Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients

Systematic review with meta-analysis: ultra-thin gastroscopy compared to conventional gastroscopy for the diagnosis of oesophageal varices in people with cirrhosis

BACKGROUND

Haemorrhage from ruptured oesophageal varices is a common cause of death in people with cirrhosis. Guidelines recommend screening for varices at time of cirrhosis diagnosis and throughout the course of the disease. Conventional gastroscopy is the criterion standard for variceal screening; however, is invasive, costly, and carries risks related to use of sedation. Ultra-thin gastroscopy (using endoscopes with a shaft diameter ≤6 mm) has been proposed as an alternative method of variceal screening that mitigates these risks.

AIM

To determine the diagnostic accuracy of ultra-thin gastroscopy compared to conventional gastroscopy for the diagnosis of varices in people with cirrhosis.

METHODS

MEDLINE, EMBASE and Cochrane library databases were searched for studies that evaluated the accuracy of ultra-thin gastroscopy compared to conventional gastroscopy in the diagnosis of oesophageal varices.

RESULTS

Ten studies, 7 in known cirrhosis, with 752 participants were included in this systematic review. The overall prevalence of oesophageal varices was 42%. On bivariate modelling, pooled estimates of sensitivity and specificity were 98% (95% CI 93%-99%) and 96% (95% CI 91%-99%) respectively. The positive and negative likelihood ratios were 28 (95% CI 10.7-73.2) and 0.02 (95% CI 0.01-0.72) respectively. Kappa coefficient for inter-observer agreement for any varices ranged from 0.45 to 0.90. No serious adverse events related to ultra-thin gastroscopy were reported.

CONCLUSIONS

Ultra-thin gastroscopy is accurate in the diagnosis of oesophageal varices, safe and well tolerated. It is a valid alternative to conventional gastroscopy for the screening and surveillance of varices in people with cirrhosis.

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

BACKGROUND AND AIM

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.

METHODS

A prospective randomized controlled trial to compare patient tolerance and adverse events.

RESULTS

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.

CONCLUSION

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.

Transnasal endoscopy: no gagging no panic!

BACKGROUND

Transnasal endoscopy (TNE) is performed with an ultrathin scope via the nasal passages and is increasingly used. This review covers the technical characteristics, tolerability, safety and acceptability of TNE and also diagnostic accuracy, use as a screening tool and therapeutic applications. It includes practical advice from an ear, nose, throat (ENT) specialist to optimise TNE practice, identify ENT pathology and manage complications.

METHODS

A Medline search was performed using the terms "transnasal", "ultrathin", "small calibre", "endoscopy", "EGD" to identify relevant literature.

RESULTS

There is increasing evidence that TNE is better tolerated than standard endoscopy as measured using visual analogue scales, and the main area of discomfort is nasal during insertion of the TN endoscope, which seems remediable with adequate topical anaesthesia. The diagnostic yield has been found to be similar for detection of Barrett's oesophagus, gastric cancer and GORD-associated diseases. There are some potential issues regarding the accuracy of TNE in detecting small early gastric malignant lesions, especially those in the proximal stomach. TNE is feasible and safe in a primary care population and is ideal for screening for upper gastrointestinal pathology. It has an advantage as a diagnostic tool in the elderly and those with multiple comorbidities due to fewer adverse effects on the cardiovascular system. It has significant advantages for therapeutic procedures, especially negotiating upper oesophageal strictures and insertion of nasoenteric feeding tubes.

CONCLUSIONS

TNE is well tolerated and a valuable diagnostic tool. Further evidence is required to establish its accuracy for the diagnosis of early and small gastric malignancies. There is an emerging role for TNE in therapeutic endoscopy, which needs further study.

Feasibility, safety, acceptability, and yield of office-based, screening transnasal esophagoscopy (with video)

BACKGROUND

Endoscopic screening for esophageal neoplasia can identify patients eligible for early intervention for precancerous lesions. Unsedated transnasal esophagoscopy may provide an efficient and accurate endoscopic assessment with fewer risks and less cost, compared with conventional upper endoscopy.

OBJECTIVE

To assess the feasibility, safety, acceptability, and yield of unsedated transnasal esophagoscopy in a primary care population.

DESIGN

Multicenter, prospective, cross-sectional study.

SETTING

Two outpatient tertiary-care centers.

PATIENTS

This study involved a general medical clinic population aged between 40 and 85 years.

INTERVENTION

Unsedated, office-based transnasal esophagoscopy.

MAIN OUTCOME MEASUREMENTS

Procedure yield; completeness of examination; procedure length; adverse events and complications; choking, gagging, pain, or anxiety during the examination; and overall tolerability.

RESULTS

A total of 426 participants (mean [± standard deviation] age 55.8 ± 9.5 years; 43% male) enrolled in the study, and 422 (99%) completed the examination. Mean (± standard deviation) examination time was 3.7 ± 1.8 minutes. There were no serious adverse events, and 12 participants (2.8%) reported minor complications. Participants reported minimal choking, gagging, pain, or anxiety. The examination was well-tolerated by most participants. Overall, 38% of participants had an esophageal finding that changed management (34% erosive esophagitis, 4% Barrett's esophagus).

LIMITATIONS

Nonrandomized study, tertiary-care centers only, self-selected population with a large proportion reporting esophageal symptoms.

CONCLUSION

Unsedated transnasal esophagoscopy is a feasible, safe, and well-tolerated method to screen for esophageal disease in a primary care population. Endoscopic findings are common in this patient population.

Randomized crossover study comparing efficacy of transnasal endoscopy with that of standard endoscopy to detect Barrett's esophagus

BACKGROUND

Unsedated transnasal endoscopy (TNE) may be safer and less expensive than standard endoscopy (SE) for detecting Barrett's esophagus (BE). Emerging technologies require robust evaluation before routine use.

OBJECTIVE

To evaluate the sensitivity, specificity, and acceptability of TNE in diagnosing BE compared with those of SE.

DESIGN

Prospective, randomized, crossover study.

SETTING

Single, tertiary-care referral center.

PATIENTS

This study enrolled consecutive patients with BE or those referred for diagnostic assessment.

INTERVENTION

All patients underwent TNE followed by SE or the reverse. Spielberger State-Trait Anxiety Inventory short-form questionnaires, a visual analogue scale, and a single question addressing preference for endoscopy type were administered.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy and tolerability of TNE were compared with those of SE.

RESULTS

Of 95 patients randomized, 82 completed the study. We correctly diagnosed 48 of 49 BE cases by TNE for endoscopic findings of columnar lined esophagus compared with the criterion standard, SE, giving a sensitivity and specificity of 0.98 and 1.00, respectively. The BE median length was 3 cm (interquartile range [IQR] 1-5 cm) with SE and 3 cm (IQR 2-4 cm) with TNE, giving high correlations between the two modalities (R(2) = 0.97; P < .001). The sensitivity and specificity for detecting intestinal metaplasia by TNE compared with those by SE was 0.91 and 1.00, respectively. The mean (± standard deviation) post-endoscopy Spielberger State-Trait Anxiety Inventory short-form score for TNE (30.0 ± 1.10 standard error of the mean [SEM]) was lower than that for SE (30.7 ± 1.29 SEM), (P = .054). The visual analogue scale scores were no different (P = .07). The majority of patients (59%) expressed a preference for TNE.

LIMITATIONS

This is a small study, with limited generalizability, a high prevalence of patients with BE, differential drop-out between the two procedures, and use of sedation.

CONCLUSION

TNE is an accurate and well-tolerated method for diagnosing BE compared with SE. TNE warrants further evaluation as a screening tool for BE.

Screening, surveillance, and prevention for esophageal cancer

The incidence of esophageal cancer, especially esophageal adenocarcinoma, is increasing and its high mortality rate is a notable fact. Improving survival rates of this disease depend on earlier detection through screening and surveillance; however, standard diagnostic modalities, such as endoscopy with biopsy, have several limitations as screening tools, including low negative predictive value and relatively high cost. Recently developed biomarkers such as FISH and improved imaging techniques, may help overcome current problems and provide improved screening and surveillance for esophageal cancer.

Endoscopic-guided versus cotton-tipped applicator methods of nasal anesthesia for transnasal esophagogastroduodenoscopy: a randomized, prospective, controlled study

BACKGROUND

Ultrathin transnasal esophagogastroduodenoscopy (UT-EGD) is well tolerated by patients, but the methods of nasal anesthesia are various.

AIM

To compare patient tolerance, safety, and adverse events between the endoscopic-guided (EGNA) and cotton-tipped applicator (CTNA) methods of nasal anesthesia.

METHODS

Between September 2005 and September 2006, we conducted a prospective, randomized, controlled study in a large tertiary referral hospital in eastern Taiwan. In total, 235 consecutive patients were randomly assigned to the CTNA group or EGNA group before unsedated UT-EGD. We compared demographic data, procedural discomfort using a validated 5-point visual analog scale, optical quality, total procedure time, and adverse events between the two groups.

RESULTS

After randomization and exclusion, 101 (43 men and 58 women) and 103 (44 men and 59 women) patients were allocated to the CTNA and EGNA groups, respectively. Baseline characteristics and periprocedural hemodynamics of patients in the two groups were similar. There was no statistical difference in insertion failure rates between the two methods (CTNA 10.9%vs EGNA 7.7%, P= 0.59). Pain scores during both anesthesia (2.3 +/- 0.4 vs 3.5 +/- 0.6, P < 0.001) and insertion (2.8 +/- 1.2 vs 3.8 +/- 1.8, P < 0.001) were significantly lower in the EGNA group; however, the sensation of bad taste was significantly worse in the EGNA group (2.3 +/- 1.3 vs 1.9 +/- 1.4, P= 0.040). Less epistaxis happened in the EGNA group than in the CTNA group. The EGNA method had a significantly better visual capacity and shorter procedure time. More patients in the EGNA group said they would like to receive the same procedure the next time.

CONCLUSION

Compared with the CTNA method, in which the taste of lidocaine gel was more acceptable, EGNA appeared to be more tolerable, caused less epistaxis, improved visualization capacity, and reduced procedure time.

Study comparing oesophageal capsule endoscopy versus EGD in the detection of varices

BACKGROUND

Endoscopic screening and surveillance of cirrhotic patients for oesophageal varices is advocated before initiation of prophylactic therapy for prevention of the first variceal haemorrhage.

AIMS

To compare the diagnostic yield of oesophageal capsule endoscopy (ECE) with Esophagogastroduodenoscopy (EGD) for detecting and grading oesophageal varices and to determine patient tolerance for each procedure.

PATIENTS

Twenty consecutive cirrhotic patients scheduled for EGD were enrolled in the study.

METHODS

Patients underwent ECE followed by EGD. Patients completed a visual analogue scale after each procedure, assessing level of anxiety, pain, overall satisfaction, and willingness to repeat each procedure.

RESULTS

On EGD, 19/20 patients had oesophageal varices. ECE detected varices in 13/19 (68% sensitivity). ECE identified nine out of ten varices rated grade II or higher on EGD. The post-study analogue scale showed a greater level of anxiety before EGD (avg. 2.75/10) versus ECE (avg. 1.5/10).

CONCLUSIONS

ECE may be used in the assessment of EV. It appears to have more discordance with EGD when evaluating smaller varices. The minimal discomfort, lack of sedation, and decreased risk make ECE a possible substitute to EGD in patients unable or unwilling to undergo EGD.

Blinded comparison of esophageal capsule endoscopy versus conventional endoscopy for a diagnosis of Barrett's esophagus in patients with chronic gastroesophageal reflux

BACKGROUND

Esophageal capsule endoscopy (ECE) is an alternative to EGD for Barrett's esophagus screening. A multicenter study found ECE to be safe, well tolerated, and accurate; however, a post hoc adjudication process was used that may have biased results.

OBJECTIVE

To assess the accuracy of ECE for the diagnosis of Barrett's esophagus.

DESIGN

Prospective and blinded, with no adjudication.

PATIENTS

Screening patients with chronic gastroesophageal reflux and surveillance patients with known Barrett's esophagus.

INTERVENTIONS

ECE followed by EGD in each subject.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and positive and negative predictive values of ECE for Barrett's esophagus by using EGD results, with histologic confirmation as the criterion standard.

RESULTS

Ninety-six subjects were enrolled, of whom 90 (94%) completed the study, including 66 screening and 24 surveillance patients. ECE was 67% sensitive and 84% specific for identifying Barrett's esophagus, diagnosing 14 of 21 cases of biopsy-confirmed Barrett's esophagus. Positive and negative predictive values were 22% and 98%, respectively (calculated for screening patients only). Sensitivity for short- and long-segment Barrett's esophagus was similar.

CONCLUSIONS

Our blinded, unadjudicated study shows that ECE had only moderate sensitivity and specificity for identifying Barrett's esophagus. ECE in its present form is not suitable as a primary screening tool for Barrett's esophagus but may be used in patients unwilling to undergo EGD. Inadequate visualization of the gastroesophageal junction may be the cause of suboptimal ECE accuracy; this may be improved by advances in ingestion protocol and capsule calibration.

Primary care physician attitudes toward endoscopic screening for GERD symptoms and unsedated esophagoscopy

BACKGROUND

Current guidelines recommend consideration of screening patients with chronic GERD for Barrett's esophagus (BE). Unsedated esophagoscopy (UE) is a less costly alternative to standard EGD for identifying BE. The aim of this study was to determine the indications for EGD referral, the barriers to screening, and the interest in performing UE.

METHODS

A one-page survey was mailed to a random sample of 500 family practitioners and 500 internists. This sample was obtained from the American Academy of Family Physicians and American Society of Internal Medicine (500 from each organization).

RESULTS

The overall response rate was 54%. The majority (78%) refer more than 50% of their GERD patients for EGD; however, 34% also refer more than 10% of their patients for barium studies. Primary care physicians cited alarm symptoms, refractory symptoms, and chronicity and severity of symptoms as the major indications for referral for EGD. Gender, age, obesity, and tobacco use were cited less frequently. Cost of endoscopy, poor patient acceptance, and lack of evidence were the most common reasons cited for not referring for EGD. A majority of respondents (62%) indicated that the availability of UE would increase referral for the procedure, and 52% would be willing to perform UE in their office.

CONCLUSIONS

Severe, refractory, and chronic symptoms are the primary reasons for endoscopic referral from primary care physicians who manage patients with GERD. Other risk factors for BE, such as gender and age, do not appear to be important determinants for endoscopic referral. Further evaluation of UE as a mechanism to increase screening for BE in primary care patients is merited.

Office-based unsedated ultrathin esophagoscopy in a primary care setting

PURPOSE

Gastroesophageal reflux disease is common and with time may be complicated by Barrett's esophagus and esophageal adenocarcinoma. Upper gastrointestinal endoscopy, including esophagoscopy, is the procedure of choice to diagnose Barrett's esophagus and other esophageal disease. The use of unsedated ultrathin esophagoscopy (UUE) has been reported by gastroenterologists in specialized endoscopy units and otolaryngologists in outpatient otolaryngology offices, but UUE has not been previously described in a primary care setting. This study examines the feasibility of office-based UUE in primary care.

METHODS

This study is a retrospective chart review in a university-based family medicine clinic in the southeastern United States. Charts were reviewed of 56 adult outpatients who were referred for further evaluation of reflux symptoms that persisted after at least 4 weeks of therapy with histamine(2) receptor agonists or proton pump inhibitors and who elected to undergo UUE in the primary care setting. Patient demographics, procedure indications and findings, changes in clinical management, and procedure times were recorded.

RESULTS

One hundred percent of patients asked to participate in UUE were willing to undergo the procedure (mean age 48.3 +/- 1.6 y, 57.1% women); 95% of the patients tolerated UUE. Barrett's esophagus was diagnosed in 5.7% (n = 3) of the patients. Mean procedure time was 5.5 +/- 1.7 min. No complications were reported in this series.

CONCLUSIONS

Initial data suggest that UUE is feasible in primary care, with the majority of patients tolerating the procedure. UUE may be an efficient method of examining the distal esophagus.

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.

Is esophagoscopy alone sufficient for patients with reflux symptoms?

BACKGROUND

Unsedated esophagoscopy with ultrathin endoscopes is a valuable screening modality for Barrett's esophagus, but the stomach and the duodenum cannot be examined completely with the smallest and best tolerated of these endoscopes. There are no data as to how often disease in the stomach and the duodenum would be missed when using this screening strategy. Our hypothesis is that patients with reflux symptoms, in the absence of daily abdominal pain, nausea, or history of ulcer, were unlikely to have clinically significant gastroduodenal disease.

METHODS

Patients scheduled for upper endoscopy at a single outpatient endoscopy unit in a tertiary referral center were screened. The inclusion criterion was reflux symptoms as the primary indication for upper endoscopy. Patients with another valid indication were excluded. A detailed history was recorded and symptom questionnaire completed for each patient before endoscopy; these data were compared with the endoscopy findings.

RESULTS

A total of 175 patients were included. Indications for upper endoscopy were the following: worsening symptoms (n=74), ongoing reflux despite therapy (n=27), and long-standing reflux (n=74). Major esophageal findings were discovered in 95 patients. In 10 patients, major gastric or duodenal findings were detected as follows: erosive gastritis (n=8), gastric ulcer (n=2), duodenal ulcer (n=2), erosive duodenitis (n=2), and duodenal polyp (n=1). Daily abdominal pain (p=0.014) or possibly daily nausea (p=0.028 unadjusted, 0.197 adjusted) was associated with major gastric/duodenal disease. Patients without daily abdominal pain, nausea, or a history of gastric/duodenal ulcer were much less likely to have major disease (0.9%) than patients with one of these predictors (13.2%, p=0.00097).

CONCLUSIONS

Daily abdominal pain and nausea, in combination with a history of ulcer disease, are strong predictors of major gastric or duodenal disease. Patients with reflux without these predictors are highly unlikely to have a major disease involving the stomach or duodenum, and are suitable candidates for esophagoscopy alone.

A prospective, blinded study of diagnostic esophagoscopy with a superthin, stand-alone, battery-powered esophagoscope

OBJECTIVES

A more widely available, well-tolerated, and cost-effective technique is needed to screen a broad population at risk for esophageal cancer. An ideal solution might be to perform unsedated esophagoscopy with an entirely self-contained, small-caliber endoscope. In a prospective, blinded study in three phases, we compared the feasibility, patient tolerance, and diagnostic accuracy of esophagoscopy performed with a prototype, superthin, battery-powered esophagoscope (BPE) with standard video esophagogastroduodenoscopy (SVE).

METHODS

In phase I, 10 healthy volunteers underwent both peroral and transnasal esophagoscopy with BPE to evaluate the technical feasibility of the examination. For phases II and III, patients were recruited to have BPE before SVE. In phase II, both procedures were performed with conscious sedation. In phase III, the BPE was performed with only topical anesthesia. Two endoscopists assessed the technical performance of the endoscope and patient tolerance and recorded the esophageal findings independently.

RESULTS

In phase I, all endoscopists reported adequate visualization of the esophagus in the 10 volunteers. A total of 181 patients were evaluated in phases II and III (89 in phase II, 92 in phase III). The sensitivity for detecting columnar lined esophagus was 94% in phase II and 95% in phase III. The sensitivity for all esophageal findings was 87% and 86% in phases II and III, respectively. The technical performance of the endoscope was significantly worse for BPE compared with the SVE. The patient tolerance as evaluated by the endoscopist was similar for both procedures. Ninety-five percent of the patients undergoing unsedated BPE were willing to have the procedure repeated under similar circumstances.

CONCLUSIONS

Unsedated esophagoscopy with a 3.1-mm, battery-powered, stand-alone esophagoscope is feasible, well tolerated, and accurate in detecting esophageal pathologies. It might be an efficient and cost-effective screening tool for the detection of columnar lined esophagus.

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

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

Endoscopic diagnosis and surveillance of Barrett's esophagus

There are many questions regarding the screening and surveiliance of BE for which there are currently no answers. Despite the use of models and extrapolations by some authors to suggest that screening and surveiliance for a cancer of such low incidence will never be justified, others argue just as vociferously that given the continued epidemic rise in incidence of this cancer, the uniformly fatal outcome of these cancers if dianosed after symptoms occur, and the enormous pool of patients remaining at risk for future cancer development, a focused and prudent screening and surveillance strategy for Barrett's-related esophageal adenocarcinoma is justified. The data also show that a single screening examination is probably as effective as almost all subsequent surveilance examinations in detecting advanced neoplasia, and much of the current resource use and energy for screening and surveillance in BE should be directed toward screening. Whether screening should be offered or recommended to only older patients (> 50-55 years), whites, and men is unknown, but it is premature to adopt this strategy until better evidence exist supporting a restricted screening policy. Regarding the optimal surveilance frequency and technique, examinations more frequent than every 3 to 5 years are not justifiable, and until proven otherwise, biopsy specimens should be obtained with the largest forceps that can be used with the endoscopic instrument and "saturation" biopsies from the Barrett's obtained. It is unlikely that too many biopsy specimens can be taken. Furthermore, the safety of this approach has been, proven. It is quite likely that the inverse is not true; clinicians likely can do much more harm by taking too few biopsy specimens. It is hoped that the current intense interest in Barrett's neoplasia allows clinicians to address these critical issues in the years to come and resolve this clinical conundrum.

Prospective evaluation of 4-mm diameter endoscopes for esophagoscopy in sedated and unsedated patients

BACKGROUND

Unsedated esophagoscopy with small-diameter endoscopes is generally well tolerated but of limited sensitivity for the diagnosis of esophageal mucosal disease. This study evaluated the sensitivity of esophagoscopy performed with new 4-mm diameter prototype battery-powered and video endoscopes. Patient tolerance for an unsedated examination with the 4-mm endoscopes was assessed and the performance characteristics of the battery-powered and video 4-mm endoscopes were compared.

METHODS

Patients referred for EGD were recruited to undergo an additional examination with a 4-mm endoscope. A prototype 60-cm long, 4-mm diameter battery-powered fiberoptic esophagoscope was used in the first 24 patients and a prototype 60-cm long, 4-mm diameter video esophagoscope in the next 27 patients. Examiners who were unaware of patient history and procedure indications recorded esophageal findings, ease of intubation, optical quality (5-point visual scale), and time for examination of the esophagus and then recorded esophageal findings after the standard EGD.

RESULTS

The sensitivity, specificity, and accuracy for identification of Barrett's esophagus was 100%; overall sensitivity, accuracy, and specificity for detecting esophageal lesions were, respectively, 91%, 98%, and 99%. Patient tolerance (assessed by symptom scores for choking, pain, and discomfort) and acceptability of unsedated esophagoscopy with the 4-mm diameter instruments were significantly better than in a historical group of patients examined with a 3-mm diameter endoscope. The optical quality of video endoscope was rated as superior to that of battery-powered endoscope, and esophageal examination was performed significantly quicker with the video versus the battery-powered endoscope (68 vs. 137 seconds; p = 0.001).

CONCLUSIONS

Unsedated esophagoscopy with 4-mm diameter endoscopes may be an alternative to EGD for screening for Barrett's esophagus. Given the current state of endoscopic technology, a minimum diameter of 4 mm is required for satisfactory esophageal imaging.

Accuracy of esophagoscopy performed by a non-physician endoscopist with a 4-mm diameter battery-powered endoscope

BACKGROUND

A cost-effective technique is needed for screening of a broad population at risk for esophageal cancer. A solution would be to have non-physician endoscopists perform esophagoscopy with small-caliber battery-powered endoscopes.

METHODS

In a prospective blinded study, the diagnostic accuracy of sedated esophagoscopy performed by a trained nurse practitioner with a battery-powered 4-mm diameter endoscope was compared with that for a sedated standard video-endoscopy performed by a gastroenterologist. Patients were recruited to undergo peroral esophagoscopy by the nurse practitioner followed by sedated standard endoscopy by the supervising gastroenterologist, each blinded to the findings of the other. Major esophageal findings of nurse practitioner and gastroenterologist were compared.

RESULTS

Findings in 40 patients were analyzed. In 4 patients both endoscopists could not assess the presence or absence of columnar-lined esophagus because of severe erosive esophagitis (n = 3) or severe candida-esophagitis (n = 1). By using sedated standard endoscopy as the standard, on a per finding basis, esophagoscopy by the nurse practitioner had a sensitivity for columnar-lined esophagus of 89%: 95% CI [75%, 97%] and specificity of 96%: 95% CI [84%, 99%]. The missed columnar epithelium was a 3 x 3-mm island. For all lesions, the sensitivity of endoscopy performed by the nurse practitioner with the battery-powered endoscope was 75%: 95% CI [67%, 82%] and specificity 98%: 95% CI [96%, 99%]. The nurse practitioner missed all of 4 rings (3 considered clinically irrelevant).

CONCLUSION

Esophagoscopy with a battery-powered 4-mm diameter endoscope by a non-physician endoscopist is feasible and accurate in detecting esophageal pathologies. It may be an efficient screening method for the detection of columnar-lined esophagus. There was a distinct underestimate of the presence of esophageal rings.

Association of prediagnosis endoscopy with stage and survival in adenocarcinoma of the esophagus and gastric cardia

BACKGROUND

Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown.

METHODS

A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files.

RESULTS

One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57-0.93; P = 0.01), but not for adenocarcinoma of the cardia.

CONCLUSIONS

Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk.