Transoral Esophagogastroduodenoscopy Research Articles

T1518: Prospective Randomized Comparative Study of Hemodynamic Effects Between Ultrathin Transnasal and Conventinal Transoral Esophagogastroduodenoscopy in Percutaneous Endoscopic Gastorstomy Placement With Modified Introducer Method Under Sedation

Percutaneous Endoscopic Gastrostomy (PEG) placement is useful method for maintaining or improving a patient's quality of life and providing an access for hydration or medication delivery. As those who require PEG placement tend to have poor cardiopulmonary functions, not only PEG placement but also esophagogastroduodenoscopy (EGD) introduction itself will be invasive for such patients. Therefore, less invasive methods are required. Recently, the fewer hemodynamic effects of ultrathin transnasal esophagogastroduodenoscopy (TNEGD) compared to transoral conventional EGD (TOEGD) was reported. In this study, we compared the hemodynamic effects between TNEGD and TOEGD in the setting of PEG placement under sedation with modified introducer technique.

S1600: Prospective Comparative Study of Cardiopulmonary Effect of Unsedated Transnasal and Sedated Transoral Endoscopy

Unsedated transnasal esophagogastroduodenoscopy (N-EGD) with a small caliber endoscope can relieve patients' discomfort. But, N-EGD was not widely used due to the limited study about its safety during the procedure. So, we evaluated the cardiopulmonary effect of unsedated N-EGD during the procedure, compared with that of sedated transoral EGD (O-EGD) in this study.

Oolong Tea from a Jet Nozzle Is a Useful Washing Solution for Lens Cleansing of Transnasal Small-Caliber Esophagogastroduodenoscope

Background and Aims: Unsedated transnasal small-caliber esophagogastroduodenoscopy (TN-EGD) has been used to examine the upper gastrointestinal tract, and its feasibility have been shown by comparative studies with conventional transoral EGD. However, one limitation to the use of TN-EGD is a well-known poorer image quality compared to conventional endoscopy due to the small size of the CCD. Further, insufficient lens cleansing for TN-EGD results due to a too small caliber water jet nozzle. Recently, use of oolong tea for lens cleansing during endoscopy has been discussed, as it contains saponin that has surfactant actions on a fat solution. We evaluated the efficacy of oolong tea for transnasal EGD, using a randomized, prospective double blind trial. Patients and Methods: Oolong tea (O), barley tea (B) and distilled water (W) were prepared as washing solutions for endoscopy. Study I: After an endoscopic lens was soiled with lard oil, it was washed using 1 of the 3 washing solutions, and photographs of a test chart were taken. Image quality was judged by 3 experts who had no knowledge of which washing solution was used. Study II: 612 patients who underwent TN-EGD were randomly assigned to O-, B- and W-groups. All TN-EGD procedures were done by 3 expert endoscopists, who judged the level for lens cleansing using a five-grade visual analogue scale after TN-EGD. The washing solution volume and the overall time for the endoscopic examination were also measured. Results: In Study I, the photographic image quality was significantly superior in the group using oolong tea compared to the other groups (P<0.001). In Study II, the level for lens cleansing in the O-group was significantly superior to those of the B- and W-groups (P<0.001). The volume used for lens washing in the O-group was 11.3 ml. This was significantly smaller than for the W-group (14.2ml) (P<0.05). The total times for EGD were 382sec, 384sec and 392sec in the O-, B- and W-groups, respectively. The time was shorter in the O-group than for the B- and W-groups. Conclusions: For EGD with transnasal small-caliber endoscope, the use of oolong tea as a washing solution for lens cleansing may be useful to maintain a good visual condition and to decrease the stress for endoscopists.

Unsedated transnasal small-caliber esophagogastroduodenoscopy in elderly and bedridden patients

To evaluate the safety of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) for elderly and critically ill bedridden patients. One prospective randomized comparative study and one crossover comparative study between transnasal small-caliber EGD and transoral conventional EGD was done (Study 1). For the comparative study, we enrolled 240 elderly patients aged > 65 years old. For the crossover analysis, we enrolled 30 bedridden patients with percutaneous endoscopic gastrostomy (PEG) (Study 2). We evaluated cardiopulmonary effects by measuring arterial oxygen saturation (SpO(2)) and calculating the rate-pressure product (RPP) (pulse rate x systolic blood pressure/100) at baseline, 2 and 5 min after endoscopic intubation in Study 1. To assess the risk for endoscopy-related aspiration pneumonia during EGD, we also measured blood leukocyte counts and serum C-reactive protein (CRP) levels before and 3 d after EGD in Study 2. In Study 1, we observed significant decreases in SpO(2) during conventional transoral EGD, but not during transnasal small-caliber EGD (0.24% vs -0.24% after 2 min, and 0.18% vs -0.29% after 5 min, P = 0.034, P = 0.044). Significant differences of the RPP were not found between conventional transoral and transnasal small-caliber EGD. In Study 2, crossover analysis showed statistically significant increases of the RPP at 2 min after intubation and the end of endoscopy (26.8 and 34.6 vs 3.1 and 15.2, P = 0.044, P = 0.046), and decreases of SpO(2) (-0.8% vs -0.1%, P = 0.042) during EGD with transoral conventional in comparison with transnasal small-caliber endoscopy. Thus, for bedridden patients with PEG feeding, who were examined in the supine position, transoral conventional EGD more severely suppressed cardiopulmonary function than transnasal small-caliber EGD. There were also significant increases in the markers of inflammation, blood leukocyte counts and serum CRP values, in bedridden patients after transoral conventional EGD, but not after transnasal small-caliber EGD performed with the patient in the supine position. Leukocyte count increased from 6053 +/- 1975/L to 6900 +/- 3392/L (P = 0.0008) and CRP values increased from 0.93 +/- 0.24 to 2.49 +/- 0.91 mg/dL (P = 0.0005) at 3 d after transoral conventional EGD. Aspiration pneumonia, possibly caused by the endoscopic examination, was found subsequently in two of 30 patients after transoral conventional EGD. Transnasal small-caliber EGD is a safer method than transoral conventional EGD in critically ill, bedridden patients who are undergoing PEG feeding.

Transnasal Route: New Approach to Endoscopy

Transnasal esophagogastroduodenoscopy (TN-EGD) has recently become one of the frequently used methods of upper gastrointestinal endoscopy in some countries. Changes in blood pressure, heart rate, and oxygen saturation are smaller for TN-EGD than for conventional transoral esophagogastroduodenoscopy, making it a safer procedure. Lower pain and gag reflex enable TN-EGD to be performed without conscious sedation. TN-EGD is applied in various gastrointestinal (GI) procedures such as percutaneous endoscopic gastrostomy, nasoenteric feeding tube placement, endoscopic retrograde cholangiopancreaticography with nasobiliary drainage and lithotripsy, long intestinal tube placement in small-bowel obstruction, esophageal manometry, foreign body removal, botulinum toxin injection for achalasia, esophageal varix evaluation with the aid of endoscopic ultrasonography, and the double-scope technique for endoscopic submucosal dissection. The establishment of standard training programs and nationwide guidelines, the dissemination of educational information, the improvement in endoscopy devices and accessories, and the availability of insurance coverage for the procedure will obviously further widen the adoption of TN-EGD.

COMPARISON OF ENDOSCOPIC DETECTION RATE OF EARLY GASTRIC CANCER AND GASTRIC ADENOMA USING TRANSNASAL EGD WITH THAT OF TRANSORAL EGD

Background: To investigate the influence of the reduced image quality of transnasal esophagogastroduodenoscopy (EGD) with the ultrathin endoscope (transnasal EGD) on endoscopic diagnoses, we compared the detection rate (DR) of early gastric cancer and gastric adenoma by transnasal EGD with that of transoral EGD using a standard endoscope.Methods: Transnasal EGD was carried out in 2791 examinations for the purposes of screening or other reasons. Controls were examined by transoral EGD and numbered 3591 examinations. The transnasal endoscope used was an EG530N. Lesions graded C‐3 or higher by Kimura‐Takemoto's classification were regarded as endoscopic atrophy.Results: (i) DR in all subjects and those with atrophy were not different between transnasal and transoral EGD. (ii) Multivariate analysis of DR in subjects with atrophy was carried out using five variables: gender, age, purposes of endoscopy, endoscopic insertion route and the four endoscopists. DR was significantly higher in males or subjects ≥60 years. No difference was noted between the endoscopic insertion routes (transnasal vs transoral). (iii) The subjects analyzed in (ii) were divided into the transnasal and transoral groups, and multivariate analysis of DR was carried out using four variables. DR was not different among the endoscopists in the transoral group. However, in the transnasal group, DR increased as the years of endoscopic experience was prolonged.Conclusions: Multivariate analysis detected no significant difference in DR between transnasal and transoral EGD. However, a significant difference in DR by transnasal EGD among the endoscopists is detected. Transnasal EGD should be carefully carried out by experienced endoscopists.

TRIAL OF TRANSNASAL ESOPHAGOGASTRODUODENOSCOPY

Background: Esophagogastroduodenoscopy (EGD) is conventionally performed transorally, although this is often a rather unpleasant experience for the patient. In the present study, we examined the merits and demerits of transnasal EGD.Materials and Methods: We used two types of small‐diameter endoscope, produced by Olympus Co. and Fujinon Toshiba ES Systems Co., Ltd.Results: Transnasal EGD was performed successfully in 98.8% (955/967) of patients examined. When questioned about premedication and the degree of discomfort, the great majority of patients stated that transnasal EGD was more comfortable than a transoral procedure. The incidences of nausea and vomiting were low at 8.6% (82/955) and 0.8% (8/955), respectively. Other identified adverse reactions were nasal pain in 42.9% (415/967) of patients, and epistaxis in 1.1% (11/967). The average time taken for transnasal EGD was 8.2 ± 0.7 min, approximately 1 min longer than for the transoral method.Conclusion: Transnasal EGD is less stressful to patients than transoral EGD, and is a feasible and safe alternative.

Cardiopulmonary Complications for Transnasal EGD Compared to That for Transoral EGD

Cardiopulmonary Complications for Transnasal EGD Compared to That for Transoral EGD

A Prospective Randomized Comparative Study on the Safety and Tolerability of Transnasal Esophagogastroduodenoscopy

Transnasal esophagogastroduodenoscopy (EGD) with a small-caliber endoscope is well tolerated by patients. However, the effect of this procedure on cardiopulmonary function has not been fully investigated. The aim of this prospective, randomized study was to investigate the effect of transnasal EGD in comparison with transoral EGD on cardiopulmonary function. The study involved 450 patients referred for diagnostic EGD. Patients were randomly assigned to one of three types of unsedated EGD (150 patients per group): transnasal EGD using a small-caliber endoscope (the "XP-N" group), transoral EGD using the same small-caliber endoscope ("XP-O" group), and transoral EGD using a conventional endoscope ("XQ" group). Systolic and diastolic blood pressure, pulse rate, and arterial oxygen saturation were monitored before, and 2, 4 and 6 minutes after intubation, and just after endoscope extubation. Gagging episodes were also counted, to determine tolerance. It was not possible to perform transnasal EGD in 12 patients (8.0%). A small amount of epistaxis was observed in eight (5.8%) of 138 patients who were examined successfully by transnasal EGD. Systolic and diastolic blood pressure, pulse rate, rate-pressure product (pulse rate x systolic blood pressure/100), and the drop in arterial oxygen saturation in the XQ group were significantly greater than in the XP-N and XP-O groups at each time point. In the XP-N group, these parameters were significantly lower than those in the XP-O group at 2 minutes after intubation. Of the tree groups the number of gagging episodes was significantly lower in the XP-N group. Transnasal EGD is safer than transoral EGD as it is associated with fewer adverse effects on cardiopulmonary function and is better tolerated by patients.

Unsedated small-caliber esophagogastroduodenoscopy (EGD) versus conventional EGD: A comparative study

Background & Aims: Significant portions of the cost and complications of esophagogastroduodenoscopy (EGD) are related to sedation. This study aimed to assess the feasibility, acceptability, and accuracy of unsedated small-caliber transoral EGD (sc-EGD). Methods: A 4-phase study was performed in healthy volunteers and patients. Phases 1 and 2 involved assessment of the technical feasibility of sedated sc-EGD and the tolerability of unsedated sc-EGD, respectively, in volunteers. Subsequently, the technical feasibility, tolerability, and diagnostic accuracy of sedated and unsedated sc-EGD were determined by having each patient undergo sc-EGD (Pentax EG-1840) with (phase 3) and without (phase 4) sedation, followed by sedated conventional EGD (c-EGD) (Olympus GIF-100 or GIF-Q140) by a staff endoscopist blinded to the findings of the sc-EGD. The t test for paired samples was used for statistical analysis. A P value of <0.05 was considered significant. Results: Sedated and unsedated sc-EGD were technically feasible and tolerable in all volunteers. In patients, compared with sedated c-EGD, sedated and unsedated sc-EGD were 96% and 97% accurate, respectively. The overall acceptability of unsedated sc-EGD was only slightly worse than that of sedated c-EGD (median, 2 vs. 1 on a scale of 1–10). After unsedated sc-EGD, 98% of patients expressed willingness to undergo the procedure again. No complications were observed during any phase of the study. Conclusions: Unsedated sc-EGD is technically feasible, tolerable, and accurate. It can potentially decrease the costs and complications of sedated conventional EGD. GASTROENTEROLOGY 1999;117:1301-1307