-ValueDiverticulum Size (cm)2,6 ± 0,5163 ± 0,4710,0897Overtube time (s)31,6 ± 8,1830,4 ± 7,650,7387Procedure time (s)352 ± 71,7783 ± 18,89<0,0001Total Time (s)383,9 ± 72,28113,4 ± 23,74<0,0001Border Length (cm)1,92 ± 0,382,38 ± 0,250,0047Extension of Damage (mm)3,2 ± 0,90,69 ± 0,25<0,0001 Open table in a new tab Table 2Patient's Dysphagia ScoresPATIENTBEFORE PROCEDUREAFTER 30 DAYS OF PROCEDURE1III02I03IIII4II05I06I07I08IIII9I010III011III012II013II014IIII15I016II017III018I019IIII20II0Grade 0 = no dysphagia; Grade I = dysphagia to solid; Grade II = dysphagia to semi-solid; Grade III = dysphagia to liquid; Grade IV = no saliva swallowing. Open table in a new tab Grade 0 = no dysphagia; Grade I = dysphagia to solid; Grade II = dysphagia to semi-solid; Grade III = dysphagia to liquid; Grade IV = no saliva swallowing. Endoscopic treatment of Zenker's Diverticulum by harmonic scalpel demonstrated to be secure and reliable technique with good control of hemorrhage.

Arachnoscopy: a special application of spinal intradural endoscopy

The microsurgical removal of obstructions to CSF flow is the treatment of choice in the surgical management of intradural arachnoid cysts. Cardiac-gated phase-contrast MR imaging is an effective tool for the primary diagnosis and localization of arachnoid cysts. Microsurgery, however, does not lend itself to assessments of further adhesions beyond the borders of the exposed area. The use of a thin endoscope allows surgeons to assess intraoperatively whether the exposure is wide enough. Between 2006 and 2010, a single neurosurgeon performed 31 consecutive microsurgical procedures with endoscopic assistance in 28 patients with spinal arachnoid adhesions. A MurphyScope endoscope was used for this purpose. The CSF flow was studied before and after surgery in all patients by using phase-contrast MR imaging in the region of the craniocervical junction, the cervical spine, the thoracic spine, and the lumbar spine. In all 31 procedures, CSF flow obstructions were detected at the level identified by phase-contrast MR imaging. In 29 procedures, image quality was sufficient for an inspection of the adjacent subarachnoid space. In 6 cases, the surgeon detected further adhesions that obstructed CSF flow in the adjacent subarachnoid space that were not visualized with the microscope. In all cases, these adhesions were identified and removed during microsurgery. Arachnoscopy is a helpful adjunct to microsurgery and can be performed safely and easily. It allows the surgeon to detect further adhesions in the subarachnoid space that would remain undetected by microscopy alone.

Development of Active Bending Electric Endoscope Using Shape Memory Alloy for Disposable and Thin Endoscope

Bending motions of the tip of a conventional endoscope are controlled from outside the body by wire traction. A shaft of an endoscope should be relatively hard to avoid buckling by wire traction. The active bending mechanism of an endoscope, which is realized using shape memory alloy (SMA) coil actuators instead of wire traction, is soft. Using micro-fabrication technology on non-planar substrate, cylindrical substrate of thin endoscope was fabricated. These endoscopes enable precise observations and treatments of deep areas of the human body.

Treating bilio-duodenal obstruction: Combining new endoscopic technique with 6 Fr stent introducer

Periampullary cancer may cause not only biliary but also duodenal obstructions. In patients with concomitant duodenal obstructions, endoscopic biliary stenting remains technically difficult and may often require percutaneous transhepatic biliary drainage. We describe a method of metal stent placement via a thin forward-viewing endoscope in patients with simultaneous biliary and duodenal obstruction. In two consecutive patients with biliary and duodenal obstruction due to pancreatic cancer, a new biliary metal stent mounted in a slim delivery catheter was placed via a thin forward viewing endoscope after passage across the duodenal stenosis without balloon dilation. In both patients, with our new placement technique, metallic stents were successfully placed in a short time without adverse events. After biliary stenting, one patient received curative resection and the other received duodenal stenting for palliation. Metallic stent placement with a forward-viewing thin endoscope is a beneficial technique, which can avoid percutaneous drainage in patients with bilio-duodenal obstructions due to periampullary cancer.

A NEW THIN ENDOSCOPIC METHOD OF TRANSANAL DRAINAGE TUBE INSERTION FOR ACUTE COLONIC OBSTRUCTION DUE TO COLORECTAL CANCER

Insertion of a transanal drainage tube is effective in the management of obstructing colorectal cancer. We devised a new method of inserting the transanal drainage tube safely and quickly using a thin endoscope. Sixteen patients (seven men and nine women) with obstructive left-sided colorectal cancer were treated by inserting a transanal drainage tube using a thin endoscope. We inserted a transanal drainage tube for 32 patients (21 men and 11 women) with left-sided colorectal cancer using the conventional method. Drainage tube placement by the conventional method was successful in 29 (90.6%) of 32 patients, while via the new method, it was successful in all 16 patients without major complications. Moreover, median insertion time was significantly shortened (34 minutes for the new method compared with 42 minutes for the conventional method). Management of acute colorectal obstruction by transanal drainage tube insertion using the thin endoscope was effective and safe.

A high-resolution, three-dimensional thin endoscope for fetal surgery

Fetal surgery is receiving considerable attention. However, surgeons must have great skill to perform this surgery. For assisting with the operation, the three-dimensional (3D) endoscope is very useful because it allows the surgeon depth perception. However, the diameter of existing 3D endoscopes is approximately 10 mm. Therefore, the authors have developed a high-resolution, thin, 3D endoscope for use in fetal surgery. The authors' system uses two 1/10-in. micro charge-coupled device (CCD) cameras at the tip of the endoscope and achieves a diameter of 5.4 mm. The endoscope's angle of convergence is 2.6 masculine, which very closely approximates the angle of convergence for humans. Thus, the surgeon experiences little visual fatigue. The view angle is 87 masculine. The authors compared image quality and depth perception between their system and conventional 3D and 2D endoscopes. Theoretical investigation of image quality allowed the surgeon to distinguish a line 0.2 to 0.25 mm wide. Furthermore, the depth perception with the thin 3D endoscope was almost the same as with an 11-mm normal 3D endoscope. In addition, with the 3D endoscope, a higher percentage of questions were answered correctly in the depth perception evaluation experiment in a water environment than with the 2D instrument. According to these experiments, the thin 3D endoscope has a sufficiently high image quality and depth perception even in a water environment.

A High-Resolution Endoscope of Small Diameter Using Electromagnetically Vibration of Single Fiber

For high resolution visual inspection in the narrow space of the human body, small diameter endoscope has been developed which utilize electromagnetically vibration of single fiber. Thin endoscopes are effective for inspection in the narrow space of the human body, for example, in the blood vessel, lactiferous duct for detection infiltration of breast cancer, and periodontal gap between gingiva and tooth. This endoscope consists of single optical fiber and photofabricated driving coils. A collimator lens and a cylindrical permanent magnet are fixed on the optical fiber, and the tilted driving coils have been patterned on a 1.08 mm outer diameter thin tube. The fiber is positioned at the center of the tube which is patterned the coils. When an electrical alternating current at the resonance frequency is supplied to the coils, the permanent magnet which is fixed to the fiber is vibrated electromagnetically and scanned one or two dimensionally. This paper reports small diameter endoscope by using electromagnetically vibration of single fiber. Optical coherence tomography imaging has also been carried out with the fabricated endoscope and cross-section image of sub-surface skin of thumb was observed.

A Patient with Infected Bulla Caused by Mycobacterium Kansasii Treated by Evacuation of Purulent Effusion Via a Thin Endoscope

A Patient with Infected Bulla Caused by Mycobacterium Kansasii Treated by Evacuation of Purulent Effusion Via a Thin Endoscope

Efficacy of Double-Balloon Enteroscopy in the Evaluation and Treatment of Bleeding and Non-Bleeding Small Bowel Disease

Double-balloon enteroscopy (DBE) is a newly developed method allowing deep insertion of a thin endoscope into the small bowel, thereby enabling inspection, biopsy and endoscopic treatment of previously inaccessible lesions. This retrospective analysis evaluates the diagnostic and therapeutic efficacy in all patients undergoing DBE at our institution. A total of 109 DBEs were performed in 82 patients (57 patients with suspected small bowel blood loss and 25 patients with other indications). The diagnostic success rate was 51 of 82 (62 %) with a higher rate in bleeders in whom angiodysplasias were the most frequent diagnosis. DBE had therapeutic consequences in 47 patients (57 %), of whom 33 patients (40 %) underwent endoscopic therapy and 6 patients (7 %) surgery. In 4 patients, malignant neoplasias were newly diagnosed (2 gastrointestinal stroma tumors, 1 neuroendocrine tumor, 1 adenocarcinoma). Other diagnostic modalities were helpful in preselecting patients for DBE and choosing the more favorable (oral or anal) access. In 16 of 26 patients, pathological findings in videocapsule endoscopy were substantiated by DBE. In 7 patients, the findings of CT or MRI enteroclysis, and in 4 patients with hematochezia, the results of a preceding erythrocyte bleeding scan were confirmed by DBE. In conclusion, this series indicates that DBE of the small bowel - in concert with other diagnostic modalities - has a high diagnostic and therapeutic efficacy.

EXAMINATION OF RESPIRATORY AND CIRCULATORY DYNAMICS DURING EXAMINATION USING A THIN GASTROINTESTINAL ENDOSCOPE IN ADVANCED‐AGE SUBJECTS

Background: Endoscopic examination influences cardiovascular hemodynamics. Upper gastrointestinal examinations are currently performed with a thin endoscope. In the present study, respiratory and circulatory dynamics and autonomic nervous activity using a thin endoscope (XP260) or a standard endoscope (XQ240) were investigated.Methods: The subjects were 25 healthy adults aged less than 60 years (middle‐aged group) and 15 healthy adults aged 60 years or older (advanced‐age group). Percutaneous oxygen saturation, tonometric blood pressure, heart rate, and autonomic nervous activity were evaluated before the examination. After the endoscopic procedure, a questionnaire survey regarding examination‐related stress was conducted.Results: In the questionnaire survey, the proportion of subjects who answered ‘very stress free’ in the thin endoscope group was significantly higher than that in the standard endoscope group. The low frequency power of blood pressure variability (LFBP), an indicator of sympathetic nervous activity, was significantly lower during the thin endoscopic procedure than during the standard endoscopic procedure. Moreover, the ratio of low frequency power to high frequency power of heart rate variability (LFRR/HFRR), an indicator of sympathetic nervous activity, was significantly lower during thin endoscopic procedure than during the standard endoscopic procedure. The maximum rates of change in the LFBP and HFRR powers in the advanced‐age group using thin and standard endoscopic procedures were significantly lower than in the middle‐aged group.Conclusions: The findings, although not in cross‐over study, suggest that a thin endoscope has a less marked influence on circulatory kinetics. Gastrointestinal endoscopic examinations using a thin endoscope might reduce complications related to endoscopic screening examinations in advanced‐age subjects.

Unsedated ultrathin upper endoscopy is better than conventional endoscopy in routine outpatient gastroenterology practice: A randomized trial

to compare the feasibility and patients' tolerance of esophagogastroduodenoscopy (EGD) using a thin endoscope with those of conventional oral EGD and to determine the optimal route of introduction of small-caliber endoscopes. One hundred and sixty outpatients referred for diagnostic EGD were randomly allocated to 3 groups: conventional (C)-EGD (9.8 mm in diameter), transnasal (TN)-EGD and transoral (TO)-EGD (5.9 mm in diameter). Pre-EGD anxiety was measured using a 100-mm visual analogue scale (VAS). After EGD, patients and endoscopists completed a questionnaire on the pain, nausea, choking, overall discomfort, and quality of the examination either using VAS or answering some questions. The duration of EGD was timed. Blood oxygen saturation (SaO2) and heart rate (HR) were monitored during EGD. Twenty-one patients refused to participate in the study. The 3 groups were well-matched for age, gender, experience with EGD, and anxiety. EGD was completed in 91.1% (41/45), 97.5% (40/41), and 96.2% (51/53) of cases in TN-EGD, TO-EGD, and C-EGD groups, respectively. TN-EGD lasted longer (3.11 +/- 1.60 min) than TO-EGD (2.25 +/- 1.45 min) and C-EGD (2.49 +/- 1.64 min) (P<0.05). The overall tolerance was higher (P<0.05) and the overall discomfort was lower (P<0.05) in TN-EGD group than in C-EGD group. EGD was tolerated "better than expected" in 73.2% of patients in TN-EGD group and 55% and 39.2% of patients in TO-EGD and C-EGD groups, respectively (P<0.05). Endoscopy was tolerated "worst than expected" in 4.9% of patients in TN-EGD group and 17.5% and 23.5% of patients in TO-EGD and C-EGD groups, respectively (P<0.05). TN-EGD caused mild epistaxis in one case. The ability to insufflate air, wash the lens, and suction of the thin endoscope were lower than those of conventional instrument (P<0.001). All biopsies performed were adequate for histological assessment. Diagnostic TN-EGD is better tolerated than C-EGD. Narrow-diameter endoscope has a level of diagnostic accuracy comparable to that of conventional gastroscope, even though some technical characteristics of these instruments should be improved. Transnasal EGD with narrow-diameter endoscope should be proposed to all patients undergoing diagnostic EGD.

Four‐Dimensional Ultrasonographic Guidance of Fetal Tracheal Occlusion in a Congenital Diaphragmatic Hernia

Intermittent fetal tracheal occlusion is considered one actual therapeutic option for a severe isolated congenital diaphragmatic hernia (CDH). 1 To reduce maternal risks such as maternal hemorrhage, premature rupture of membranes, and preterm labor, minimally invasive procedures with extremely thin endoscopes have been introduced. 1,2 The thinnest cannula used up to now was 3.3 mm with an endoscope of 1.2 mm.' This procedure is usually guided by conventional 2-dimensional ultrasonography (2DUS). Recently, 4-dimensional ultrasonography (4DUS) was used to guide invasive obstetric procedures such as amniocentesis, chorionic villus sampling, and cordocentesis, 3,4 as well as cauterization of an umbilical cord in twin-twin transfusion syndrome.5 The advantage of 4DUS may be related to the reduction of procedure time and the ability to use thinner endoscopes. We report another possible contribution of 4DUS in the guidance of introduction of a thinner fetoscope (1.0 mm) into the fetal oral cavity.

Placement of the Bravo wireless pH monitoring capsule onto the gastric wall under endoscopic guidance

The Bravo system was designed mainly to monitor esophageal pH, and there have been no reports on gastric pH monitoring using this system. To place the Bravo capsule on the gastric wall and monitor gastric pH. Experimental clinical trial with the cooperation of volunteers. Academic medical center. Eleven volunteers (9 men, 2 women; mean age 38 years; 3 had symptoms of GERD). The Bravo system was introduced into the esophagus and stomach along a thin endoscope and capsules were attached, one each to the esophageal and gastric walls under direct vision through the endoscope. Esophageal and gastric pHs were simultaneously monitored. The 2 capsules were successfully placed in 10 of the 11 subjects, and both esophageal and gastric pHs were monitored for 48 hours in 9 subjects. Mild to moderate precordial pain was observed in 7 subjects, but no other complications or side effects were observed in this study. The gastric pH of 10 subjects increased after meals and returned to baseline pH 2 hours later. Decrease of esophageal pH was observed 1 hour after a meal in the symptomatic subjects and corresponded to the time when gastric pH decreased secondary to the increase of pH with meals. The Bravo capsule is easily placed on the gastric wall under endoscopic assistance and enables long ambulatory monitoring of gastric pH.

Double-balloon endoscopy for the diagnosis and treatment of small intestinal disease

Evaluation of the small bowel has long been hampered because of its long and multiple complex loop configurations. Yamamoto et al have developed a new method of inserting an endoscope, known as the double-balloon method of enteroscopy, the Fujinon double-balloon endoscopy system being specialised for this application. Two types of endoscope are currently available for this technique. The EN-450 P5 is a thin endoscope for regular use, whereas the EN-450 T5 is a therapeutic double-balloon endoscope with a larger accessory channel of 2.8mm in diameter. Double-balloon endoscopy enables visualisation of the entire small bowel and also allows for interventional therapy in the small intestine. This method can be used either from an oral or an anal insertion. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, haemostasis, balloon dilatation, stent placement, polypectomy and endoscopic mucosal resection, to be performed. In our large study series, it was demonstrated that double-balloon endoscopy permitted exploration of the small intestine with the high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.

Double-Balloon Endoscopy for Diagnosing and Treating Small-Intestine Diseases

Preliminary reports indicate that the Fujinon double-balloon enteroscope system using an overtube and thin endoscope allows much deeper intubation of

Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases

A specialized system for a new method for enteroscopy, the double-balloon method, was developed. The aim of this study was to evaluate the usefulness of this endoscopic system for small-intestinal disorders. The double-balloon endoscopy system was used to perform 178 enteroscopies (89 by the anterograde approach and 89 by the retrograde approach) in 123 patients. The system was assessed on the basis of the rates of success in jejunal and ileal insertion and the entire examination of the small intestine, diagnostic yields, ability to perform treatment, and complications. Insertion of the endoscope beyond the ligament of Treitz or ileocecal valve was possible in all 178 procedures. It was possible to observe approximately one half to two thirds of the entire small intestine by each approach, and observation of the entire small intestine was possible in 24 (86%) of 28 trials. The source of bleeding was identified in 50 (76%) of 66 patients with GI bleeding, scrutiny of strictures was possible in 23 patients, and a tumor was examined endoscopically in 17 patients. Two complications (1.1%) occurred. Endoscopic therapies in the small intestine including hemostasis (12 cases), polypectomy (1 case), endoscopic mucosal resection (1 case), balloon dilation (6 cases), and stent placement (2 cases) were performed successfully. Double-balloon endoscopy permits the exploration of the small intestine with a high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.

PATIENT ACCEPTANCE OF PER ORAL UNSEDATED THIN CALIBER GASTROSCOPY

Purpose: Conscious sedation for endoscopic procedures increases the cost of the procedure because of time and personnel required to recover the patient. We evaluated the patient acceptance of unsedated per oral EGD performed with a thin caliber gastroscope. Methods: The procedure was explained to the patient in detail and informed consent was obtained. The throat was thoroughly anesthetized with liberal use of topical anesthetic. Using Olympus GIF-XP160 scope which has a di-ameterof5.9mn, 2.0 mm biopsy channel, 120o field of view, 103cm working length, and angulation of 180o/90o (up/down) and 100o/100o (right/left), EGD was performed in the left lateral position. The scope was passed orally. The procedure time was noted as also the diagnoses. After the procedure, the patients were asked to rate the degree of discomfort on a scale of 1–5 (5 being the most uncomfortable); they were also asked if they were willing for similar repeat procedure in future. Results: There were 42 patients; there were two women (4.7%). The mean age was 61.6 years range (30–83). Mean procedure time was 4.4 minutes (range 2–11). The mean degree of discomfort was 2.2 (range 1–5). Only 2/42 (4.7%) said they would not undergo the procedure again. There were no complications. The following diagnoses were made. Esophagitis + Gastritis in 13/42 (30.9%), esophagitis alone 5/42 (11.9%); gastritis alone 10/42 (23.8%) other 4/42 (9.5%) normal 10/42 (23.8%). Conclusions: Per oral unsedated EGD performed with a thin endoscope has a high degree of patient acceptance.

Miscellaneous topics.

Thin transnasal endoscopes (diameter 5 - 6 mm) have been on the market for some time, and have been shown to be better tolerated than endoscopy via the oral route (without sedation) - possibly at the loss of image quality, although this is difficult to quantify. In a multicenter study in France involving 500 patients, the transnasal endoscope was compared with the standard gastroscope introduced transorally, and only a local spray was allowed. The rate of failure to intubate was higher with the transnasal route (6.8 % vs. 1.7 %), and visibility was better with the standard endoscope (significant only for the cardia). The transnasal route was better tolerated by patients (willingness to repeat endoscopy 90 % versus 75 %), although 25 % of patients reported pain in the nostrils [1]. A similar endoscope was used in routine practice in 1327 consecutive outpatients, with a mean examination time of 3.1 min (we had thought that Olympic records in gastroscopy were over) and a completion rate of 95 %, with good patient tolerance [2]. Two groups presented the next step - use of a battery-powered ultrathin endoscope (3 mm in diameter), which is intended only for esophageal examination; its accuracy in detecting disease was substantially inferior to that of standard EGD (sensitivities for various disorders 54 - 84 %) [3]. Another study found that patient acceptance of unsedated esophagoscopy, even with this very thin endoscope, was limited - only 50 % of the 48 patients who underwent both ultrathin and conventional endoscopy stated that they would prefer the thin scope in the future [4]. It remains to be seen whether slim endoscopes will be able to establish themselves, by improving both patient acceptance and image quality.