Unsedated ultrathin EGD by using a 5.2-mm-diameter videoscope: evaluation of acceptability and diagnostic accuracy

Blue light imaging and linked color imaging as a screening mode for esophageal squamous cell carcinoma in high-risk patients: Multicenter randomized trial

OBJECTIVES

Blue light imaging (BLI) and linked color imaging (LCI) are superior to conventional white light imaging for detecting esophageal squamous cell carcinoma (ESCC). Hence, we compared their diagnostic performances in ESCC screening.

METHODS

This open-labeled, randomized controlled trial was performed at seven hospitals. Patients with a high risk of ESCC were randomly assigned to the BLI group (BLI followed by LCI) and LCI group (LCI followed by BLI). The primary end-point was the detection rate of ESCC in the primary mode. The main secondary end-point was its miss rate in the primary mode.

RESULTS

In total, 699 patients were enrolled. The detection rate of ESCC did not significantly differ between the BLI and LCI groups (4.0% [14/351] vs. 4.9% [17/348]; P = 0.565); however, the number of patients with ESCC tended to be smaller in the BLI group (19 vs. 30). Notably, the miss rate of ESCC was lower in the BLI group (26.3% [5/19] vs. 63.3% [19/30]; P = 0.012) and LCI detected no ESCCs missed by BLI. The sensitivity was higher in BLI (75.0% vs. 47.6%; P = 0.042); on the other hand, the positive predictive value in BLI tended to be lower (28.8% vs. 45.5%; P = 0.092).

CONCLUSIONS

The detection rates of ESCC did not significantly differ between BLI and LCI. Although BLI may have the potential to be advantageous over LCI for the diagnosis of ESCC, it is still unclear whether BLI is superior to LCI, and a further large-scale study is needed.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCT1022190018-1).

Efficacy of Novel Ultrathin Single-Balloon Enteroscopy for Crohn's Disease: A Propensity Score-Matched Study

Background/Aims

The evaluation of small bowel lesions of Crohn's disease (CD) using balloon-assisted enteroscopy (BAE) is crucial because mucosal healing is associated with a good prognosis. However, BAE procedures are invasive, requiring sedation or analgesia to reduce the patient's pain. This study evaluated the clinical usefulness of a novel ultrathin single-balloon enteroscopy (SBE) procedure for CD.

Methods

This single-center retrospective study included 102 CD patients who underwent trans-anal SBE between January 2012 and May 2018. Of these patients, 82 underwent enteroscopy using conventional SBE, while 20 underwent ultrathin SBE. Patients were analyzed using propensity score matching, with 20 patients per group. The median duration of the examination, terminal ileum intubation rate, median cecum intubation time, median insertion depth, adverse events, and sedated dose in each group were compared.

Results

Before propensity score matching, the conventional SBE group had a larger number of surgical history patients than the ultrathin SBE group (p=0.05). After matching, the two groups did not significantly differ clinically. There were no significant differences in the mean duration of the examination, cecum intubation time, or terminal ileal intubation rate between ultrathin SBE and conventional SBE. The mean insertion depth of ultrathin SBE tended to be deeper than that of conventional SBE (p=0.09). The use of ultrathin SBE also reduced the sedative dose during needed for enteroscopy compared with conventional SBE (p=0.005).

Conclusions

Novel ultrathin SBE may be less painful for CD patients than conventional SBE.

Comparing blind spots of unsedated ultrafine, sedated, and unsedated conventional gastroscopy with and without artificial intelligence: a prospective, single-blind, 3-parallel-group, randomized, single-center trial

BACKGROUND AND AIMS

EGD is the most vital procedure for the diagnosis of upper GI lesions. We aimed to compare the performance of unsedated ultrathin transoral endoscopy (U-TOE), unsedated conventional EGD (C-EGD), and sedated C-EGD with or without the use of an artificial intelligence (AI) system.

METHODS

In this prospective, single-blind, 3-parallel-group, randomized, single-center trial, 437 patients scheduled to undergo outpatient EGD were randomized to unsedated U-TOE, unsedated C-EGD, or sedated C-EGD, and each group was then divided into 2 subgroups: with or without the assistance of an AI system to monitor blind spots during EGD. The primary outcome was the blind spot rate of these 3 groups with the assistance of AI. The secondary outcomes were to compare blind spot rates of unsedated U-TOE, unsedated, and sedated C-EGD with or without the assistance of AI, respectively, and the concordance between AI and the endoscopists' review.

RESULTS

The blind spot rate with AI-assisted sedated C-EGD was significantly lower than that of unsedated U-TOE and unsedated C-EGD (3.42% vs 21.77% vs 31.23%, respectively; P < .05). The blind spot rate of the AI subgroup was lower than that of the control subgroup in all 3 groups (sedated C-EGD: 3.42% vs 22.46%, P < .001; unsedated U-TOE: 21.77% vs 29.92%, P < .001; unsedated C-EGD: 31.23% vs 42.46%, P < .001).

CONCLUSIONS

The blind spot rate of sedated C-EGD was the lowest among the 3 types of EGD, and the addition of AI had a maximal effect on sedated C-EGD. (Clinical trial registration number: ChiCTR1900020920.).

Current status of transnasal endoscopy worldwide using ultrathin videoscope for upper gastrointestinal tract

Transnasal endoscopy with an ultrathin endoscope has been reported to be highly acceptable even without any sedative measures. Poor image quality and complex manipulation have been reported as shortcomings of this type of endoscopy compared with standard transoral endoscopy. However, image quality has improved markedly with the latest ultrathin endoscopes. To investigate the status of clinical use of endoscopes, we recently conducted a questionnaire survey involving 149 facilities (98 in Japan and 51 overseas). In Japan, transnasal endoscopes were being used primarily in clinics (34% in clinics and 9% in hospitals). Overseas, however, transnasal endoscopes were seldom used (1% in hospitals and 0% in clinics). This may be attributable to the complex pretreatment and more challenging manipulation required for transnasal endoscopes. However, it is evident that transnasal endoscopes are highly acceptable for patients. If the pretreatment required is simplified and healthcare physicians improve their skills and understanding, this type of endoscopy will have high potential for common use.

Performance characteristics of unsedated ultrathin video endoscopy in the assessment of the upper GI tract: systematic review and meta-analysis

BACKGROUND AND AIMS

Reports on the performance of unsedated ultrathin endoscopy via the transnasal (uTNE) and transoral (uTOE) routes are conflicting. We aimed to estimate the technical success rate, patient preference, and acceptability of uTNE and uTOE alone and in comparison with conventional EGD (cEGD; with or without sedation).

METHODS

A systematic review and meta-analysis was performed on all primary studies reporting the outcomes of interest. Electronic databases (Cochrane library, MEDLINE, EMBASE) were searched on February 1, 2014.

RESULTS

Thirty-four studies met the inclusion criteria with 6659 patients in total. The pooled technical success rate was 94.0% for uTNE (95% confidence interval [CI], 91.6-95.8; 30 studies) and 97.8% for uTOE (95% CI, 95.6-98.9; 16 studies). The difference in proportion of success for uTNE compared with cEGD was -2.0% (95% CI, -4.0 to -1.0; 18 studies), but that difference was not significant when uTNE < 5.9 mm in diameter was used (-1.0%; 95% CI, -3.0 to .0; 9 studies). There was no significant difference in success rate between uTOE and cEGD (.0%; 95% CI, -1.0 to 2.0; 10 studies). The pooled difference in proportion of patients who preferred uTNE over cEGD was 63.0% (95% CI, 49.0-76.0; 10 studies), whereas preference for uTOE versus cEGD was not significantly different (38.0%; 95% CI, -4.0 to 80.0; 2 studies). Acceptability was high for both uTNE (85.2%; 95% CI, 79.1-89.9; 16 studies) and uTOE (88.7%; 95% CI, 82.4-92.9; 10 studies).

CONCLUSIONS

Technical success rate for uTNE < 5.9 mm is equivalent to cEGD. uTNE has high patient acceptability, with better patient preference, and therefore could be a useful alternative to cEGD for screening purposes. uTOE had a similar technical success rate but an equivocal preference to cEGD.

Analysis of cardiopulmonary stress during endoscopy: is unsedated transnasal esophagogastroduodenoscopy appropriate for elderly patients?

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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'.

CONCLUSIONS

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 and stability of transnasal endoscopy for examination of the pharynx - a prospective study and comparison with transoral endoscopy

OBJECTIVE

Transnasal endoscopy may be used to observe the head and neck part readily without excessive reflexes. We aimed to evaluate the utility and stability of transnasal esophagogastroduodenoscopy (TN-EGD) in comparison with transoral EGD (TO-EGD) for observation of the pharynx.

STUDY DESIGN

Prospective study

METHODS

A total of 497 patients received unsedated TN-EGD with a 5.5 mm diameter endoscope or unsedated TO-EGD with endoscopes of 6.5 mm, 7.9 mm and 9.2 mm diameter. The rate of completion of pharyngeal observation and numbers of gag reflexes and cough reflexes were recorded.

RESULTS

TN-EGD was performed in 175 patients and TO-EGD was performed in 322 patients. Pharyngeal observation was completed in 173 patients (98.9%) in the TN-EGD group and 235 patients (73.2%) in the TO-EGD group, a significant difference (p<0.001). The TN-EGD group had a low rate of occurrence of gag reflex (0.57%), in contrast, 28.3% of the TO-EGD group had a gag reflex, a significant difference (p<0.01). Multivariable analyses revealed that the use of TN-EGD was the only predictive factor for completion of pharyngeal observation (p<0.0001).

CONCLUSIONS

TN-EGD is ideally suited to observation of the pharynx by unsedated EGD.

Evaluation of patient satisfaction of an outpatient gastroscopy service in an Asian tertiary care hospital

Background

There are limited published studies on patient satisfaction towards endoscopy from Asian countries. Different methods of evaluation of patient satisfaction may yield different results and there is currently no study to compare results of on-site versus phone-back interviews.

Method

On-site followed by phone-back interviews were carried out on consecutive patients attending the outpatient gastroscopy service of University of Malaya Medical Centre between July 2010 and January 2011 using the modified Group Health Association of America-9 (mGHAA-9) questionnaire. The question on technical skill of endoscopist was replaced with a question on patient comfort during endoscopy.

Results

Seven hundred patients were interviewed. Waiting times for appointment and on gastroscopy day, and discomfort during procedure accounted for over 90% of unfavorable responses. Favorable response diminished to undesirable level when waiting times for appointment and on gastroscopy day exceeded 1 month and 1 hour, respectively. Satisfaction scores were higher for waiting time for appointment but lower for personal manner of nurses/staff and explanation given during phone-back interview. There was no significant difference in satisfaction scores for other questions, including overall rating between the two methods.

Conclusion

Waiting times and discomfort during procedure were main causes for patient dissatisfaction. Phone-back interview may result in different scores for some items compared with on-site interview and should be taken into account when comparing results using the different methods.

Pain relief by applying transcutaneous electrical nerve stimulation (TENS) during unsedated colonoscopy: a randomized double-blind placebo-controlled trial

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative to traditional pain treatments. TENS has been studied in the past as a pain reduction modality in colonoscopy with limited success. Reviews and meta-analysis have shown that the inconclusive results of TENS may be due to the lack of randomized controlled trials and the difficulty in defining precise output parameters. The objective of this double-blind randomized placebo-controlled trial was to investigate the pain-relieving effect of a new application of TENS in unsedated screening colonoscopy. Ninety patients undergoing unsedated screening colonoscopy were randomly allocated to one of three groups: a control group (n=30), a group to receive active TENS (n=30), or a group to receive placebo TENS (n=30). A visual analogue scale (VAS) and a five-point Likert scale were used to assess pain 5 min into the procedure and at the end of the procedure. The patient's bloating sensation during colonoscopy and the effect on the duration of the procedure were also evaluated. Throughout the procedure, the active TENS group experienced a VAS pain score reduction ≥50% compared to the placebo TENS group (P<0.001) and the control group (P<0.001). On the five-point Likert scale, there was also a significant reduction in pain score in the active TENS group compared to the placebo TENS and control groups (P=0.009). No significant differences were found between the study groups as to the bloating sensation and the duration of the procedure. We conclude that TENS can be used as a pain relief therapy in unsedated screening colonoscopy.

Transnasal transesophageal echocardiography in the detection of left atrial thrombus

BACKGROUND

The widespread use of transesophageal echocardiography (TEE) is limited by disadvantages, including patient intolerance and increased medical costs. We aimed to investigate the feasibility and safety of transnasal TEE in the detection of possible embolic sources in patients with atrial fibrillation (AF) and/or stroke, using an ultrathin TEE probe.

METHODS

Sixty-two patients with AF and/or stroke underwent transnasal TEE without conscious sedation. The presence or the absence of the following parameters was evaluated: left atrial (LA) thrombus; LA spontaneous echocardiographic contrast; intraatrial shunts; and aortic plaque.

RESULTS

The insertion of a TEE probe was successful in 52 (84%) patients. TEE found LA thrombus in 10 (19%) patients and other embolic sources in 4 (8%) patients. Two (4%) patients had mild epistaxis.

CONCLUSIONS

This study demonstrated that the use of transnasal TEE was feasible and safe in the detection of LA thrombus in patients with AF and/or stroke.

Low-dose propofol sedation for diagnostic esophagogastroduodenoscopy: results in 10,662 adults

OBJECTIVE

The use of propofol sedation during endoscopic procedures has increased in recent years. The aim of this study was to evaluate the safety and effectiveness of nurse-administered low-dose propofol sedation for diagnostic esophagogastroduodenoscopy (EGD).

METHODS

We prospectively assessed the outcome and complications of low-dose bolus propofol for endoscopic sedation for diagnostic EGD. Propofol was administered by bolus injection, with a standard protocol of 40 mg for patients <70 years old, 30 mg for patients 70-89 years old, and 20 mg for patients 90 years or older. When required for adequate sedation, additional doses were given, to a maximum of 120 mg. The primary outcome measure was respiratory depression, defined as oxygen desaturation (SpO(2) <90%) that continued for more than 20 s. Secondary measures included successful procedures, full recovery within 60 min of the procedure, and complications.

RESULTS

All procedures were successful; 8,431 of 10,662 patients (79.1%) completed diagnostic EGD with a single bolus of propofol. Only 0.26% (28 patients) required transient supplemental oxygen supply; neither mask ventilation nor endotracheal intubation was required. Full recovery occurred in 99.9% of patients 60 min after the procedure. Men and younger patients required significantly higher doses of propofol than did the women and older patients (men vs. women, 46.5+/-19 vs. 42.7+/-15 mg, P=0.0008; age 40-49 vs. age 50-59, 51.5+/-16 vs. 46.3+/-13 mg, P<0.0001). Of the 400 patients, 368 (92%) wanted to drive home or to their offices, and all did so without incident. A total of 99% were willing to repeat the same procedure again.

CONCLUSIONS

Low-dose nurse-administered propofol sedation is safe and practical for diagnostic EGD.

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.

Prospective comparison between sedated high-definition oral and unsedated ultrathin transnasal esophagogastroduodenoscopy in the same subjects: pilot study

BACKGROUND

Recently, quality as well as acceptability has been a concern regarding endoscopy. The aim of the present study was to compare the acceptability and quality of sedated high-definition esophagogastroduodenoscopy (sHD-EGD) using a newly developed high-definition videoscope with those of unsedated ultrathin esophagogastroduodenoscopy (uUT-EGD) using a 5.2 mm videoscope.

METHODS

Twenty-two volunteers underwent both peroral sHD-EGD and transnasal uUT-EGD on the same day. Sedation consisted of 40 mg of propofol i.v. Both endoscopist and subject satisfaction levels were assessed using a 10 cm visual analogue scale.

RESULTS

All 22 subjects completed the sHD-EGD and 21 subjects completed the uUT-EGD. The endoscopist and subject satisfaction levels of sHD-EGD were significantly better than those of uUT-EGD (overall endoscopist satisfaction: 9 vs 4, P < 0.0001; overall subject satisfaction: 9 vs 3, P < 0.0001). The optical quality of the endoscopic images of sHD-EGD was significantly higher than that of uUT-EGD except in the duodenal bulb (overall quality: 8 vs 7, P < 0.0001). The interobserver agreement for EGD findings in sHD-EGD was better than with uUT-EGD, although the EGD findings in both sHD-EGD and uUT-EGD were similar. After undergoing both procedures, 91% were willing to have sHD-EGD again compared to 9% with uUT-EGD.

CONCLUSIONS

The endoscopist and subject satisfaction levels and image quality of sHD-EGD were better than those of uUT-EGD. The routine use of high-definition videoscopes would be expected to provide better acceptability than that obtained with unsedated endoscopy.

Transnasal OGD: practice survey and impact of a live video retransmission

BACKGROUND

Unsedated transnasal oesogastroduodenoscopy significantly improves patient tolerance compared to unsedated conventional peroral oesogastroduodenoscopy.

AIMS

To assess the adoption of transnasal oesogastroduodenoscopy among endoscopists from various European countries and its determinants.

METHODS

A survey was distributed to 624 endoscopists attending a live course on digestive endoscopy; a poll was also performed immediately before and after live video retransmission of a transnasal oesogastroduodenoscopy.

RESULTS

Answer rate was 48%; transnasal oesogastroduodenoscopy was practised by 31% of respondents. In multivariate analysis, practice of transnasal oesogastroduodenoscopy was associated with location in France and Netherlands (P<0.0001), availability of many gastroscopes (P<0.0001) and less frequent use of sedation (P=0.006). Endoscopists who did not practise transnasal oesogastroduodenoscopy cited doubts about its advantages over conventional oesogastroduodenoscopy and lack of training (34% each) as barriers to adoption. Seventy-four percent of endoscopists practicing transnasal oesogastroduodenoscopy did actually use it in <20% of eligible cases. Live video retransmission of a transnasal oesogastroduodenoscopy increased the proportion of endoscopists interested in this technique (P=0.006).

CONCLUSIONS

Adoption of transnasal oesogastroduodenoscopy largely varies between European countries; endoscopists practicing this technique use it in a minority of eligible cases. Live case demonstration may decrease barriers to the adoption of this technique.

Feasibility and tolerance of 2-way and 4-way angulation videoscopes for unsedated patients undergoing transnasal EGD in GI cancer screening

BACKGROUND

The differences between 2-way and 4-way angulation endoscopes for use in unsedated patients undergoing transnasal EGD have not been elucidated.

OBJECTIVE

Our purpose was to evaluate the feasibility and tolerance of 2- and 4-way angulation endoscopes for unsedated transnasal EGD in GI cancer screening of elderly people.

DESIGN

A total of 291 patients were randomized to receive unsedated transnasal EGD with a 5.2-mm diameter 2-way angulation endoscope (GIF-N260, Olympus, Tokyo, Japan) (n = 146) or 5.5-mm diameter 4-way angulation endoscope (XGIF-XP240N2, Olympus) (n = 145). The transnasal insertion success rate and incidence of epistaxis were compared. The following parameters were evaluated: overall quality of the examination, ease of passing the endoscope through the pylorus, intubation of the second portion of the duodenum, ability to observe the entire upper GI tract and perform target biopsy, and examination time. Patient tolerance and acceptance were also assessed with regard to nasal pain, choking, gagging, abdominal discomfort, and overall pain and discomfort.

SETTING

Matsushita Health Care Center, Moriguchi, Japan.

PATIENTS

A total of 291 patients had unsedated transnasal EGD as part of a gastric cancer screening program.

RESULTS

Use of the pediatric 4-way angulation endoscope significantly shortened the examination time when biopsy was performed compared with the 2-way angulation instrument, whereas the examination time without biopsy was not significantly different. Other parameters were not significantly different between the 2 endoscopes.

CONCLUSION

For unsedated transnasal EGD with biopsy, the 5.5-mm 4-way angulation videoscope shortens examination time while providing easy transnasal insertion and improved patient tolerance.

Self-training in unsedated transnasal EGD by endoscopists competent in standard peroral EGD: prospective assessment of the learning curve

BACKGROUND

Training programs in unsedated transnasal (UT) EGD are scarce.

OBJECTIVE

To prospectively assess the learning curve for unsupervised UT-EGD.

SETTING

Endoscopy service, without experience in UT-EGD.

SUBJECTS

Consecutive patients referred for diagnostic EGD.

INTERVENTION

UT-EGD was attempted in 140 study patients by 2 endoscopists who trained by themselves in UT-EGD (skilled endoscopist [n = 70]; a trainee having recently achieved competency in conventional EGD [n = 70]) and in 10 controls (endoscopist skilled in UT-EGD) by using a 4.9-mm-diameter videoendoscope.

MAIN OUTCOME MEASUREMENTS

Technical success, sedation administered, patient tolerance acceptance, procedure duration for each decade of 10 consecutive patients investigated by the same endoscopist; intention-to-treat analysis.

RESULTS

Both self-trained endoscopists fulfilled predefined criteria of competency in UT-EGD since the first attempts. They completed examinations of adequate quality with exclusive transnasal scope insertion (n = 139 [99.3%]), no sedation (n = 138 [98.6%]), and patient accepting repeat procedure (n = 135 [96.4%]) in proportions not significantly different from controls for all decades. Compared with a median procedure duration of 5.5 minutes (interquartile range [IQR] 5.0-8.5 minutes) in controls, procedures were significantly longer for all trainee's decades (eg, first decade 20.0 minutes [IQR 15.0-29.0 minutes], P < .001) but none for the skilled endoscopist. Overall discomfort, pain, gagging, and belching were not significantly different for study patients versus controls. Fifty-six of 69 study patients (81%) with a previous history of conventional EGD preferred UT-EGD.

LIMITATIONS

Generalizability to other small-caliber endoscopes.

CONCLUSIONS

Endoscopists competent in conventional EGD may obtain excellent results with UT-EGD (except for procedure duration) beginning with their first attempts, even without supervision or structured training.