Unsedated Transnasal Esophagogastroduodenoscopy Research Articles

Evaluation of Acute Mountain Sickness by Unsedated Transnasal Esophagogastroduodenoscopy at High Altitude

It is not clear how rapid ascent to a high altitude causes the gastrointestinal symptoms of acute mountain sickness (AMS). We assessed the incidence of endoscopic lesions in the upper gastrointestinal tract in healthy mountaineers after a rapid ascent to high altitude, their association with symptoms, and their pathogenic mechanisms. In a prospective study, 25 mountaineers (10 women; mean age, 43.8 ± 9.5 y) underwent unsedated, transnasal esophagogastroduodenoscopy in Zurich (490 m) and then on 2 test days (days 2 and 4) at a high altitude laboratory in the Alps (Capanna Regina Margherita, 4559 m). Symptoms were assessed using validated instruments for AMS (the acute mountain sickness score and the Lake Louise scoring system) and visual analogue scales (scale, 0-100). Levels of messenger RNAs (mRNAs) in duodenal biopsy specimens were measured by quantitative polymerase chain rection. The follow-up endoscopy at high altitude was performed in 19 of 25 patients on day 2 and in 23 of 25 patients on day 4. The frequency of endoscopic lesions increased from 12% at baseline to 26.3% on day 2 and to 60.9% on day 4 (P < .001). The incidence of ulcer disease increased from 0 at baseline to 10.5% on day 2 and to 21.7% on day 4 (P= .014). Mucosal lesions were associated with lower hunger scores (37.3 vs 67.4 in patients without lesions; P= .012). Subjects with peptic lesions had higher levels of HIF2A mRNA, which encodes a hypoxia-induced transcription factor, and ICAM1 mRNA, which encodes an adhesion molecule, compared with subjects without lesions (fold changes, 1.38 vs 0.63; P= .001; and 1.37 vs 0.66; P= .011, respectively). In a prospective study of 25 mountaineers, fast ascent to a high altitude resulted in rapid onset of clinically meaningful mucosal lesions and ulcer disease. Duodenal biopsy specimens from these subjects had increased levels of HIF2A mRNA and ICAM1 mRNA, which might contribute to the formation of hypoxia-induced peptic lesions. Further studies are needed of the mechanisms of this process.

Endoscopic meatus scoring scale versus sniff test to predict insertability before transnasal endoscopy: A prospective, randomized study

Sniff test is a common method before unsedated transnasal esophago-gastro-duodenoscopy (UT-EGD) to select a nostril insertion site. Yet there is no objective method to select a more specific meatus insertion tract for anesthesia and insertion. We devised an endoscopic meatus scoring scale by anterior meatuscopy to select the most optimal meatus insertion tract. We hypothesized that meatuscopy instead of sniff test might improve tolerance and reduce adverse events during nasal anesthesia and UT-EGD. A prospective randomized controlled trial to compare patient tolerance and adverse events. A total of 359 patients were assessed and finally 310 patients were analyzed. There were no statistical differences in patient characteristics and insertion failure rates. Pain scores during nasal anesthesia, nasal insertion/exsertion, UT-EGD, and overall tolerance were significantly lower in the meatuscopy group than sniff test group. Compared with the sniff tested patients, the meatuscopied patients had significantly lower epistaxis rates during insertion/exsertion, better visual capacity after decongestive anesthesia, and shorter total procedure time. A significantly higher proportion of the meatuscopied than sniff tested patients would like to receive the same procedure next time. Nasal discharge, nasal pain, epistaxis, and blowing out blood clots occurred significantly less frequent in the meatuscopy group than sniff test group. More sniff tested than meatuscopied patients had headache, delayed epistaxis, and sinusitis although they were not statistically significant. Selection of an optimal meatus insertion tract by an anterior meatuscopy causes lesser nasal pain, epistaxis, and post-procedural side effects in nasal anesthesia and UT-EGD than the conventional sniff test.

Regular screening of esophageal cancer for 248 newly diagnosed hypopharyngeal squamous cell carcinoma by unsedated transnasal esophagogastroduodenoscopy

Esophageal squamous cell carcinoma (ESCC) is common in hypopharyngeal squamous cell carcinoma (HSCC) patients. This prospective study is to reveal the prevalence of simultaneous ESCC in newly diagnosed HSCC patients by unsedated transnasal esophagogastroduodenoscopy (EGD) and to analyze the clinical predictors for simultaneous esophageal lesions and their survival. 248 patients with newly diagnosed HSCC and without previous head and neck cancer between 2007 and 2014 were prospectively evaluated for HSCC and simultaneous esophageal lesions by unsedated transnasal EGD. The clinical factors for simultaneous esophageal lesions were evaluated. Survival analysis of the HSCC patients receiving complete treatment was done. The mean age was 58years. 170 HSCC (68.5%) were classified as T3-T4. The procedures were successfully performed (98.4%), except 4 huge tumors. 174 HSCC (85.7%, out of 203 tumors biopsied) were pathologically proved malignancy by this technique. Regarding esophageal lesions (45.5%), ESCC occurred in 36 patients (14.8%), dysplasia without ESCC occurred in 23 (9.4%) and Lugol voiding lesion without ESCC or dysplasia occurred in 52 (21.3%). Alcohol drinking (adjusted OR: 6.95, p<0.05) and N3 classification (adjusted OR: 2.41, p<0.05) of HSCC were the independent risk factors for the presence of esophageal lesions. The overall survival of the HSCC patients with ESCC was significantly lower than those without ESCC (p=0.013). Unsedated transnasal EGD is a promising technique for diagnosis of HSCC and simultaneous ESCC. Simultaneous esophageal lesions including ESCC (15%) are common in newly diagnosed HSCC patients, especially with alcohol drinking or N3 disease.

Anterior meatuscopy is more reliable than a sniff test for predicting nasal patency before transnasal endoscopy.

Background and study aims: Unsedated transnasal esophago-gastro-duodenoscopy (UT-EGD) has been performed for at least two decades but many techniques related to the procedure have yet to be standardized. We aimed to develope a simple endoscopic method, anterior meatuscopy, to replace the sniff test for selecting the most patent nasal meatus before UT-EGD. We hypothesized that access to the common nasal meatus (CNM), if confirmed by anterior meatuscopy, was a safer route than the inferior (INM) and middle nasal meatuses (MNM) because it would result in reduced epistaxis, nasal pain, and nasal discharge. Patients and methods: We used anterior meatuscopy and an endoscopic meatus scoring scale (EMSS) to identify the optimal meatus for insertion. We evaluated the EMSS frequency distributions for the INM, CNM, and MNM and the reliability of a sniff test in 1,000 consecutive patients. The adverse effects of passing through the CNM versus the INM and MNM, respectively, were compared. Results: In the INM and MNM, the EMSS frequencies were grade I > II > III > 0 whereas those in the CNM were grade II > I > 0 > III. A sniff test was not reliable, given its low sensitivity (63.3 %), specificity (67.3 %), positive predictive value (69.1 %), negative predictive value (61.4 %), and accuracy (65.2 %). Although only 9.2 % of our patients had grade III anterior-to-posterior CNMs, passage through this spacious CNM rather than through the MNM or the INM could significantly reduce epistaxis, nasal pain, and nasal discharge. Conclusions: Anterior meatuscopy is more reliable than a sniff test before UT-EGD. Transnasal endoscopic passage through the endoscopically patent CNM, if detected by anterior meatuscopy, may prevent epistaxis and nasal pain and minimize nasal discharge.

Analysis of Cardiopulmonary Stress during Endoscopy: Is Unsedated Transnasal Esophagogastroduodenoscopy Appropriate for Elderly Patients?

Transnasal esophagogastroduodenoscopy (EGD) without sedation has been reported to be safe and tolerable. It has recently been used widely in Japan for the detection of upper gastrointestinal disease. Alternatively, transoral examination using a thin endoscope has also been reported to be highly tolerable. To examine the cardiocirculatory effects of transoral versus transnasal EGD in an attempt to determine the most suitable endoscopic methods for patients ≥75 years of age. Subjects who underwent monitoring of respiratory and circulatory dynamics without sedation during endoscopic screening examinations were enrolled at the New Ooe Hospital (Kyoto, Japan) between April 2008 and March 2009. A total of 165 patients (age ≥75 years) provided written informed consent and were investigated in the present study. Patients were randomly divided into three subgroups: UO group--thin endoscope; SO group--standard endoscope; and UT group--transnasal EGD. Percutaneous arterial blood oxygen saturation, heart rate and blood pressure were evaluated just before EGD and at five time points during EGD. After transnasal EGD, patients who had previously been examined using transoral EGD with a standard endoscope were asked about preferences for their next examination. There were no statistical differences in the characteristics among the groups. Percutaneous oxygen saturation in the UT group showed a transient drop compared with the SO and UO groups at the beginning of the endoscopic procedure. Heart rate showed no significant differences among the SO, UO and UT groups; Systolic blood pressure in the UO group was lower immediately after insertion compared with the SO and UT groups. The rate pressure product in the UO group was comparable with that in the UT group during endoscopy, and the SO group showed a continuously higher level than the UO and UT groups. More than one-half (54.4%) of patients were 'willing to choose transnasal EGD for next examination'. For elderly patients, unsedated transnasal EGD failed to show an advantage over unsedated standard endoscopy. Transoral thin EGD was estimated to be safe and tolerable.

Utility of unsedated transnasal endoscopy for pharyngeal observation during esophagogastroduodenoscopy. A prospective study to assess cardiopulmonary function

Objectives. Emergence of image-enhanced endoscopy has enabled an early detection of pharyngeal carcinoma. Pharyngeal observation during esophagogastroduodenoscopy (EGD) is sometimes difficult because of excessive reflexes and is a great burden to the patients and impacts on their cardiopulmonary function. In this study, the authors aimed to evaluate the utility of transnasal EGD (TN-EGD) in comparison with sedated and unsedated transoral EGD (TO-EGD) in pharyngeal observation using a continuous monitoring device. Methods. A total of 70 patients receiving diagnostic EGD (unsedated TN-EGD, sedated TO-EGD, and unsedated TO-EGD) were enrolled in this study and were evaluated by the following three criteria: (1) numbers of patients with excessive gag and/or cough reflex, (2) vital signs before and during the pharyngeal observation, and (3) response to the request for vocalization or breath-holding. Results.Unsedated TN-EGD, sedated TO-EGD, and unsedated TO-EGD were performed in 30, 20, and 20 patients, respectively. The rate of gag reflex was significantly lower in TN-EGD than in both types of TO-EGD (0% vs. 30%, chi-square test, p < 0.005). The changes in average values of both arterial oxygen saturation (SpO2) and pulse rate (PR) in TN-EGD were smaller than those in sedated TO-EGD (−0.23% vs. −1.23% in SpO2 and 1.57 vs. 8.11 bpm in PR, p < 0.01, respectively). Unsedated TN-EGD patients could respond to the instructions of utterance and breath-holding during the observation (p < 0.05, p < 0.001, respectively). Conclusion. Unsedated TN-EGD is safe and feasible for pharyngeal observation during normal EGD examination.

Ultrathin endoscope flexibility can predict discomfort associated with unsedated transnasal esophagogastroduodenoscopy

To evaluate the effects of choice of insertion route and ultrathin endoscope types. This prospective study (January-June 2012) included 882 consecutive patients who underwent annual health checkups. Transnasal esophagogastroduodenoscopy (EGD) was performed in 503 patients and transoral EGD in 235 patients using six types of ultrathin endoscopes. Patients were given a choice of insertion route, either transoral or transnasal, prior to EGD examination. For transoral insertion, the endoscope was equipped with a thin-type mouthpiece and tongue depressor. Conscious sedation was not used for any patient. EGD-associated discomfort was assessed using a visual analog scale (VAS; no discomfort 0- maximum discomfort 10). Rates of preference for transnasal insertion were significantly higher in male (male/female 299/204 vs 118/117) and younger patients (56.8 ± 11.2 years vs 61.3 ± 13.0 years), although no significant difference was found in VAS scores between transoral and transnasal insertion (3.9 ± 2.3 vs 4.1 ± 2.5). Multivariate analysis revealed that gender, age, operator, and endoscope were independent significant predictors of VAS for transnasal insertion, although gender, age, and endoscope were those for transoral insertion. Further analysis revealed only the endoscopic flexibility index (EFI) as an independent significant predictor of VAS for transnasal insertion. Both EFI and tip diameter were independent significant predictors of VAS for transoral insertion. Flexibility of ultrathin endoscopes can be a predictor of EGD-associated discomfort, especially in transnasal insertion.

Unsedated transnasal endoscopy with ultrathin endoscope as a screening tool for research studies

Asymptomatic subjects volunteering for research studies are generally stratified as healthy based on a questionnaire, medical interviewing, and physical examination. The aim of this study was to evaluate the prevalence of upper gastrointestinal (GI) abnormalities in healthy asymptomatic volunteers using unsedated transnasal esophagogastroduodenoscopy (T-EGD) with an ultrathin endoscope as an additional screening tool. A prospective study from one academic medical center with extensive experience in T-EGD. Consecutive 150 subjects volunteering for research studies were initially screened by using a gastroesophageal reflux disease (GERD) questionnaire, interviewing, and examination. Based on these, they were stratified as healthy asymptomatic volunteers or with GERD. Unsedated T-EGD was then performed by a faculty member who was blinded to the results of the initial assessment. On initial assessment using GERD questionnaire, medical interviewing, and physical examination, of the total 150 consecutive research volunteers, 83 (average age 33 ± 16 years; 46 females, 37 males) subjects were healthy asymptomatic volunteers and 67 (average age 36 ± 15 years; 35 females, 32 males) had symptoms of GERD. On T-EGD, GI pathology was found in 15 of 83 (18%) healthy asymptomatic volunteers as compared to 24 of 67 (36%) stratified as having GERD (P < .01). The esophageal abnormalities found in healthy asymptomatic volunteers were esophagitis (13.3%), Barrett's esophagus (2.4%), hiatus hernia (2.4%), and gastritis (2.4%). A small but significant number of asymptomatic subjects have abnormal upper GI findings. Hence, transnasal unsedated endoscopy can be considered as a screening tool to stratify subjects as healthy, especially when considering them for research studies.

Krefeld CONTRA Study: Conventional Peroral Esophago-Gastro-Duodenoscopy (EGD) vs. Transnasal EGD – a Prospective and Randomised Study with Independent Evaluation of Conscious Sedation, Endoscope Diameter, and Access Path

The guidelines of the German Gastroenterology Society (Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten, DGVS) demand the presence of an additional qualified person solely responsible for patient monitoring during sedated endoscopy. Transnasal esophagogastroduodenoscopy (EGD) allows easy access to the upper gastrointestinal tract and may avoid the complications induced by conscious sedation and reduce medical costs. 120 patients referred to diagnostic EGD were assigned to six groups: group 1, unsedated peroral EGD with normal-caliber endoscope; group 2, unsedated peroral EGD with small-caliber endoscope; group 3, sedated peroral EGD with normal-caliber endoscope; group 4, sedated peroral EGD with small-caliber endoscope; group 5, unsedated transnasal EGD with small-caliber endoscope; group 6, sedated transnasal EGD with small-caliber endoscope. Outcome parameters included objective (duration, oxygen saturation) and subjective measures (standardised visual analogue scales) of the endoscopy staff (handling, insertion, retroflexion, tolerability, overall assessment) and patients (pain, unpleasantness, sore throat, choking, gagging, meteorism, anxiety, acceptability). The patients were comparable according to age, sex, anxiety, and respiratory function before EGD. Sedoanalgesia was without effect on EGD handling and duration, patient tolerability and overall assessment by endoscopists and assistants. Negative effects of sedoanalgesia (decreased oxygen saturation, patient acceptability) were much lower and without significance for transnasal compared to peroral EGD. Patient tolerability and acceptability of the endoscopic staff (handling, insertion, retroflexion) were significantly better for the small-caliber endoscope. Duration of unsedated transnasal EGD was slightly but significantly longer, pain, unpleasantness, and anxiety slightly but significantly higher compared to sedated peroral EGD. However, these differences could no loner be detected seven days after endoscopy. Cost analysis revealed major advantage for transnasal EGD. Unsedated transnasal EGD may replace diagnostic peroral EGD, reduces costs with acceptable patient discomfort and has advantagous acceptability of the endoscopic staff.

T1080 Unsedated Transnasal Esophago-Gastroduodenoscopy at 4559 M (14957 Ft) -Endoscopic Findings in Healthy Mountaineers After Rapid Ascent to High Altitude

T1080 Unsedated Transnasal Esophago-Gastroduodenoscopy at 4559 M (14957 Ft) -Endoscopic Findings in Healthy Mountaineers After Rapid Ascent to High Altitude

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.

CURRENT STATUS AND EVALUATION OF TRANSNASAL ESOPHAGOGASTRODUODENOSCOPY

We reviewed the current status of transnasal esophagogastroduodenoscopy (EGD) with regard to tolerance, safety, feasibility and accuracy. Comparison of standard and ultrathin scopes and recently reported endoscopic techniques with transnasal insertion are also described as well as the current status of transnasal EGD in European countries compared with Japan. As several studies concluded that transnasal EGD can facilitate comfortable endoscopy without the need for sedative drugs, it has been tried in countries in which a relatively high number of unsedated EGD are carried out in daily practice. Long-tube intubation of the jejunum with the assistance of transnasal EGD will also be a part of the daily practice in the near future. However, its safety and accuracy should be further investigated. Even a standard scope whose charge-coupled device (CCD) has the same resolution as an ultrathin scope is superior to an ultrathin scope in terms of luminosity and resolution. Given the small number of procedures reported to date, the absolute complication rate of unsedated transnasal EGD is unknown. Methods of nasal anesthesia, as well as informed consent, indications and contraindications for transnasal EGD are not standardized. A guideline of transnasal EGD is under discussion by the Japanese Gastroenterological Endoscopy Society.

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

Unsedated transnasal esophagogastroduodenoscopy for the evaluation of dysphagia following treatment for previous primary head neck cancer

Dysphagia is not uncommon after curative treatment for primary head and neck cancer. Local recurrences or second primary cancers in the upper digestive tract need to be excluded firstly before treatment for dysphagia. However, many patients have trismus or pharyngeal stenosis following treatment, both of which prevent rigid/flexible transoral laryngoscopy/esophagoscopy evaluating the entire upper digestive tract. The purpose of this study was to prospectively investigate the diagnostic value of unsedated transnasal esophagogastroduodenoscopy (EGD) in 36 primary head and neck cancer patients with post-treatment dysphagia. Except three patients with very narrow space or the presence of the tumor in the neopharynx, transnasal EGD could completely evaluate the upper digestive tract in 33 patients and found one patient with local recurrent hypopharyngeal cancer, seven patients with newly diagnosed hypopharyngeal cancer, four patients with esophageal cancer, and one patient with simultaneous hypopharyngeal and esophageal cancers, which were all successfully biopsied and proven microscopically. Five patients previously receiving total laryngectomy had various degrees of stenosis of the neopharynx without local recurrence or esophageal cancer. Thirteen patients had no significant organic or pathological lesions. One patient had a benign tumor on the epiglottis and the other NPC patient had extensive soft tissue necrosis in the pyriform sinus as a cause of dysphagia. The mean duration of the entire procedure was 16min. All patients tolerated the procedure well. No significant complications were noted during and after examination. The present study indicates that unsedated transnasal EGD is feasible to confidently distinguish between functionally/anatomically-related dysphagia and newly growing tumors in the upper digestive tract, and to obtain biopsy specimens for pathological diagnosis from the tumors in a single session.

Endoscopic-guided or cotton-tipped applicator nasal anesthesia for transnasal esophagogastroduodenoscopy?

Unsedated transnasal esophagogastroduodenoscopy (EGD) is emerging as a viable alternative to conventional sedated EGD in a number of clinical settings. The success of this technique depends upon careful patient selection, the endoscope technology available and selection of the optimal method of topical nasal anesthesia. This Practice Point commentary discusses a randomized, prospective study by Hu that compared endoscopic-guided nasal anesthesia with cotton-tipped applicator nasal anesthesia for unsedated transnasal EGD in Taiwanese patients. In this study, endoscopic-guided nasal anesthesia was associated with superior patient tolerability, less epistaxis, better visualization capacity and a shorter procedure time compared with cotton-tipped applicator nasal anesthesia. This study was, however, performed at a single center by a single investigator and involved a single racial group without patient crossover. It is well recognized that nasal cavity anatomical differences exist between white and Asian individuals. It is our opinion that the most important factor for successful unsedated transnasal EGD is the size of the outer diameter of the endoscope.

Application of unsedated transnasal esophagogastroduodenoscopy in the diagnosis of hypopharyngeal cancer

This study evaluates the efficacy of unsedated transnasal esophagogastroduodenoscopy (EGD) in the diagnosis of hypopharyngeal cancer and screening of esophageal lesions. Twenty-seven patients with newly diagnosed hypopharyngeal cancer were evaluated by transnasal EGD without conscious sedation. Twenty-two hypopharyngeal cancers arose from the pyriform sinus, and the other 5 tumors were from the posterior hypopharyngeal wall. Seventeen tumors were classified as T3-T4. Twenty-four hypopharyngeal tumors were pathologically proved malignancy by this technique. Regarding simultaneous esophageal lesions, esophageal dysplasia was noted in 4 patients and esophageal cancer occurred in 6 patients. The procedures were performed without difficulty except in 1 patient with huge posterior wall tumor. The mean procedure time was 22 minutes. All patients tolerated the procedure well, without significant bleeding or respiratory distress during examination. Unsedated transnasal EGD is a safe, tolerable, and accurate endoscopic technique for diagnosis of hypopharyngeal cancer and screening of simultaneous esophageal cancer.

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.

Prospective randomized trial of transnasal versus peroral endoscopy using an ultrathin videoendoscope in unsedated patients

The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients. A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated). Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis. For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.

Unsedated Transnasal Percutaneous Endoscopic Gastrostomy Placement in Selected Patients

The placement of a percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for the long-term management of dysphagic patients with neurological disease or with trauma or tumors of the head and neck. It is not always possible to perform conventional upper gastrointestinal endoscopy in such patients due to stenosis and/or occlusion of the mouth or pharynx and/or partial or complete trismus. The aim of this study was to show whether transnasal esophagogastroduodenoscopy (EGD) offers a feasible and effective alternative method for PEG placement in these selected patients. PEG placement was required for 155 patients at our institution during a 27-month period. In 12 patients oral access of an endoscope into the esophagus was not possible. Unsedated transnasal EGD (T-EGD) was then performed using an ultrathin video gastroscope, which had a distal-end diameter of 5.9 mm. A 16-Fr polyurethane PEG tube with a conical, flexible, soft distal end and a collapsible bumper was used in all cases. The Gauderer-Ponsky pull technique was used for PEG placement. T-EGD and perendoscopic transnasal placement of a PEG tube was successfully performed in all 12 patients. No patient required sedation during the procedure. No immediate or late-onset procedure-related complications occurred in any of the 12 patients. In some dysphagic patients in whom the oral route is not accessible with a standard endoscope, a transnasal endoscopic approach allows the placement of a PEG tube. In these selected patients this technique has been shown to be safe and effective and does not require the use of sedation.