Unsedated Transnasal Endoscopy Research Articles

Prevalence of Barrett esophagus in first-degree relatives of patients with esophageal adenocarcinoma.

The aim of this study is to determine the prevalence of Barrett esophagus (BE) in first-degree relatives of patients with esophageal adenocarcinoma (EAC) and Barrett high-grade dysplasia (HGD). After Institutional Review Board approval, first-degree relatives of patients with EAC/HGD underwent unsedated ultrathin transnasal endoscopy (UUTNE) with biopsy. BE was suspected if any salmon-colored epithelial tongues were seen above the gastroesophageal junction. A diagnosis of BE was made only if biopsy from these areas confirmed columnar-lined epithelium with intestinal metaplasia. From 23 families, 47 first-degree relatives underwent ultrathin transnasal endoscopy and 1 patient underwent routine upper endoscopy with sedation as part of this study. The mean age of cases was 44.4 years. All patients tolerated the procedure well and there were no procedure-related complications. BE was suspected in 16 (34%) patients and confirmed in 13 of 16 (27.7%) patients. There were 4 long segments (>3 cm) and 9 short segments (<3 cm) of BE. There is a significantly higher than expected prevalence of BE in first-degree relatives of patients with EAC/HGD. This should be taken in to consideration to develop further screening guidelines. Further work is needed to confirm these findings. Unsedated transnasal endoscopy is a safe and well-tolerated method for BE screening.

Unsedated small caliber esophagogastroduodenoscopy: Can we trust this technique?

Small caliber endoscopes are one of the best examples of fantastic technological advancements in gastrointestinal endoscopy. First designed for pediatric patients in the 1970s, current small caliber videoendoscopes were used for unsedated transnasal gastrointestinal endoscopy after 1994. Nowadays, unsedated endoscopy can be successfully done using small caliber endoscopes via transoral or transnasal route in nearly 90% of cases. Several large studies have shown that small caliber endoscopy is feasible, safe and well-tolerated. These devices can decrease the potential risks of upper gastrointestinal endoscopy by eliminating the need for sedation since these ultrathin endoscopes induce much less gag reflex or choking sensation in patients. Moreover, gastrointestinal endoscopy with small caliber endoscopes results in less sympathetic system activation as well as less oxygen desaturation compared to standard endoscopy, especially in aged, severely ill, bedridden patients. Nevertheless, there is no overall consensus on its cost effectiveness. Though indications are similar with standard endoscopy, small caliber endoscopy can be preferred in patients with gastrointestinal stenosis. Less common indications include transnasal endoscopic retrograde cholangiography and postpyloric feeding tube insertion. The esophagogastroduodenoscopy procedure with small caliber endoscopes is easy to perform, and there is generally no need for further training for this technique. However, the additional cost of equipment and some medicolegal and technical issues have resulted in the unpopularity of small caliber endoscopy in most countries other than France and Japan. However, sharing information about this technique and stressing its potential advantages can help in its widespread use in various countries including Turkey. We believe that routine use of small caliber endoscopes during daily gastrointestinal endoscopy practice is not far away in many countries.

Sa1532 Feasibility and Effectiveness of Unsedated TransNasal Endoscopy With Chromoendoscopy for Esophageal Cancer Screening

Esophageal cancer is usually detected at an advanced stage precluding curative treatment. Alcohol and tobacco abuse and head and neck cancer are risk factors for squamous-cell carcinoma of the esophagus. Transnasal endoscopy (TNE) is routinely practiced in Japan and in European centers. The main advantage is that no sedation is required and therefore patient recovery is faster and costs are lower. In western countries, particularly in North and South America, TNE is seldom practiced and there is not enough evidence about its suitability to these populations.

Screening for Barrettʼs Esophagus in the Population: Results from a Population Based Survey

Purpose: Knowledge and attitudes regarding BE and esophageal adenocarcinoma (EAC) screening in the community are unknown. Screening for BE has been hampered by the lack of an acceptable and widely applicable tool. The acceptability of screening using novel non-invasive techniques in the general population compared to sedated endoscopy (sEGD) is unknown. We AIMED to assess attitudes towards these issues using a survey administered to the population in south-eastern Minnesota. Methods: A population-based, mixed-mode (mail and telephone) survey approach focused on a random community sample of adults aged 50 and older in the seven county area in Southeastern Minnesota was used. The core variables for this survey consisted of items assessing awareness regarding BE and its premalignant potential, willingness to participate in screening for BE/esophageal adenocarcinoma, preferences regarding optimal method of screening for BE: Sedated endoscopy (sEGD), unsedated transnasal endoscopy (uTNE) and capsule endoscopy (CE) were described in the survey, potential barriers to participation in population based screening for BE/esophageal adenocarcinoma, and selected demographics. Results: 114 of 413 (28%) of surveys have been returned. 58 (51%) of the respondents were females, with a mean age of 63 years (SD10.2) compared to non-responders who had a mean age of 65 years (SD 11.4) and similar gender distribution (females 147 (49%). 30 (27%) subjects had heard of BE before the survey, however 72% of subjects were moderately to extremely interested in a screening test for BE/EAC after reading the educational section of the survey. 64 (66%)were aware of sEGD (22% had undergone sEGD), while only 18 (16%) and 15 (13%) were aware of uTNE and CE (5.5% had undergone uTNE and 1% had undergone CE before). 72 (67%) preferred unsedated techniques (CE: 56% or uTNE: 11%) while the rest (33%) preferred sEGD. 18 (16%) had been diagnosed with cancer before (5 breast, 3 prostate, 2 colon, 6 skin, 6 others). 99 (87%) had undergone colonoscopy, 51 (86%) mammography and 45 (82%) prostate cancer screening. 99 (87%) were interested in being invited to undergo screening using one of the three techniques described in the survey. Conclusion: Though only a minority of residents in south eastern Minnesota were initially aware of BE, following education about BE, a majority of subjects expressed willingness to undergo screening. Respondents appear to be more willing to undergo screening by unsedated techniques with Esophageal capsule endoscopy being the most acceptable technique. Responders appear to be willing to undergo non-invasive screening tests for BE. Predictors of participation in screening need to be identified.

M2034 Evaluation of Esophageal Peristalsis With a New Method Using Unsedated Transnasal Endoscopy

M2034 Evaluation of Esophageal Peristalsis With a New Method Using Unsedated Transnasal Endoscopy

511a: Nasal or Standard Endoscopy (NOSE) for Diagnosis of Barrett's Oesophagus - Efficacy and Patient Tolerance

In order to detect all cases of Barrett's oesophagus (BE) in the population, with the aim of reducing adenocarcinoma associated mortality, screening needs to be considered. Unsedated transnasal endoscopy (TNE) can potentially offer a safer and less expensive alternative to conventional sedated endoscopy (CE) for detecting BE.

PTU-019 Nasal or standard endoscopy (nose) for diagnosis of Barrett's oesophagus – efficacy and patient tolerance: Abstract PTU-019

Introduction In order to detect all cases of Barrett9s oesophagus (BE) in the population, with the aim of reducing adenocarcinoma associated mortality, screening needs to be considered. Unsedated transnasal endoscopy (TNE) can potentially offer a safer and less expensive alternative to conventional sedated endoscopy (CE) for detecting BE. Aims (1) To evaluate the sensitivity and specificity of TNE in diagnosing BE compared with CE. (2) To assess patient acceptability of TNE for a future multicentre screening trial. Methods Patients with known BE under surveillance and those referred for routine endoscopy for other reasons underwent both TNE and CE in a randomised cross-over design. TNE findings of endoscopic BE, biopsy size and presence of intestinal metaplasia (IM) were compared against CE, which was used as gold standard. Pre and post endoscopy short-form spielberger state-trait questionnaires (SF6), a visual analogue scale and a single question addressing preference for endoscopy type were used to measure patient acceptability of the procedures. Results Of 57 patients randomised, 50 completed the study. All 22 BE cases with columnar lined epithelium (CLE) on CE were correctly diagnosed by TNE. Although the biopsy size of TNE was significantly smaller compared to CE (mean size 2.59 vs 4.74 p Conclusion TNE is accurate in diagnosing BE and detecting IM. Despite the smaller biopsy size, it detected an equal number of IM cases and showed potential to detect dysplasia. It was well tolerated and preferred by patients and may be an efficient screening method for BE.

A Randomized Trial of Topical Anesthesia Comparing Lidocaine Versus Lidocaine Plus Xylometazoline for Unsedated Transnasal Upper Gastrointestinal Endoscopy

The optimal topical anesthesia regimen for unsedated transnasal endoscopy is unknown. The addition of a nasal decongestant, such as xylometazoline (X), to a topical anesthestic may improve patient comfort. To determine the effectiveness of lidocaine (L) versus L plus X (LX) for anesthesia in unsedated transnasal endoscopy. Consecutive participants of the Aklavik Helicobacter pylori project were prospectively randomly assigned to receive LX or L for unsedated transnasal 4.9 mm ultrathin endoscopy. The primary outcome was overall procedure discomfort on a validated 10-point visual analogue scale (1 = no discomfort, 10 = severe discomfort). Secondary outcomes included pain, endoscope insertion difficulty, gagging, adverse events and encounter times. Results were presented as mean +/- SD, difference in mean, 95% CI. A total of 181 patients were randomly assigned to receive LX (n=94) and L (n=87). Baseline characteristics between the two groups were similar (mean age 40 years, 59% women). Overall, patient procedural discomfort with LX and L were 4.2+/-2.4 versus 3.9+/-2.1, respectively (0.29; 95% CI -0.39 to 0.96). Transnasal insertion difficulty was significantly lower with LX than with L (2.4+/-2.1 versus 3.2+/-2.8, respectively [-0.80; 95% CI -1.54 to -0.06]). Compared with L, the use of LX was associated with significantly less time needed to apply anesthesia (2.4+/-1.8 min versus 3.5+/-2.2 min, respectively [-1.10; 95% CI -1.71 min to -0.50 min]) and less time for insertion (3.2+/-1.8 min versus 3.9+/-2.2 min, respectively [-0.70 min; 95% CI -1.30 min to -0.10 min]). Epistaxis was rare but occurred less frequently with LX (1.1%) than with L (4.6%) (P=0.19). LX did not improve patient comfort for transnasal endoscopy compared with L alone. However, LX was associated with less difficulty with endoscope transnasal insertion and reduced insertion time. Further studies on the optimal regimen and dosing of anesthesia are required.

T1104 Comparative Study On the Cardiovascular Considerations of Unsedated Transoral and Transnasal Gastrointestinal Endoscopy in Younger, Middle, and Advanced Aged Patients

T1104 Comparative Study On the Cardiovascular Considerations of Unsedated Transoral and Transnasal Gastrointestinal Endoscopy in Younger, Middle, and Advanced Aged Patients

An Adequate Level of Training for Technical Competence in Diagnostic Unsedated Transnasal Endoscopy: A Prospective Assessment of the Learning Curve

Backgrounds/Aims: There is a limited study about the training program of unsedated transnasal esophagogastroduodenoscopy (UT-EGD) for a trainee who has no previous experience of this technique. The goal of this study was to determine the adequate level of training for technical competence in diagnostic UT-EGD for the trainee. Methods: From May 2008 to November 2008, three hundred patients who underwent UT-EGD under local anesthesia at a tertiary care academic medical center were included in this study. Four trainees who had no experience performing UT-EGD but very competent in conventional EGD, performed UT-EGD on 50 patients each. In a control group, four experts performed UT-EGD on a total of 100 patients. All trainees and experts used 5.2mm caliber endoscopes (GIF-260N, Olympus Medical Systems Corp., Tokyo, Japan). Technical success, procedure duration (intubation time to esophagus, intubation time to duodenal 2nd portion), complications, frequency of belching, and vital signs were checked. Results: Technical successes were 85%, 90%, 92.5%, 90%, 100% for every 10 patients totalling 50 patients each per trainee and 98% consistency in the control group. Intubation time to esophagus(sec) was 55.1 ± 26.9, 42.0 ± 13.6, 38.3 ± 13.1, 31.1 ± 7.4, 29.8 ± 6.6 in trainees and 31.5 ± 11.6 in the control group. Intubation time to duodenal 2nd portion(sec) was 130 ± 45.8, 121 ± 34.6, 110.5 ± 29.9, 102.5 ± 28.2, 98.5 ± 25.7 in trainees and 100.9 ± 27.4 in the control group, and showed no statistical significant difference after the first 3 lots of 10 patients. Epistaxis showed no statistical differences in both groups (18/200 vs 7/100), but the patients who complained of nasal pain were lower in the control group (44//200 vs 15/100). Frequencies of belching were 2.45 ± 1.36, 2.24 ± 2.06, 1.89 ± 1.72, 1.68 ± 1.99, 1.05 ± 1.27 in trainees and 1.39 ± 1.97 in the control group, and showed no significant difference after the first 3 lots of 10 patients. The willing to retry (164/200 vs 77/100) showed no significant differences in both groups, but patients who had previously experienced sedated EGD did not want to retry UT-EGD (26/186 vs 33/114). There were no significant difference in change of systolic and diastolic pressure, pulse rate, and oxygen saturation during UT-EGD between trainees and the control group, and there were no patients who experienced unstable vital signs and demanded oxygenation. Conclusions: Endoscopists who are competent in conventional EGD are able to obtain acceptable results from their first attempts, but 30 cases of experience is needed to acquire skillful hands for performing UT-EGD. Key words: Unsedated transnasal endoscopy, Learning curve

Prevalence of Abnormal Upper GI Findings in Apparently Healthy Volunteers Enrolled for Research Studies

Introduction: Subjects volunteering in research studies are stratified as healthy based on questionnaire, medical interviewing, and physical examination. Using unsedated transnasal endoscopy (T-EGD) as an additional technique for screening, we previously reported erosive esophagitis in 4 (9%) of 43 apparently healthy volunteers (Hofmann et al Gastroenterology; G0818; 1999). We now report our results on a large number of separate volunteers evaluated after our above pilot study. Aims: To evaluate the impact of T-EGD as a screening tool to stratify research volunteers.

Unsedated transnasal endoscopy: Is it all about the size?

Unsedated transnasal endoscopy: Is it all about the size?

Prospective Comparative Study on the Acceptability of Unsedated Transnasal Endoscopy in Younger Versus Older Patients

The aim of this prospective study was to compare the acceptance and tolerance for unsedated transnasal esophagogastroduodenoscopy (EGD) between younger and older patients. Little information is available on comparisons of younger and older patients with regard to acceptance and tolerance of transnasal EGD. A total of 260 patients were referred for unsedated transnasal EGD and divided into 2 groups according to their age: less than 60 years of age (group A, n=160) and 60 years of age and older (group B, n=100). A questionnaire for tolerance was completed by each patient (a validated 0 to 10 scale where "0" represents no discomfort/well tolerated and "10" represents severe discomfort/poorly tolerated). In 94.4% of group A and 95.0% of group B, insertions were successfully completed (P>0.05). Between groups A and B, discomfort during nasal anesthesia (1.7+/-0.2 vs. 1.6+/-0.2) and overall tolerance during procedure (1.7+/-0.2 vs. 1.5+/-0.2) were similar (P>0.05). However, discomfort during insertion was significantly greater in group A than in group B (2.5+/-0.2 vs. 1.9+/-0.2, P=0.02). Of all, 97.4% of group A and 94.7% of group B were willing to undergo unsedated transnasal EGD in the future (P>0.05). There was no significant difference in acceptability between younger and older patients for unsedated transnasal EGD. Otherwise, younger patients experienced significantly more discomfort during insertion than did older patients.

Unsedated Transnasal Endoscopy: A Canadian Experience in Daily Practice

Esophagogastroduodenoscopy (EGD) is the most frequently performed diagnostic procedure for upper gastrointestinal disorders. The procedure is routinely performed under conscious sedation in North America. A significant proportion of morbidity and mortality associated with EGD is related to hypoxia due to conscious sedation. The use of sedation is also associated with an increase in cost, loss of work on the day of endoscopy and the need for the patient to be accompanied home after the procedure. Transnasal endoscopy has advantages such as no sedation and less patient monitoring, nursing time and expenses than conventional per oral EGD. To assess the feasibility and acceptability of unsedated transnasal EGD in daily practice. Patients due to undergo EGD were given a choice of either unsedated transnasal EGD or per oral EGD with sedation. Patients who chose unsedated transnasal EGD had the procedure performed in the office by a senior gastroenterologist with experience in transnasal EGD. All procedures were performed using a small-calibre esophagogastroduodenoscope. All patients were surveyed using a patient satisfaction questionnaire, and were asked to give specific scores in terms of choking sensation, sore throat, nasal discomfort and abdominal discomfort. All variables were assessed by scores between 0 and 10, with 10 indicating the most severe degree of each variable. Any complications were also recorded. Between March 2002 and August 2003, 231 patients underwent transnasal EGD. The median age of the patients was 57 years (range 15 to 87 years). Complete examinations were possible in 98% of patients. Patients reported a high degree of acceptability (mean score 6.6, range 1 to 10) and low degrees of choking sensation (mean 1.8, range 0 to 10), nasal discomfort (mean 1.7, range 0 to 10), sore throat (mean 0.8, range 0 to 9) and abdominal discomfort (mean 1.1, range 0 to 10). The only complications reported by the patients were epistaxis (n=2, 0.9%) and sinusitis (n=1, 0.4%). Some patients also reported transient light-headedness (n=12, 5%) and mucous discharge (n=2, 0.9%). When asked, 185 patients (88%) stated that they were willing to undergo the same procedure in the future if medically indicated. Of the 84 patients who had conventional EGD under conscious sedation in the past, 52 patients (62%) preferred transnasal EGD without sedation. Transnasal EGD is generally well tolerated, feasible and safe. It can be performed with topical anesthesia in an outpatient setting. The low complication rate, high patient satisfaction and potential cost savings make transnasal endoscopy an attractive alternative to conventional EGD to screen patients for upper gastrointestinal tract diseases.

Unsedated transnasal endoscopy (the Shaker technique): an alternative for assessment of supraesophageal complications of gastroesophageal reflux

This article reviews problems associated with sedated endoscopy, and describes the rationale for unsedated endoscopy as an alternative. Costs, tolerability, potential for complications, and general patient and physician acceptance for unsedated endoscopy are reviewed. A new technique, the transnasal esophagogastroduodenoscopy (the Shaker technique), is described.

Unsedated transnasal endoscopy accurately detects Barrett's metaplasia and dysplasia

Background: Unsedated transnasal upper endoscopy has a diagnostic yield comparable with that of sedated conventional upper endoscopy. The ability of transnasal upper endoscopy to detect Barrett's metaplasia or dysplastic change has not been systematically evaluated. The aim of this study was to assess the feasibility of transnasal upper endoscopy for surveillance of patients with Barrett's esophagus and to evaluate its histopathologic yield for Barrett's metaplasia and dysplasia. Methods: Thirty-two patients with Barrett's esophagus were evaluated with conventional upper endoscopy and transnasal upper endoscopy. An effort was made to recruit patients known to have dysplasia. Quadrantic biopsy specimens were taken with standard (conventional upper endoscopy) and pediatric (transnasal upper endoscopy) biopsy forceps at procedures performed at least 1 week apart. Two blinded pathologists evaluated the specimens. Results: Transnasal upper endoscopy detected Barrett's metaplasia histopathologically in 31 of 32 patients. Level of agreement for presence of dysplasia in biopsy specimens obtained between conventional upper endoscopy and transnasal upper endoscopy was excellent (k = 0.79). Interobserver agreement for dysplasia in specimens obtained by conventional upper endoscopy (k = 0.61) and by transnasal upper endoscopy (k = 0.61) were similar. Intraobserver agreement between conventional upper endoscopy and transnasal upper endoscopy biopsy specimens for dysplasia by pathologist 1 (k = 0.73) and pathologist 2 (k = 0.75) were also similar. No significant adverse effects were noted. Conclusions: Transnasal upper endoscopy is feasible and accurate for identification and histopathologic confirmation of Barrett's metaplasia with a histopathologic yield for dysplasia comparable with conventional upper endoscopy. (Gastrointest Endosc 2002;56:472-8.)

Unsedated transnasal endoscopy: a new technique for accurately detecting and grading esophageal varices in cirrhotic patients

OBJECTIVES: Endoscopic screening of cirrhotics for large esophageal varices (EV) is advocated before initiation of prophylactic therapy for variceal bleeding. Conscious sedation for conventional endoscopy is problematic in cirrhotic patients because of risk of prolonged encephalopathy. Unsedated transnasal endoscopy (T-EGD) is a new technique, which allows for unsedated examination because it is well tolerated. The aims of this study were to determine whether T-EGD is feasible for screening of cirrhotic patients for presence of EV and to compare the diagnostic yield of T-EGD with conventional endoscopy for detecting and grading of EV. METHODS: Fifteen cirrhotics with no history of variceal bleeding, known EV, severe thrombocytopenia, or recurrent epistaxis were evaluated by unsedated T-EGD using a 5.3-mm outer diameter endoscope. Immediately afterward, a different endoscopist, blinded to T-EGD findings, performed sedated conventional endoscopy in standard fashion. The presence and size of EV, gastric varices, and other findings were recorded. Patient tolerance was also evaluated. RESULTS: Both modalities detected EV in the same 10 and gastric varices in the same two patients and completely agreed on size of EV. No stigmata of recent variceal bleeding were noted. Average time for unsedated T-EGD was 5 min 6 s. All patients found both procedures acceptable overall, with no significant difference in choking, discomfort, and sore throat. One patient developed self-limited epistaxis after T-EGD. CONCLUSIONS: 1) EV are accurately detected and graded by T-EGD in cirrhotic patients. 2) T-EGD is a safe and less costly screening alternative for EV in cirrhotic patients.

Unsedated transnasal endoscopy: a safe and less costly alternative.

Upper endoscopy is an integral component in the management of upper gastrointestinal disorders, but it is underutilized because of its high cost and potential complications. Unsedated transnasal endoscopy (T-EGD) is a relatively new technique using an ultrathin endoscope. Because it is better tolerated than standard upper endoscopy, it is performed with the patient unsedated, thus avoiding the associated costs and complications of conscious sedation. In this review, the technique of T-EGD and its current experience are discussed. In addition, potential future applications, special considerations, and potential pitfalls are reviewed.

Does biopsy size of unsedated transnasal endoscopy (T-EGD) impact histologic interpretation of Barrett's dysplasia?

Does biopsy size of unsedated transnasal endoscopy (T-EGD) impact histologic interpretation of Barrett's dysplasia?

Impact of unsedated transnasal endoscopy (T-EGD) on the management of dyspepsia: A decision analysis

Impact of unsedated transnasal endoscopy (T-EGD) on the management of dyspepsia: A decision analysis