A prospective controlled trial of an ultrathin versus a conventional endoscope in unsedated upper gastrointestinal endoscopy

Analysis of painful situations during unsedated esophagogastroduodenoscopy

Background and study aims Although esophagogastroduodenoscopy (EGD) is a widely used technique, the procedure is often associated with discomfort. This study aimed to analyze painful situations, their frequency, and factors associated with patient discomfort during EGD. Patients and methods This prospective observational study included patients scheduled to undergo EGD. Seven endoscopists recruited patients scheduled for EGD screening or surveillance. Each endoscopist enrolled 20 patients, performing 10 EGD procedures using ultraslim endoscopes and 10 with standard-sized endoscopes. Data regarding painful situations and frequency were collected using specialized buttons pressed by the patients during EGD. A survey about overall discomfort was conducted after the procedure. Results We analyzed data from 140 patients. Esophageal insertion and duodenal observation were associated with the highest incidence of pressing the pain button, accounting for 59.3% and 40.7% of the cases, respectively. The factor associated with pressing the pain button during esophageal insertion was endoscopist experience (< 10 years). In contrast, younger age and female sex were the factors associated with pressing the pain button during duodenal observation. In the post-procedure survey, 63.6% of patients reported discomfort. Factors associated with patient discomfort included pressing the pain button during esophageal insertion (odds ratio [OR]: 2.84, P = 0.01) and previous painful EGD experience (OR: 2.41, P = 0.03). Concusions This study provides objective data on painful situations, their frequency, and related factors during EGD. Further research and interventions focusing on pain reduction during endoscopic procedures are warranted. The results of this study will help endoscopists manage painful situations and potentially improve skills.

A single-center prospective study on pain alleviation during peroral upper endoscopy with an ultrathin endoscope

BACKGROUND

The efficacy of transnasal endoscopy using an ultrathin endoscope has been reported in several studies. However, few studies regarding peroral endoscopy with ultrathin endoscopes with high resolution have been reported. This study investigates the pain alleviation of peroral endoscopy with an ultrathin endoscope.

METHODS

Patients with a history of peroral endoscopy using a conventional, normal-diameter scope with no sedation who underwent peroral esophagogastroduodenoscopy (EGD) using a thin scope between April-July 2022 were included in this study. After the procedure, the patients completed a questionnaire evaluating pain during the examination and willingness to repeat the procedure. The physicians were surveyed regarding their level of satisfaction. The primary endpoint was patient satisfaction, which corresponded to the rate of patients who rated the thin endoscope as more comfortable or somewhat more comfortable than the previously-used, conventional endoscope.

RESULTS

One hundred and forty-five patients were included in the analyses. Patient satisfaction was achieved in 86.2% (125/145) of patients. The median visual analog scale pain score was 3 (0-7) points in this study, which is significantly lower than the pain score after the previous endoscopy (5 (0-10) points; p < 0.001). In addition, 96% (24/25) of patients who underwent EGD by an expert and 95.8% (115/120) who underwent EGD by a non-expert were willing to repeat endoscopy using the thin scope (p = 0.69).

CONCLUSION

Peroral endoscopy using a thin scope reduces patient pain regardless of the endoscopist's experience.

Effect of Premedication with Glycopyrrolate on Patient Tolerance and Procedure Outcomes in Patients Undergoing Unsedated Upper Gastrointestinal Endoscopy: A Randomized Placebo-controlled Trial

Background and aim

An optimal topical pharyngeal anesthesia (TPA) is required for better patient tolerance and procedural outcomes of an unsedated upper gastrointestinal endoscopy (UGIE). Several additional strategies have been tried to improve patient tolerance with limited success. We hypothesized that premedication with glycopyrrolate would enhance TPA and improve patient tolerance and procedural outcomes of an unsedated UGIE.

Materials and methods

We conducted a randomized, double-blind, placebo-controlled trial between July 2020 and May 2022. Consecutive patients undergoing unsedated UGIE were randomly assigned to receive either intravenous glycopyrrolate or a placebo 30 minutes before TPA. Patient tolerance, comfort level for the endoscopist, cardiorespiratory fluctuations, percentage of failed esophageal intubation, and incomplete examination were studied.

Results

380 patients were randomized to 190 in each arm. The median (IQR) VAS scores for the overall patient satisfaction in the glycopyrrolate and placebo groups were 8 (1) and 7 (2), respectively (p = 0.04). The median (IQR) VAS scores for endoscopist assessment of patient cooperation in the glycopyrrolate and placebo groups were 8 (1.3) and 8 (1), respectively (p = 0.04). There was no difference in the percentage of failed esophageal intubation and incomplete examination, fluctuations in heart rate, and oxygen saturation of the participants. However, the mean arterial pressure (MAP) on-table before the start of the procedure at 1 minute and 3 minutes was significantly higher in the glycopyrrolate group (p = 0.01, 0.01, and 0.04, respectively).

Conclusion

In unsedated UGIE, glycopyrrolate premedication significantly improves the patient tolerance and endoscopist's comfort, with minimal cardiorespiratory effects. Hence, it could be incorporated into day-care unsedated endoscopy practice.Trial registration - CTRI/2020/07/026786.

How to cite this article

Ramalingam R, Senthamizhselvan K, Harichandrakumar KT, et al. Effect of Premedication with Glycopyrrolate on Patient Tolerance and Procedure Outcomes in Patients Undergoing Unsedated Upper Gastrointestinal Endoscopy: A Randomized Placebo-controlled Trial. Euroasian J Hepato-Gastroenterol 2023;13(2):55-60.

Pre-screening for bariatric surgery patients: comparative effectiveness of transnasal endoscopy versus esophagogastroduodenoscopy

BACKGROUND

Endoscopic evaluation is frequently performed before bariatric surgery to identify foregut pathology that may alter procedure selection. Transnasal endoscopy (TNE) is an alternative to esophagogastroduodenoscopy (EGD). The objective of this study was to compare TNE to EGD.

METHODS

Patients who underwent TNE or EGD before bariatric surgery from January 2012 through April 2019 were reviewed. Statistical analyses included Chi-square, Wilcoxon two-sample, and Fisher's exact tests. A p value < 0.05 was considered significant.

RESULTS

Three hundred and forty-five patients underwent preoperative screening (63% EGD, 37% TNE) before bariatric surgery. Mean age and preoperative body mass index in the TNE and EGD groups were 46.2 ± 12.4 vs 45.5 ± 11.6 years (p = 0.58) and 46.5 ± 7.1 vs. 45.5 ± 6.1 kg/m² (p = 0.25), respectively. Three TNEs were aborted, resulting in a success rate of 98%. Of patients who underwent EGD, 1 (0.5%) visited the emergency department (ED), and 7 (3%) called the nurse with post-procedure concerns. There were no ED visits or nurse calls from patients who underwent TNE. The median total time in the procedure room was 77 (57-97) min for EGD vs. 26 (8-33) min for TNE (p < 0.001). One patient who underwent TNE required subsequent EGD. Mean charge per patient for EGD and TNE was $5034.70 and $1464.00, respectively.

CONCLUSIONS

TNE was associated with less post-procedure care, shorter procedure time and fewer charges compared to EGD. TNE could be considered an initial screening tool for patients undergoing bariatric surgery, while EGD could be used selectively in patients with abnormal TNE findings.

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.

Unsedated transnasal esophagoscopy for monitoring therapy in pediatric eosinophilic esophagitis

BACKGROUND AND AIMS

Unsedated transnasal endoscopy (TNE) is safer and less costly than sedated EGD. The aim of this study was to evaluate the performance of TNE with biopsies in monitoring the esophageal mucosa of pediatric patients with eosinophilic esophagitis.

METHODS

Patients between 8 and 17 years of age with eosinophilic esophagitis and their parents were enrolled. Unsedated TNE was performed. A 2.8-mm (1.2-mm channel) or a 4-mm flexible bronchoscope (2-mm channel) was used, and esophageal biopsy specimens were obtained. Biopsy specimen analysis, duration, adverse events, and billing charges of TNE were assessed. Immediately after TNE and a minimum of 2 weeks later, a modified Group Health Association of America 9 survey and a preference questionnaire were completed, respectively.

RESULTS

Twenty-one of 22 enrolled patients underwent TNE. TNE was performed with no serious adverse events. Histopathological analysis revealed 0 eosinophils per high-power field (n = 12), fewer than 15 eosinophils per high-power field (n = 4), and more than 15 eosinophils per high-power field (n = 5). The total epithelial surface area of mucosal biopsy samples from either TNE Forceps (1.2 mm or 2 mm biopsy channel forceps) compared with those obtained during the subject's previous EGD by using standard endoscopic forceps was not statistically different (P = .308 [1.2 mm]/P = .492 [2 mm]). All parents and 76.2% of subjects would undergo the TNE again. TNE was preferred over EGD by 85.7% of parents and 52.4% of subjects. The modified Group Health Association of America 9 survey revealed a high degree of satisfaction (average, 43.19 ± 2.6; maximum score, 45). Charges associated with TNE were 60.1% lower than for previous EGDs.

CONCLUSIONS

Unsedated TNE is an effective, lower-cost procedure for monitoring the esophageal mucosa of children with eosinophilic esophagitis.

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.

Usefulness of transesophageal bronchoscopic ultrasound-guided fine-needle aspiration in the pathologic and molecular diagnosis of lung cancer lesions adjacent to the esophagus

BACKGROUND

The discovery of driver oncogenes has increased the need to obtain a sufficient amount of tissue specimens for lung cancer diagnosis. Although endoscopic ultrasound (with bronchoscope)-guided fine-needle aspiration (EUS-B-FNA) is reportedly a feasible and well-tolerated modality, additional advantages of EUS-B-FNA are yet to be thoroughly investigated. The purpose of this study was to evaluate the ability of EUS-B-FNA to obtain sufficient tissue specimens for pathologic and molecular diagnoses of lung cancer.

METHODS

Among lung cancer patients who were diagnosed between December 2010 and December 2012 in our institute, patients who underwent EUS-B-FNA to diagnose lung cancer were enrolled (n=26). EUS-B-FNA was performed when bronchoscopic diagnosis was impossible or difficult to obtain sufficient samples. Epidermal growth factor receptor (EGFR) mutations and echinoderm microtubule-associated protein-like 4 and the anaplastic lymphoma kinase (EML4-ALK) fusion gene were evaluated using EUS-B-FNA samples of non-small cell lung cancer.

RESULTS

EUS-B-FNA was performed on 28 lesions in 26 patients. Among the target lesions, 23 were mediastinal lymph nodes including nodal stations 2L, 4L, 7, 8, and 10L. The remaining 5 were intrapulmonary lesions. EUS-B-FNAs were completed without complications in all the patients. The diagnostic yield of EUS-B-FNA in diagnosing lung cancer was 100% (26/26). Additional diagnostic gain of EUS-B-FNA was 69.2% (18/26) as compared to bronchoscopy alone. EGFR mutations and EML4-ALK fusion gene could be evaluated in all patients with non-small cell lung cancer (n=20) using EUS-B-FNA samples. One case with EGFR mutation and 1 case with ALK fusion gene were diagnosed. Six non-small cell carcinomas were also diagnosed by bronchoscopy, but all bronchoscopic samples were insufficient to evaluate mutation analyses.

CONCLUSIONS

EUS-B-FNA is a practical and feasible method to obtain abundant tumorous tissue samples for pathologic diagnosis and molecular analysis, particularly when the target lesions are inaccessible by other modalities because of their locations or because of the patient's poor physical condition.

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.

Transnasal esophagoscopy

Since the mid 1900s, esophagoscopy has been performed under sedation or general anesthesia. With transnasal esophagoscopy (TNE), there has been a return to awake, in-office esophagoscopy. Technologic advances have allowed the advent of a ultrathin, flexible esophagoscope that is introduced transnasally, allowing esophagoscopy to be performed in unsedated patients. TNE correlates with conventional esophagoscopy (sedated, flexible esophagoscopy) in diagnostic capacity. Over time, as the benefits of TNE have become elucidated, the procedure has gained wider acceptance and continues to have its role in patient care defined.

A prospective randomized study comparing transnasal and peroral 5-mm ultrathin endoscopy

BACKGROUND/PURPOSE

Differences in patient tolerance, acceptance, and satisfaction of esophagogastroduodenoscopy (EGD) between transnasal (TN) and peroral (PO) routes using a 5-mm video endoscope.

METHODS

A total of 220 enrolled patients were assigned randomly to two groups undergoing EGD-110 patients each for TN and PO. The successful rate, procedure time, and adverse events were recorded. After the procedure, patients answered a validated questionnaire of tolerance, acceptance, and satisfaction.

RESULTS

There were 6 failures (5.7%) of nasal intubation and two nasal bleeding (2%) among 105 TN-EGD procedures. All PO patients (n=102) completed EGD successfully without adverse event. Compared to PO, the procedure of TN achieved lower successful rate (94% vs. 100%, p=0.01), was complicated with epistaxis (2% vs. 0%) and took longer (mean ± SD 19.9 ± 6.1 min vs. 16.8 ± 6.4 min, p=0.0001). The patients undergoing TN-EGD indicated less discomfort during passing pharynx (scores of 2.1 ± 2.0 vs. 3.1 ± 2.6, p=0.011) but more pain during inserting scope (scores of 2.2 ± 1.6 vs. 1.5 ± 1.8, p=0.0001). Eventually, there were no significant differences between TN and PO regarding the overall procedure discomfort (scores of 10.7 ± 6.6 vs. 11.1 ± 7.8 scores, p=0.9), satisfaction (scores of 41.2 ± 4.2 vs. 41.3 ± 4.6, p=0.91), and acceptability (87.8% vs. 94.2%, p=0.91).

CONCLUSION

PO intubation seems an excellent alternative method when using a 5-mm ultrathin endoscopy because it achieves comparable patient tolerance, acceptance, and satisfaction as TN intubation, takes less time and causes lower intubation failure and epistaxis.

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.

Monitored anesthesia care with propofol versus surgeon-monitored sedation with benzodiazepines and narcotics for preoperative endoscopy in the morbidly obese

BACKGROUND

Although still controversial, upper endoscopy is frequently performed before bariatric surgery. This study investigated the hypothesis that morbidly obese patients would prefer anesthesiologist-monitored sedation (AMS) compared to surgeon-monitored sedation (SMS) during preoperative endoscopy.

METHODS

All patients who underwent endoscopy before their bariatric surgery were given a post-procedure survey regarding their experience with the preoperative endoscopy. The survey inquired about issues during and after the procedure. We compared patients who had AMS with IV propofol versus SMS IV narcotics and benzodiazepines.

RESULTS

There were 100 patients (SMS=49 and AMS=51). Few patients complained of pain in the abdomen or throat during the procedure (AMS vs. SMS=2 vs. 8% and 2 vs. 10%, respectively; p=NS). More patients complained about throat pain after the procedure (AMS vs. SMS=37 vs. 45%; p=NS). More patients in the SMS group remembered the scope being placed in the mouth versus AMS (33 vs. 10%; p<0.02). More patients remembered gagging during the procedure in the SMS group versus the AMS group, but this did not reach statistical significance (24 vs. 10%; p=0.06). There was a trend that more patients in the AMS group felt they recovered in less than 1 h (53%) compared to the SMS group (37%; p=0.1).

CONCLUSION

Patients who undergo upper endoscopy with either AMS or SMS seem to tolerate the procedure well. The preliminary benefits seen with AMS need to be further explored. AMS should be considered for patients undergoing preoperative upper endoscopy before bariatric surgery.

Unsedated transnasal versus transoral sedated upper gastrointestinal endoscopy: a one-series prospective study on safety and patient acceptability

BACKGROUND

While conventional oesophagogastroduodenoscopy is frequently performed under sedation to improve acceptability, transnasal oesophagogastroduodenoscopy would appear to be less invasive.

STUDY AIMS

To compare diagnostic accuracy, feasibility, acceptability and safety of transnasal oesophagogastroduodenoscopy without sedation versus conventional oesophagogastroduodenoscopy under sedation.

PATIENTS

Following anxiety assessment, 30 dyspeptic patients underwent transnasal oesophagogastroduodenoscopy under local anaesthesia (lidocaine) and conventional oesophagogastroduodenoscopy under conscious sedation (i.v. midazolam) on two consecutive days. Transnasal oesophagogastroduodenoscopy was performed with an ultrathin and conventional oesophagogastroduodenoscopy with a standard endoscope.

METHODS

Safety, evaluated by monitoring cardio-respiratory functions. Acceptability, rated according to discomfort and preference between the two examinations. Diagnostic accuracy evaluated taking into account endoscopic patterns and adequacy of biopsy specimens for histology. Feasibility, defined according to endoscopic performance, quality of images and overall opinion of the endoscopist. Only gastric biopsies were evaluated.

RESULTS

All patients but one who refused conventional oesophagogastroduodenoscopy underwent both transnasal oesophagogastroduodenoscopy and conventional oesophagogastroduodenoscopy. No cardiorespiratory complications occurred during either technique. Majority of patients (87%) preferred transnasal oesophagogastroduodenoscopy. Examinations were completed in all cases, with comparable endoscopic patterns. All biopsy specimens were suitable for histology.

CONCLUSIONS

Transnasal oesophagogastroduodenoscopy without sedation provides good diagnostic accuracy, is safer and better accepted than conventional oesophagogastroduodenoscopy under sedation and, therefore, represents a valid alternative in routine diagnosis of upper digestive tract diseases.

Transnasal esophagoscopy: a position statement from the American Bronchoesophagological Association (ABEA)

OBJECTIVE

To review and summarize the current literature on transnasal esophagoscopy, and to compare information with conventional esophagoscopy.

DATA SOURCES

Medline (Ovid), book chapters.

REVIEW METHODS

A thorough review of the literature using the Medline database was performed with the following search terms: esophagoscopy, transnasal esophagoscopy, ultrathin endoscopy, and esophagoscope.

RESULTS

The literature seems to support the equivalence of transnasal esophagoscopy and conventional esophagoscopy in image quality and diagnostic capability. It also points to some potential advantages of transnasal esophagoscopy.

CONCLUSIONS

Transnasal esophagoscopy is a useful tool for accurate diagnosis and can be used in a variety of office procedures.

Lidocaine lollipop as single-agent anesthesia in upper GI endoscopy

BACKGROUND

Conscious sedation is usually achieved during EGD by a combination of intravenous benzodiazepines and opiates; however, these have potential serious adverse effects. The addition of topical oropharyngeal anesthetics such as lidocaine may be useful. Recent data suggest that the administration of topical lidocaine by means of a lollipop is effective for endotracheal intubation and bronchoscopy.

OBJECTIVE

Our purpose was to evaluate the safety and efficacy of a lidocaine lollipop as single-agent anesthesia for EGD and to determine whether its use reduces the need for intravenous sedatives and analgesics.

DESIGN

Single-blinded, randomized, prospective study.

SETTING

University hospital.

PATIENTS

50 patients undergoing diagnostic EGD.

INTERVENTIONS

Patients were randomized to either lidocaine lollipop or lidocaine spray. Intravenous meperidine and midazolam were administered during the procedure as needed.

MAIN OUTCOME MEASUREMENTS

The success and safety of local anesthesia by lidocaine lollipop in addition to the need for intravenous sedation.

RESULTS

Patients were equally randomized between the lollipop and the spray groups. The lollipop group had less gag reflex, accommodated scope introduction more, and tolerated the procedure better. Thirty-two percent of patients receiving the lollipop required sedation compared with 96% of patients in the spray group (P < .001). The majority in the lollipop group were satisfied with their mode of anesthesia compared with the spray group.

CONCLUSIONS

Lidocaine lollipop is a promising form of local oropharyngeal anesthesia for EGD. Its use resulted in sparing the use of intravenous sedation. It is well tolerated and safe and may be particularly important in the elderly, patients with comorbidities, and office-based endoscopy.

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

AIM: to compare the feasibility and patients’ tolerance of esophagogastroduodenoscopy (EGD) using a thin endoscope with those of conventional oral EGD and to determine the optimal route of introduction of small-caliber endoscopes.

METHODS: One hundred and sixty outpatients referred for diagnostic EGD were randomly allocated to 3 groups: conventional (C)-EGD (9.8 mm in diameter), transnasal (TN)-EGD and transoral (TO)-EGD (5.9 mm in diameter). Pre-EGD anxiety was measured using a 100-mm visual analogue scale (VAS). After EGD, patients and endoscopists completed a questionnaire on the pain, nausea, choking, overall discomfort, and quality of the examination either using VAS or answering some questions. The duration of EGD was timed. Blood oxygen saturation (SaO₂) and heart rate (HR) were monitored during EGD.

RESULTS: Twenty-one patients refused to participate in the study. The 3 groups were well-matched for age, gender, experience with EGD, and anxiety. EGD was completed in 91.1% (41/45), 97.5% (40/41), and 96.2% (51/53) of cases in TN-EGD, TO-EGD, and C-EGD groups, respectively. TN-EGD lasted longer (3.11 ± 1.60 min) than TO-EGD (2.25 ± 1.45 min) and C-EGD (2.49 ± 1.64 min) (P < 0.05). The overall tolerance was higher (P < 0.05) and the overall discomfort was lower (P < 0.05) in TN-EGD group than in C-EGD group. EGD was tolerated “better than expected” in 73.2% of patients in TN-EGD group and 55% and 39.2% of patients in TO-EGD and C-EGD groups, respectively (P < 0.05). Endoscopy was tolerated “worst than expected” in 4.9% of patients in TN-EGD group and 17.5% and 23.5% of patients in TO-EGD and C-EGD groups, respectively (P < 0.05). TN-EGD caused mild epistaxis in one case. The ability to insufflate air, wash the lens, and suction of the thin endoscope were lower than those of conventional instrument (P < 0.001). All biopsies performed were adequate for histological assessment.

CONCLUSION: Diagnostic TN-EGD is better tolerated than C-EGD. Narrow-diameter endoscope has a level of diagnostic accuracy comparable to that of conventional gastroscope, even though some technical characteristics of these instruments should be improved. Transnasal EGD with narrow-diameter endoscope should be proposed to all patients undergoing diagnostic EGD.

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

BACKGROUND

This study was designed to assess the acceptability and the diagnostic accuracy of unsedated ultrathin EGD (uUT-EGD) by using a newly developed 5.2-mm-diameter videoscope compared with unsedated small-caliber EGD (uSC-EGD) by using a 6.5-mm-diameter videoscope or sedated conventional EGD (sC-EGD) by using a 9.0-mm-diameter videoscope.

DESIGN

First, 80 patients who had undergone uSC-EGD approximately 1 year earlier were randomized to receive uUT-EGD (n = 40) or uSC-EGD (n = 40). Endoscopist satisfaction and patient comfort were assessed by using a 10-cm visual analog scale. Patient comfort level was compared with that of the previous uSC-EGD. Second, 40 patients who had undergone sC-EGD within the previous 1.5 years underwent uUT-EGD. The optical quality and EGD findings of uUT-EGD were compared with those of the previous sC-EGD. Last, in the 80 patients undergoing uUT-EGD, the ability to identify a validated endoscopic marker, the rearrangement of collecting venues (RAC) pattern, for no Helicobacter pylori, was compared with the results of a (13)C-urea breath test or H pylori stool antigen test.

SETTING

Showa Inan General Hospital, Komagane, Japan.

PATIENTS

A total of 120 patients who undergo EGD every year as part of a gastric cancer surveillance program.

RESULTS

The patient comfort level of uUT-EGD was significantly better than that of uSC-EGD (P < .0001). The optical quality of the endoscopic images and the EGD findings of uUT-EGD were similar to those of the previous sC-EGD. The overall sensitivity, specificity, and accuracy of the RAC pattern in uUT-EGD in recognizing H pylori-uninfected patients were 90%, 100%, and 93%, respectively. The interobserver agreement for RAC was good (kappa = 0.42).

CONCLUSIONS

The use of a 5.2-mm-diameter videoscope is expected to enhance the patient acceptance of unsedated EGD.

Upper gastrointestinal endoscopy: Are preparatory interventions or conscious sedation effective? A randomized trial

AIM: The fears and concerns are associated with gastroscopy (EGD) decrease patient compliance. Conscious sedation (CS) and non-pharmacological interventions have been proposed to reduce anxiety and allow better execution of EGD. The aim of this study was to assess whether CS, supplementary information with a videotape, or presence of a relative during the examination could improve the tolerance to EGD.

METHODS: Two hundred and twenty-six outpatients (pts), scheduled for a first-time non-emergency EGD were randomly assigned to 4 groups: Co-group (62 pts): throat anaesthesia only; Mi-group (52 pts): CS with i.v. midazolam; Re-group (58 pts): presence of a relative throughout the procedure; Vi-group (54 pts): additional information with a videotape. Anxiety was measured using the "Spielberger State and Trait Anxiety Scales". The patients assessed the overall discomfort during the procedure on an 100-mm visual analogue scale, and their tolerance to EGD answering a questionnaire. The endoscopist evaluated the technical difficulty of the examination and the tolerance of the patients on an 100-mm visual analogue scale and answering a questionnaire.

RESULTS: Pre-endoscopy anxiety levels were higher in the Mi-group than in the other groups (P < 0.001). On the basis of the patients' evaluation, EGD was well tolerated by 80.7% of patients in Mi-group, 43.5% in Co-group, 58.6% in Re-group, and 50% in Vi-group (P < 0.01). The discomfort caused by EGD, evaluated by either the endoscopist or the patients, was lower in Mi-group than in the other groups. The discomfort was correlated with "age" (P < 0.001) and "groups of patients" (P < 0.05) in the patients' evaluation, and with "gender" (females tolerated better than males, P < 0.001) and "groups of patients" (P < 0.05) in the endoscopist's evaluation.

CONCLUSION: Conscious sedation can improve the tolerance to EGD. Male gender and young age are predictive factors of bad tolerance to the procedure.

Efficiency issues in sedation and monitoring

Sedation and monitoring are key elements of the endoscopy process. There continues to be intense study of better methods for sedation and monitoring to improve the endoscopic "experience" for both patient and physicians alike. Our current practices will likely change in the future with technologic advances (monitoring) and expansion of our pharmacologic armamentarium (sedation).

Unsedated endoscopy

Unsedated endoscopy will likely play an increasingly important role in the daily practice of GI endoscopy. Although there is adequate evidence that un-sedated endoscopy is technically feasible in selected patient populations, there area number of obstacles preventing its widespread adoption. Small-caliber endoscopy is not as accurate as conventional EGD. This may be remedied as improvements in endoscope technology emerge. Many patients refuse to consider an unsedated examination, and those who do participate report more symptoms of discomfort than patients undergoing conventional endoscopy. Whether patients will accept mild discomfort in exchange for substantial cost savings has not been evaluated. Finally, although unsedated endoscopy seems to have a low complication rate, its safety has not been formally addressed in large studies. Large, randomized, controlled studies are needed to better determine the role of un-sedated small-caliber endoscopy in daily practice. Unsedated colonoscopy may follow the footsteps of unsedated upper endoscopy with even more obstacles to overcome before its widespread application.

Unsedated ultrathin EGD is well accepted when compared with conventional sedated EGD: a multicenter randomized trial

BACKGROUND & AIMS

In the United States, upper gastrointestinal endoscopy is usually performed using intravenous sedation. Sedation increases the rate of both complications and costs of endoscopy. Unsedated esophagogastroduodenoscopy (EGD) using conventional 8-11-mm endoscopes is an alternative to sedated endoscopy but is generally perceived as unacceptable to many American patients. Unsedated EGD using ultrathin 5-6-mm endoscopes is better tolerated. A randomized trial comparing unsedated ultrathin EGD (UT-EGD) with sedated conventional EGD (C-EGD) in a diverse American population is needed.

METHODS

In this multicenter, randomized, controlled trial, 80 patients scheduled to undergo elective outpatient EGD were randomized to unsedated UT-EGD or sedated C-EGD. The study was carried out at San Francisco General Hospital, San Francisco Veterans Affairs Medical Center, and the Liver and Digestive Health Medical Clinic, San Jose.

RESULTS

Baseline characteristics of patients randomized to unsedated UT-EGD and sedated C-EGD were similar. Moreover, there were no significant differences in overall patient satisfaction and willingness to repeat endoscopy in the same manner among the 2 study groups. There was, however, a significant difference in median total procedure time between the 2 study groups of 1.5 hours (P < 0.0001). The mean (+/- SD) total procedure cost was 512.4 US dollars (+/- 100.8 US dollars) for sedated C-EGD and 328.6 US dollars (+/- 70.3 US dollars) for unsedated UT-EGD (P < 0.0001).

CONCLUSIONS

Patients undergoing unsedated UT-EGD are as satisfied as patients undergoing sedated C-EGD and are just as willing to repeat an unsedated UT-EGD. Unsedated UT-EGD was also faster, less costly, and may allow greater accessibility to this procedure.

The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.