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Shoda T, Taylor RJ, Sakai N, Rothenberg ME. Common and disparate clinical presentations and mechanisms in different eosinophilic gastrointestinal diseases. J Allergy Clin Immunol 2024; 153:1472-1484. [PMID: 38555071 PMCID: PMC11162323 DOI: 10.1016/j.jaci.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/02/2024]
Abstract
Eosinophilic gastrointestinal diseases (EGIDs) are a group of diseases characterized by selective eosinophil infiltration of the gastrointestinal (GI) tract in the absence of other causes of eosinophilia. These diseases are generally driven by type 2 inflammation, often in response to food allergen exposure. Among all EGIDs, the clinical presentation often includes a history of atopic disease with a variety of GI symptoms. EGIDs are traditionally separated into eosinophilic esophagitis (EoE) and non-EoE EGIDs. EoE is relatively better understood and now associated with clinical guidelines and 2 US Food and Drug Administration-approved treatments, whereas non-EoE EGIDs are rarer and less well-understood diseases without US Food and Drug Administration-approved treatments. Non-EoE EGIDs are further subclassified by the area of the GI tract that is involved; they comprise eosinophilic gastritis, eosinophilic enteritis (including eosinophilic duodenitis), and eosinophilic colitis. As with other GI disorders, the disease presentations and mechanisms differ depending on the involved segment of the GI tract; however, the differences between EoE and non-EoE EGIDs extend beyond which GI tract segment is involved. The aim of this article is to summarize the commonalities and differences between the clinical presentations and disease mechanisms for EoE and non-EoE EGIDs.
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Affiliation(s)
- Tetsuo Shoda
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard J Taylor
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Naoya Sakai
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio.
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2
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Aya I, Ichijima R, Sugita T, Nakayama M, Takasu A, Ogura K, Gotoda T, Kogure H. A single-center prospective study on pain alleviation during peroral upper endoscopy with an ultrathin endoscope. BMC Gastroenterol 2023; 23:325. [PMID: 37735366 PMCID: PMC10514927 DOI: 10.1186/s12876-023-02965-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/20/2023] [Indexed: 09/23/2023] Open
Abstract
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.
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Affiliation(s)
- Iwao Aya
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
- Health Management Center, Toranomon Hospital, Tokyo, Japan
| | - Ryoji Ichijima
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Tomomi Sugita
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Masako Nakayama
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Ayaka Takasu
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kanako Ogura
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hirofumi Kogure
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
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Hayashi T, Asahina Y, Takeda Y, Miyazawa M, Takatori H, Kido H, Seishima J, Iida N, Kitamura K, Terashima T, Miyagi S, Toyama T, Mizukoshi E, Yamashita T. Necessity of pharyngeal anesthesia during transoral gastrointestinal endoscopy: a randomized clinical trial. Clin Endosc 2023; 56:594-603. [PMID: 37041735 PMCID: PMC10565444 DOI: 10.5946/ce.2022.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/24/2022] [Accepted: 08/03/2022] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND/AIMS The necessity for pharyngeal anesthesia during upper gastrointestinal endoscopy is controversial. This study aimed to compare the observation ability with and without pharyngeal anesthesia under midazolam sedation. METHODS This prospective, single-blinded, randomized study included 500 patients who underwent transoral upper gastrointestinal endoscopy under intravenous midazolam sedation. Patients were randomly allocated to pharyngeal anesthesia: PA+ or PA- groups (250 patients/group). The endoscopists obtained 10 images of the oropharynx and hypopharynx. The primary outcome was the non-inferiority of the PA- group in terms of the pharyngeal observation success rate. RESULTS The pharyngeal observation success rates in the pharyngeal anesthesia with and without (PA+ and PA-) groups were 84.0% and 72.0%, respectively. The PA- group was inferior (p=0.707, non-inferiority) to the PA+ group in terms of observable parts (8.33 vs. 8.86, p=0.006), time (67.2 vs. 58.2 seconds, p=0.001), and pain (1.21±2.37 vs. 0.68±1.78, p=0.004, 0-10 point visual analog scale). Suitable quality images of the posterior wall of the oropharynx, vocal fold, and pyriform sinus were inferior in the PA- group. Subgroup analysis showed a higher sedation level (Ramsay score ≥5) with almost no differences in the pharyngeal observation success rate between the groups. CONCLUSION Non-pharyngeal anesthesia showed no non-inferiority in pharyngeal observation ability. Pharyngeal anesthesia may improve pharyngeal observation ability in the hypopharynx and reduce pain. However, deeper anesthesia may reduce this difference.
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Affiliation(s)
- Tomoyuki Hayashi
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Yoshiro Asahina
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Yasuhito Takeda
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Masaki Miyazawa
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Hajime Takatori
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Hidenori Kido
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Jun Seishima
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Noriho Iida
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Kazuya Kitamura
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Takeshi Terashima
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Sakae Miyagi
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Tadashi Toyama
- Innovative Clinical Research Center, Kanazawa University, Kanazawa, Japan
| | - Eishiro Mizukoshi
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University, Kanazawa, Japan
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Venkatesh RD, Leinwand K, Nguyen N. Pediatric Unsedated Transnasal Endoscopy. Gastrointest Endosc Clin N Am 2023; 33:309-321. [PMID: 36948748 DOI: 10.1016/j.giec.2022.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Unsedated transnasal endoscopy (TNE) is a feasible, safe, and cost-effective procedure for pediatric patients. TNE provides direct visualization of the esophagus and enables acquisition of biopsy samples while eliminating the risks associated with sedation and anesthesia. TNE should be considered in the evaluation and monitoring of disorders of the upper gastrointestinal tract, particularly in diseases such as eosinophilic esophagitis that often require repeated endoscopy. Setting up a TNE program requires a thorough business plan as well as training of staff and endoscopists.
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Affiliation(s)
- Rajitha D Venkatesh
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, 700 Childrens Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Kristina Leinwand
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Northwest Permanente, Portland, OR, USA; Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Doernbecher Children's Hospital at Oregon Health and Science University, Portland, OR, USA
| | - Nathalie Nguyen
- Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Colorado, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine
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5
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Tai FWD, Healy A, Thokala P, Chetcuti Zammit S, Sidhu R, McAlindon M. Cost comparison of oral, transnasal and magnet assisted capsule endoscopy in the examination of the upper gastrointestinal tract in patients with dyspepsia. Frontline Gastroenterol 2022; 14:300-305. [PMID: 37409341 PMCID: PMC11138180 DOI: 10.1136/flgastro-2022-102256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Conventional oral upper gastrointestinal (GI) endoscopy can obe uncomfortable. By comparison, transnasal endoscopy (TNE) and magnet assisted capsule endoscopy (MACE) have superior tolerability. A cost comparison of competing upper GI endoscopic modalities have yet to be performed. Methods We performed a cost comparison study of oral, TNE and MACE by a combination of activity-based costing and averaging of fixed costs over 24 481 upper GI endoscopies performed for dyspepsia over a 10-year period. Results On average, 9.4 procedures were performed daily. TNE was cheapest at €125.90 per procedure, costing 30% less than oral endoscopy at €184.10 and threefold cheaper than MACE at €407.10. Flexible endoscope reprocessing cost €53.80. TNE was cheaper than oral endoscopy as sedation was not required. Oral endoscopies have a further rate of infectious complications, estimated to cost €16.20 per oral procedure in inpatient admissions. Oral and TNE equipment are more expensive to purchase and maintain than MACE costing €79 330 and €81 819, respectively compared with MACE at €15 420 per annum. However, capsule endoscopes cost significantly more per procedure at €369.00 than the consumables for flexible endoscopy (per oral €12.30, TNE €5.30). Conclusions TNE cost less to perform than conventional per oral endoscopy. The cost of capsule endoscopes will need to be reduced significantly if routine use is to be expected.
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Affiliation(s)
- Foong Way David Tai
- Academic Unit of Gastroenterology and Hepatology, Royal Hallamshire Hospital, Sheffield, UK
| | - Ailish Healy
- Academic Unit of Gastroenterology and Hepatology, Royal Hallamshire Hospital, Sheffield, UK
| | - Praveen Thokala
- Health Economics and Decision Science, The University of Sheffield School of Health and Related Research, Sheffield, UK
| | | | - Reena Sidhu
- Academic Unit of Gastroenterology and Hepatology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mark McAlindon
- Academic Unit of Gastroenterology and Hepatology, Royal Hallamshire Hospital, Sheffield, UK
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Huibertse LJ, Peters Y, Westendorp D, Siersema PD. Unsedated transnasal endoscopy for the detection of Barrett's esophagus: systematic review and meta-analysis. Dis Esophagus 2022; 36:6643449. [PMID: 35830873 PMCID: PMC9885739 DOI: 10.1093/dote/doac045] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 02/02/2023]
Abstract
Conventional esophagogastroduodenoscopy (cEGD) is currently the gold standard endoscopic procedure for diagnosis and surveillance of Barrett's esophagus (BE). This procedure is however less suitable for widespread screening because of its invasiveness and costs. An alternative endoscopic procedure is unsedated transnasal endoscopy (uTNE). We performed a systematic review and meta-analysis to evaluate the diagnostic accuracy, patient tolerability, technical success rate, and safety of uTNE compared with cEGD for detecting BE and related neoplasia. PubMed, EMBASE, and Cochrane Library were searched for studies that reported the diagnostic accuracy of uTNE compared with cEGD for detecting BE and related neoplasia. Eight prospective studies were included, in which 623 patients underwent both uTNE and cEGD. Pooled sensitivity and specificity of uTNE for detecting columnar epithelium were 98% (95% CI 83-100%) and 99% (95% CI 82-100%), respectively. Pooled sensitivity and specificity of uTNE for detecting intestinal metaplasia in biopsies were 89% (95% CI 78-95%) and 93% (95% CI 71-98%), respectively. In three of the six studies that reported patient tolerability, a higher patient tolerability of uTNE compared with cEGD was reported. The technical success rate of uTNE ranged from 89% to 100% and no (serious) adverse events were reported. This systematic review and meta-analysis provides evidence that uTNE is an accurate, safe, and well-tolerated procedure for the detection of columnar epithelium and can be considered as screening modality for BE.
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Affiliation(s)
- Lotte J Huibertse
- Address correspondence to: Lotte J. Huibertse, MSc, Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dieuwertje Westendorp
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Chuah KH, Yim CCW, Abdul Aziz NA, Loh EC, Capelle DP, Shahrizaila N, Leow AHR. Percutaneous endoscopic gastrostomy using the introducer method with ultra-slim endoscopy in amyotrophic lateral sclerosis patients with respiratory compromise: A safe technique. J Gastroenterol Hepatol 2022; 37:1367-1372. [PMID: 35470471 DOI: 10.1111/jgh.15870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/28/2022] [Accepted: 04/08/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Percutaneous endoscopic gastrostomy (PEG) placement is recommended in patients with amyotrophic lateral sclerosis (ALS), but the procedure is considered high risk. In this study, we aimed to compare the outcome of ALS patients with and without PEG. The success of the procedure and complications of PEG insertion were also explored. METHODS Patients with ALS who met the criteria for enteral feeding support were consecutively recruited. Patients who consented had PEG insertion using the modified technique of introducer method with transoral ultra-slim endoscopy. RESULTS A total of 64 patients were recruited, of which 36 (56%) patients consented to PEG. The median age of all patients was 65 years and 59% were male. There was no difference in demographic and clinical characteristics between patients who agreed to a PEG and those who did not. The mortality rate at 6 and 12 months was lower in the PEG cohort compared with non-PEG, but this was not statistically significant (6 months: 28.6% vs 32.2%, P = 0.561; 12 months: 38.9% vs 50.0%, P = 0.374). Amongst the PEG cohort, 61% were stratified high risk and 31% moderate risk. Thirty-one percent of them required long-term home noninvasive ventilation. All patients (100%) underwent successful PEG insertion at single attempt using the modified approach. The complications reported over a period of 6 months were infected PEG site (17%), dislodged gastrostomy tube (14%), and minor bleeding (8%). CONCLUSION In ALS patients with moderate to high risk of PEG insertion, the introducer technique utilizing ultra-slim endoscopy guidance was well tolerated and safe.
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Affiliation(s)
- Kee Huat Chuah
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Carolyn Chue Wai Yim
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nur Adilah Abdul Aziz
- Neurology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ee Chin Loh
- Palliative Care Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - David Paul Capelle
- Palliative Care Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Neurology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Alex Hwong Ruey Leow
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Tai FWD, Ching HL, Sloan M, Sidhu R, McAlindon M. Comparison of patient tolerance and acceptability of magnet-controlled capsule endoscopy and flexible endoscopy in the investigation of dyspepsia. Endosc Int Open 2022; 10:E735-E744. [PMID: 35692932 PMCID: PMC9187367 DOI: 10.1055/a-1790-5996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Oropharyngeal intubation during Esophagogastroduodenoscopy (EGD) is uncomfortable, associated with aerosol generation and transmission of airborne microbes. Less-invasive alternatives may be better tolerated. In this study, patient tolerance and acceptability of EGD and transnasal endoscopy (TNE) have been compared with magnet-controlled capsule endoscopy (MACE). Patients and methods A comparison of MACE with EGD and TNE in the investigation of dyspepsia was performed. Factors affecting patient tolerance and acceptability were examined using the Endoscopy Concerns Scale (ECS) and Universal Patient Centeredness Questionnaire (UPC-Q). Results Patients were significantly more distressed (scoring least to most distress: 1-10) by gagging (6 vs 1), choking (5 vs 1), bloating (2 vs 1), instrumentation (4 vs 1), discomfort during (5 vs 1) and after (2 vs 1) EGD compared to MACE (all P < 0.0001). Patients were more distressed by instrumentation (5 vs 1) and discomfort during (5 vs 1) TNE compared to MACE ( P = 0.001). Patients were more accepting of MACE than EGD and TNE with a UPC-Q score (scoring least to most acceptable: 0-100) lower for EGD (50 vs 98, P < 0.0001) and TNE (75 vs 88, P = 0.007) than MACE, and a post-procedure ECS score (scoring most to least acceptable: 10-100) higher for EGD (34 vs 11, P < 0.0001) and TNE (25 vs 10.5, P = 0.001) than MACE. MACE would be preferred by 83 % and 64 % of patients even if EGD or TNE respectively was subsequently recommended to obtain biopsies in half of examinations. Conclusions Gagging and choking during instrumentation, the main causes of patient distress during EGD, occurred less during TNE but tolerance, acceptability and patient experience favored MACE.
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Affiliation(s)
- Foong Way David Tai
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, Sheffield, United Kingdom,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Hey Long Ching
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, Sheffield, United Kingdom,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | | | - Reena Sidhu
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals, Sheffield, United Kingdom,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Mark McAlindon
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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9
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Grant RK, Brindle WM, Robertson AR, Kalla R, Plevris JN. Unsedated Transnasal Endoscopy: A Safe, Well-Tolerated and Accurate Alternative to Standard Diagnostic Peroral Endoscopy. Dig Dis Sci 2022; 67:1937-1947. [PMID: 35239094 PMCID: PMC8893049 DOI: 10.1007/s10620-022-07432-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/30/2022] [Indexed: 12/23/2022]
Abstract
Diagnostic unsedated transnasal endoscopy (uTNE) has been proven to be a safe and well-tolerated procedure. Although its utilization in the United Kingdom (UK) is increasing, it is currently available in only a few centers. Through consideration of recent studies, we aimed to perform an updated review of the technological advances in uTNE, consider their impact on diagnostic accuracy, and to determine the role of uTNE in the COVID-19 era. Current literature has shown that the diagnostic accuracy of uTNE for identification of esophageal pathology is equivalent to conventional esophagogastroduodenoscopy (cEGD). Concerns regarding suction and biopsy size have been addressed by the introduction of TNE scopes with working channels of 2.4 mm. Advances in imaging have improved detection of early gastric cancers. The procedure is associated with less cardiac stress and reduced aerosol production; when combined with no need for sedation and improved rates of patient turnover, uTNE is an efficient and safe alternative to cEGD in the COVID-19 era. We conclude that advances in technology have improved the diagnostic accuracy of uTNE to the point where it could be considered the first line diagnostic endoscopic investigation in the majority of patients. It could also play a central role in the recovery of diagnostic endoscopic services during the COVID-19 pandemic.
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Affiliation(s)
- Rebecca K. Grant
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - William M. Brindle
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Rahul Kalla
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John N. Plevris
- The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
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10
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Innovations in Screening Tools for Barrett's Esophagus and Esophageal Adenocarcinoma. Curr Gastroenterol Rep 2021; 23:22. [PMID: 34654955 DOI: 10.1007/s11894-021-00821-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Esophageal adenocarcinoma (EAC) is a lethal disease with rapidly rising incidence. Screening for EAC and its metaplastic precursor, Barrett's esophagus (BE), followed by endoscopic surveillance and endoscopic treatment of dysplasia or early EAC are promising approaches to decreasing EAC incidence and EAC mortality. Historically, screening for EAC has been completed with a traditional per-oral esophagogastroduodenoscopy (EGD); however, this method has limitations including cost, tolerability, and accessibility. For this reason, much effort has been put forward to develop more effective, minimally invasive, and accessible BE and EAC screening tools. The purpose of this review is to describe recent developments of these novel tools. RECENT FINDINGS While endoscopic alternatives such as transnasal endoscopy are cheaper and well tolerated, they have not gained acceptance. Non-endoscopic modalities namely, swallowable cell collection devices coupled with biomarker analysis have been found to have excellent performance characteristics, tolerability, and cost effectiveness. In this article, we provide an update on innovative developments in EAC/BE screening modalities including transnasal endoscopy, capsule endomicroscopy, swallowable cell collection devices, and exhaled volatile organic compound analyses.
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11
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Peters Y, Huibertse LJ, Schrauwen RWM, Tan AC, van der Post RS, Siersema PD. Increased risk of Barrett's oesophagus and related neoplasia in individuals with a positive family history. Eur J Cancer 2021; 155:116-126. [PMID: 34375895 DOI: 10.1016/j.ejca.2021.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/27/2021] [Accepted: 07/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Considering the poor prognosis of oesophageal adenocarcinoma (EAC), it is important to identify individuals at increased risk of developing EAC who may benefit from early detection and prevention strategies. We aimed to determine whether individuals with a positive family history of Barrett's oesophagus (BE) and EAC are at an increased risk of oesophageal neoplasia. METHODS In a multi-centre case-control study, BE patients with or without related oesophageal neoplasia and randomly selected population controls filled out a questionnaire to collect information on family history and other risk factors for BE and EAC. Positive family history was defined as having ≥1 first-degree relative with BE or EAC whose diagnosis was histologically confirmed in the Dutch nationwide histopathology database. FINDINGS We included 480 BE patients and 420 controls without BE who had a total of 6393 first-degree relatives. A pathologically confirmed positive family history was significantly higher in BE patients compared with controls (6.5% versus 0.9; p < 0.001). Positive family history was independently associated with an increased risk of BE (OR 5.04; 95% CI 1.45-17.58; p = 0.01) after adjusting for known risk factors, such as gastroesophageal reflux disease and body mass index, and family size. INTERPRETATION We found that familial clustering of BE and EAC is present in 6.5% of Dutch BE patients. Subjects with ≥1 first-degree relative with BE or EAC have a 5-fold increased risk of BE and EAC. These findings emphasize the importance of a detailed family history in patients with BE or EAC to identify individuals at increased risk who may benefit from early detection strategies to prevent EAC-related mortality.
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Affiliation(s)
- Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Lotte J Huibertse
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Uden, the Netherlands
| | - Adriaan C Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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12
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Yusuf A, Fitzgerald RC. Screening for Barrett's Oesophagus: Are We Ready for it? ACTA ACUST UNITED AC 2021; 19:321-336. [PMID: 33746508 PMCID: PMC7962426 DOI: 10.1007/s11938-021-00342-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 01/10/2023]
Abstract
Purpose of review The targeted approach adopted for Barrett’s oesophagus (BO) screening is sub-optimal considering the large proportion of BO cases that are currently missed. We reviewed the literature highlighting recent technological advancements in efforts to counteract this challenge. We also provided insights into strategies that can improve the outcomes from current BO screening practises. Recent findings The standard method for BO detection, endoscopy, is invasive and expensive and therefore inappropriate for mass screening. On the other hand, endoscopy is more cost-effective for screening a high-risk population. A consensus has however not been reached on who should be screened. Risk prediction algorithms have been tested as an enrichment pre-screening tool reporting modest AUC’s but require more prospective evaluation studies. Less invasive endoscopy methods like trans-nasal endoscopy, oesophageal capsule endsocopy and non-endoscopic cell collection devices like the Cytosponge coupled with biomarker analysis have shown promise in BO detection with randomised clinical trial evidence. Summary A three-tier precision cancer programme whereby risk prediction algorithms and non-endoscopic minimally invasive cell collection devices are used to triage test a wider pool of individuals may improve the detection rate of current screening practises with minimal cost implications.
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Affiliation(s)
- Aisha Yusuf
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, CB2 0XZ United Kingdom
| | - Rebecca C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, CB2 0XZ United Kingdom
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Chang JW, Haller E, Dellon ES. Dietary Management of Eosinophilic Esophagitis: Man Versus Food or Food Versus Man? Gastroenterol Clin North Am 2021; 50:59-75. [PMID: 33518169 DOI: 10.1016/j.gtc.2020.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
An alternative to pharmacologic management of eosinophilic esophagitis, elimination of food antigens for diet therapy is an effective first-line treatment strategy to induce and maintain symptomatic, histologic, and endoscopic disease remission. The 3 dietary strategies for eosinophilic esophagitis include elemental diet, empiric elimination diet, and targeted elimination diet. We review the studies supporting various diet therapy strategies, practical considerations and challenges for applying an elimination diet, and novel testing to identify triggers and optimize food reintroduction.
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Affiliation(s)
- Joy W Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA.
| | - Emily Haller
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Drive, SPC 5362, Ann Arbor, MI 48109, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB #7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC 27599, USA
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Introduction of Transnasal Endoscopy to a Scottish District General Hospital. Gastroenterol Nurs 2021; 44:E24-E28. [PMID: 33795625 DOI: 10.1097/sga.0000000000000589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/13/2021] [Indexed: 10/21/2022] Open
Abstract
Esophagogastroduodenoscopy can be uncomfortable and distressing with many patients opting for conscious sedation over topical local anesthetic spray. Transnasal endoscopy is an alternative and we sought to assess how easily it could be introduced to a district general hospital and how acceptable patients found it. Selected patients requiring diagnostic endoscopy were offered transnasal endoscopy with topical nasal anesthetic by clinicians new to transnasal endoscopy but competent at esophagogastroduodenoscopy. Postal feedback questionnaires were used to assess comfort, distress, recollection of periprocedural consultation, and overall experience (visual analog scale 1-10). A total of 213 transnasal endoscopy procedures were undertaken with 207 completed successfully (97.2%). Two patients (0.9%) had self-limiting epistaxis and no patient required admission. One hundred (47%) questionnaires were returned including 98 from those with completed transnasal endoscopy. Thirty-three (33%) had previous esophagogastroduodenoscopy and 28 (85%) reported a preference for transnasal endoscopy. Fifty-eight patients (59%) found transnasal endoscopy comfortable (visual analog scale >6) with 17 reporting discomfort (visual analog scale <5). Seventeen patients found the procedure distressing (visual analog scale >6) but 70 (73%) did not (visual analog scale <5). Eighty-four patients (85.7%) had clear recollection of their procedure (visual analog scale >6) and overall satisfaction was reported as good (visual analog scale >6) by 94.7%. Transnasal endoscopy can be adopted by clinicians competent with conventional esophagogastroduodenoscopy with expectation of high procedure completion rate and low complication rate. Our patients reported high levels of satisfaction with few reporting distress. Perhaps as a consequence, most patients had a clear recollection of their procedure.
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Ono S, Ito S, Maejima K, Hosaka S, Umeki K, Sato SI. Tapering body stiffness shortens upper gastrointestinal examination via transoral insertion with ultrathin endoscope. Endosc Int Open 2020; 8:E1748-E1753. [PMID: 33269306 PMCID: PMC7671759 DOI: 10.1055/a-1266-3203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/18/2020] [Indexed: 12/04/2022] Open
Abstract
Background and study aims Ultrathin endoscopes are commonly used for surveillance esophagogastroduodenoscopy (EGD) to reduce discomfort associated with scope insertion. However, the flexibility of an ultrathin endoscope is a trade-off between reducing discomfort and lengthening examination time. Patients and methods The EG17-J10 (EG17) is a novel ultrathin endoscope characterized by its tapering body stiffness; however, the flexibility of its tip is comparable to that of the traditional ultrathin endoscope EG16-K10 (EG16). We compared EGD examination time between EG17 and EG16. A total of 319 examinees who underwent EGD from November 2019 to January 2020 at the Chiba-Nishi General Hospital were enrolled. Six examinees were excluded due to past history of surgical resection of the upper gastrointestinal tract or too much food residues; 313 examinees (EG17, 209; EG16,104) were retrospectively analyzed. The examination time was divided into three periods: esophageal insertion time (ET), gastroduodenal insertion time (GDT), and surveillance time of the stomach (ST). The total amount of ET, GDT, and ST was defined as total examination time (TT). Results TT of EGD using EG17 was significantly shorter compared to EGD using EG16 (222.7 ± 68.9 vs. 245.7 ± 78.5 seconds) ( P = 0.004). Among the three periods of examination time, ET (66.7 ± 24.1 vs. 76.0 ± 24.1 seconds) ( P = 0.001) and GDT (47.9 ± 17.4 vs. 55.2 ± 35.2 seconds) ( P = 0.007) of EGD using EG17 were significantly shorter compared to EGD using EG16, except for ST (108.1 ± 51.5.1 vs. 114.5 ± 50.1 seconds) ( P = 0.148). Conclusion An ultrathin endoscope with tapering body stiffness can shorten EGD examination time, mainly due to the shortening of insertion time.
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Affiliation(s)
- Satoshi Ono
- Department of Gastroenterology, Chiba-nishi General Hospital, 1-107, Kanegasaku, Matsudo, Chiba
| | - Shun Ito
- Department of Gastroenterology, Chiba-nishi General Hospital, 1-107, Kanegasaku, Matsudo, Chiba
| | - Kyohei Maejima
- Department of Gastroenterology, Chiba-nishi General Hospital, 1-107, Kanegasaku, Matsudo, Chiba
| | - Shosuke Hosaka
- Department of Gastroenterology, Chiba-nishi General Hospital, 1-107, Kanegasaku, Matsudo, Chiba
| | - Kiyotaka Umeki
- Department of Gastroenterology, Chiba-nishi General Hospital, 1-107, Kanegasaku, Matsudo, Chiba
| | - Shin-ichiro Sato
- Department of Gastroenterology, Chiba-nishi General Hospital, 1-107, Kanegasaku, Matsudo, Chiba
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16
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DeBoer AM, Mellion KM, Frankki SM, Kallies KJ, Grover BT, Pfeiffer JD, Kothari SN. Pre-screening for bariatric surgery patients: comparative effectiveness of transnasal endoscopy versus esophagogastroduodenoscopy. Surg Endosc 2020; 35:4153-4159. [PMID: 32797285 DOI: 10.1007/s00464-020-07892-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/05/2020] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Austin M DeBoer
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Katelyn M Mellion
- Department of Medical Education, Gundersen Health System, La Crosse, WI, USA
| | - Susan M Frankki
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Brandon T Grover
- Department of General Surgery, Gundersen Health System, 1900 South Ave. C05-001, La Crosse, WI, 54601, USA.
| | - Joshua D Pfeiffer
- Department of General Surgery, Gundersen Health System, 1900 South Ave. C05-001, La Crosse, WI, 54601, USA
| | - Shanu N Kothari
- Department of General Surgery, Gundersen Health System, 1900 South Ave. C05-001, La Crosse, WI, 54601, USA
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Accurate Nonendoscopic Detection of Barrett's Esophagus by Methylated DNA Markers: A Multisite Case Control Study. Am J Gastroenterol 2020; 115:1201-1209. [PMID: 32558685 PMCID: PMC7415629 DOI: 10.14309/ajg.0000000000000656] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nonendoscopic Barrett's esophagus (BE) screening may help improve esophageal adenocarcinoma outcomes. We previously demonstrated promising accuracy of methylated DNA markers (MDMs) for the nonendoscopic diagnosis of BE using samples obtained from a capsule sponge-on-string (SOS) device. We aimed to assess the accuracy of these MDMs in an independent cohort using a commercial grade assay. METHODS BE cases had ≥ 1 cm of circumferential BE with intestinal metaplasia; controls had no endoscopic evidence of BE. The SOS device was withdrawn 8 minutes after swallowing, followed by endoscopy (the criterion standard). Highest performing MDMs from a previous study were blindly assessed on extracted bisulfite-converted DNA by target enrichment long-probe quantitative amplified signal (TELQAS) assays. Optimal MDM combinations were selected and analyzed using random forest modeling with in silico cross-validation. RESULTS Of 295 patients consented, 268 (91%) swallowed the SOS device; 112 cases and 89 controls met the pre-established inclusion criteria. The median BE length was 6 cm (interquartile range 4-9), and 50% had no dysplasia. The cross-validated sensitivity and specificity of a 5 MDM random forest model were 92% (95% confidence interval 85%-96%) and 94% (95% confidence interval 87%-98%), respectively. Model performance was not affected by age, gender, or smoking history but was influenced by the BE segment length. SOS administration was well tolerated (median [interquartile range] tolerability 2 [0, 4] on 10 scale grading), and 95% preferred SOS over endoscopy. DISCUSSION Using a minimally invasive molecular approach, MDMs assayed from SOS samples show promise as a safe and accurate nonendoscopic test for BE prediction.
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18
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Xavier AT, Alvares AV, Iyer PG, Arantes VN. Unsedated Transnasal Endoscopy for Preoperative Examination of Bariatric Patients: a Prospective Study. Obes Surg 2020; 30:238-243. [PMID: 31377993 DOI: 10.1007/s11695-019-04120-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Esophagogastroduodenoscopy is a preoperative examination commonly required for candidates to bariatric surgery (BS). Overweight individuals have a greater risk of cardiorespiratory complications during endoscopy under sedation. This study aimed to investigate the feasibility, tolerance, and cardiovascular stress of transnasal endoscopy (TNE) without sedation in obese patients eligible for BS. METHODS This prospective study enrolled obese adult patients with indication for BS that consented to undergo unsedated preoperative TNE. All examinations were carried out in an outpatient center. The outcomes assessed were endoscopic findings, procedural success, patients' tolerance according to a visual analogic scale, cardiovascular stress estimated by double product (i.e., systolic blood pressure × heart rate) and adverse events. Statistical analyses were used to compare each patient's double product among different examination periods. RESULTS Ninety-four patients (77.6% female) completed the study, with an average body mass index (BMI) of 53 kg/m2 (range, 35-73.4 kg/m2). There were 63 super-obese individuals (67%), with BMI > 50 kg/m2. In 93 patients (98.9%), unsedated TNE was successfully completed up to the second part of the duodenum. TNE failed in one patient. Tolerance was rated as excellent or good in 95.7%. Minimal cardiovascular stress was noted in obese individuals, whereas the double product remained stable throughout the procedure in super-obese patients. Three patients (3.2%) had self-limited epistaxis. CONCLUSIONS Unsedated TNE for preoperative endoscopic evaluation of obese patients is feasible, safe, and well tolerated and should be preferentially considered when examining super-obese patients.
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Affiliation(s)
- Amaury Teixeira Xavier
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil. .,Instituto Alfa de Gatroenterologia, Universidade Federal de Minas Gerais - Medicine, Avenida Professor Alfredo Balena, 110, Santa Efigenia, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
| | - Arthur V Alvares
- Endoscopy Unit, Military Hospital of Minas Gerais, Belo Horizonte, Brazil
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA
| | - Vitor N Arantes
- Endoscopy Unit, Alfa Institute of Gastroenterology, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, Brazil
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19
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Abstract
Barrett esophagus is a metaplastic change in the lining of the distal esophageal epithelium, characterized by replacement of the normal squamous epithelium by specialized intestinal metaplasia. The presence of Barrett esophagus increases the risk of esophageal adenocarcinoma several-fold. Esophageal adenocarcinoma is a malignancy with rapidly rising incidence and persistently poor outcomes when diagnosed after the onset of symptoms. Risk factors for Barrett esophagus include chronic gastroesophageal reflux, central obesity, white race, male gender, older age, smoking, and a family history of Barrett esophagus or esophageal adenocarcinoma. Screening for Barrett esophagus in those with several risk factors followed by endoscopic surveillance to detect dysplasia or adenocarcinoma is currently recommended by society guidelines. Minimally invasive nonendoscopic tools for the early detection of Barrett esophagus are currently being developed. Multimodality endoscopic therapy-using a combination of endoscopic resection and ablation techniques-for the treatment of dysplasia and early adenocarcinoma is successful in eliminating intestinal metaplasia and preventing progression to adenocarcinoma, with outcomes comparable to those after esophagectomy. Risk stratification of those diagnosed with Barrett esophagus is a challenge at present, with active research focused on identifying clinical and biomarker panels to identify those with low and high risk of progression. This narrative review highlights some of the challenges and recent progress in this field.
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Affiliation(s)
- Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY.
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20
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Abstract
PURPOSE OF REVIEW There has been an exponential increase in the incidence of esophageal adenocarcinoma (EAC) over the last half century. Barrett's esophagus (BE) is the only known precursor lesion of EAC. Screening for BE in high-risk populations has been advocated with the aim of identifying BE, followed by endoscopic surveillance to detect dysplasia and early stage cancer, with the intent that treatment can improve outcomes. We aimed to review BE screening methodologies currently recommended and in development. RECENT FINDINGS Unsedated transnasal endoscopy allows for visualization of the distal esophagus, with potential for biopsy acquisition, and can be done in the office setting. Non-endoscopic screening methods being developed couple the use of swallowable esophageal cell sampling devices with BE specific biomarkers, as well as trefoil factor 3, methylated DNA markers, and microRNAs. This approach has promising accuracy. Circulating and exhaled volatile organic compounds and the foregut microbiome are also being explored as means of detecting EAC and BE in a non-invasive manner. Non-invasive diagnostic techniques have shown promise in the detection of BE and may be effective methods of screening high-risk patients.
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Affiliation(s)
- Don C Codipilly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
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21
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Wickremeratne T, Turner S, O'Beirne J. Systematic review with meta-analysis: ultra-thin gastroscopy compared to conventional gastroscopy for the diagnosis of oesophageal varices in people with cirrhosis. Aliment Pharmacol Ther 2019; 49:1464-1473. [PMID: 31059160 DOI: 10.1111/apt.15282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/06/2018] [Accepted: 04/08/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Tehara Wickremeratne
- Gastroenterology and Hepatology, Sunshine Coast University Hospital, Birtinya, Qld, Australia
| | - Stephanie Turner
- Gastroenterology and Hepatology, Sunshine Coast University Hospital, Birtinya, Qld, Australia
| | - James O'Beirne
- Gastroenterology and Hepatology, Sunshine Coast University Hospital, Birtinya, Qld, Australia.,Hepatology, University of the Sunshine Coast, Sippy downs, Qld, Australia
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22
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Peters Y, Al-Kaabi A, Shaheen NJ, Chak A, Blum A, Souza RF, Di Pietro M, Iyer PG, Pech O, Fitzgerald RC, Siersema PD. Barrett oesophagus. Nat Rev Dis Primers 2019; 5:35. [PMID: 31123267 DOI: 10.1038/s41572-019-0086-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Barrett oesophagus (BE), the only known histological precursor of oesophageal adenocarcinoma (EAC), is a condition in which the squamous epithelium of the oesophagus is replaced by columnar epithelium as an adaptive response to gastro-oesophageal reflux. EAC has one of the fastest rising incidences of cancers in Western countries and has a dismal prognosis. BE is usually detected during endoscopic examination, and diagnosis is confirmed by the histological presence of intestinal metaplasia. Advances in genomics and transcriptomics have improved our understanding of the pathogenesis and malignant progression of intestinal metaplasia. As the majority of EAC cases are diagnosed in individuals without a known history of BE, screening for BE could potentially decrease disease-related mortality. Owing to the pre-malignant nature of BE, endoscopic surveillance of patients with BE is imperative for early detection and treatment of dysplasia to prevent further progression to invasive EAC. Developments in endoscopic therapy have resulted in a major shift in the treatment of patients with BE who have dysplasia or early EAC, from surgical resection to endoscopic resection and ablation. In addition to symptom control by optimization of lifestyle and pharmacological therapy with proton pump inhibitors, chemopreventive strategies based on NSAIDs and statins are currently being investigated for BE management.
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Affiliation(s)
- Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ali Al-Kaabi
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, OH, USA
| | - Andrew Blum
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, OH, USA
| | - Rhonda F Souza
- Department of Medicine and the Center for Esophageal Diseases, Baylor University Medical Center at Dallas and the Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, TX, USA
| | | | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Oliver Pech
- Department of Gastroenterology, St John of God Hospital, Regensburg, Germany
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.
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Sami SS, Iyer PG, Pophali P, Halland M, di Pietro M, Ortiz-Fernandez-Sordo J, White JR, Johnson M, Guha IN, Fitzgerald RC, Ragunath K. Acceptability, Accuracy, and Safety of Disposable Transnasal Capsule Endoscopy for Barrett's Esophagus Screening. Clin Gastroenterol Hepatol 2019; 17:638-646.e1. [PMID: 30081223 PMCID: PMC6330075 DOI: 10.1016/j.cgh.2018.07.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/03/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Screening for Barrett's esophagus (BE) with conventional esophagogastroduodenoscopy (C-EGD) is expensive. We assessed the performance of a clinic-based, single use transnasal capsule endoscope (EG Scan II) for the detection of BE, compared to C-EGD as the reference standard. METHODS We performed a prospective multicenter cohort study of patients with and without BE recruited from 3 referral centers (1 in the United States and 2 in the United Kingdom). Of 200 consenting participants, 178 (89%) completed both procedures (11% failed EG Scan due to the inability to intubate the nasopharynx). The mean age of participants was 57.9 years and 67% were male. The prevalence of BE was 53%. All subjects underwent the 2 procedures on the same day, performed by blinded endoscopists. Patients completed preference and validated tolerability (10-point visual analogue scale [VAS]) questionnaires within 14 days of the procedures. RESULTS A higher proportion of patients preferred the EG Scan (54.2%) vs the C-EGD (16.7%) (P < .001) and the EG Scan had a higher VAS score (7.2) vs the C-EGD (6.4) (P = .0004). No serious adverse events occurred. The EG Scan identified any length BE with a sensitivity value of 0.90 (95% CI, 0.83-0.96) and a specificity value of 0.91 (95% CI, 0.82-0.96). The EG Scan identified long segment BE with a sensitivity value of 0.95 and short segment BE with a sensitivity values of 0.87. CONCLUSIONS In a prospective study, we found the EG Scan to be safe and to detect BE with higher than 90% sensitivity and specificity. A higher proportion of patients preferred the EG Scan to C-EGD. This device might be used as a clinic-based tool to screen populations at risk for BE. ISRCTN registry identifier: 70595405; ClinicalTrials.gov no: NCT02066233.
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Affiliation(s)
- Sarmed S. Sami
- Barrett’s Esophagus Unit, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G. Iyer
- Barrett’s Esophagus Unit, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prachi Pophali
- Barrett’s Esophagus Unit, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Magnus Halland
- Barrett’s Esophagus Unit, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Massimiliano di Pietro
- Cambridge University Hospitals NHS Trust and MRC Cancer Unit, Hutchinson/MRC Research Center, University of Cambridge, Cambridge, UK
| | - Jacobo Ortiz-Fernandez-Sordo
- National Institute for Health Research (NIHR) Biomedical Research Center in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Center Campus, Nottingham, UK
| | - Jonathan R. White
- National Institute for Health Research (NIHR) Biomedical Research Center in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Center Campus, Nottingham, UK
| | - Michele Johnson
- Barrett’s Esophagus Unit, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Indra Neil Guha
- National Institute for Health Research (NIHR) Biomedical Research Center in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Center Campus, Nottingham, UK
| | - Rebecca C. Fitzgerald
- Cambridge University Hospitals NHS Trust and MRC Cancer Unit, Hutchinson/MRC Research Center, University of Cambridge, Cambridge, UK
| | - Krish Ragunath
- National Institute for Health Research Biomedical Research Center in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Center Campus, Nottingham, United Kingdom.
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24
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Iyer PG, Taylor WR, Johnson ML, Lansing RL, Maixner KA, Yab TC, Simonson JA, Devens ME, Slettedahl SW, Mahoney DW, Berger CK, Foote PH, Smyrk TC, Wang KK, Wolfsen HC, Ahlquist DA. Highly Discriminant Methylated DNA Markers for the Non-endoscopic Detection of Barrett's Esophagus. Am J Gastroenterol 2018; 113:1156-1166. [PMID: 29891853 DOI: 10.1038/s41395-018-0107-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Minimally invasive methods have been described to detect Barrett's esophagus (BE), but are limited by subjectivity and suboptimal accuracy. We identified methylated DNA markers (MDMs) for BE in tissue and assessed their accuracy on whole esophagus brushings and capsule sponge samples. METHODS Step 1: Unbiased whole methylome sequencing was performed on DNA from BE and normal squamous esophagus (SE) tissue. Discriminant MDM candidates were validated on an independent patient cohort (62 BE cases, 30 controls) by quantitative methylation specific PCR (qMSP). Step 2: Selected MDMs were further evaluated on whole esophageal brushings (49 BE cases, 36 controls). 35 previously sequenced esophageal adenocarcinoma (EAC) MDMs were also evaluated. Step 3: 20 BE cases and 20 controls were randomized to swallow capsules sponges (25 mm, 10 pores or 20 pores per inch (ppi)) followed endoscopy. DNA yield, tolerability, and mucosal injury were compared. Best MDM assays were performed on this cohort. RESULTS Step 1: 19 MDMs with areas under the ROC curve (AUCs) >0.85 were carried forward. Step 2: On whole esophageal brushings, 80% of individual MDM candidates showed high accuracy for BE (AUCs 0.84-0.94). Step 3: The capsule sponge was swallowed and withdrawn in 98% of subjects. Tolerability was superior with the 10 ppi sponge with minimal mucosal injury and abundant DNA yield. A 2-marker panel (VAV3 + ZNF682) yielded excellent BE discrimination (AUC = 1). CONCLUSIONS Identified MDMs discriminate BE with high accuracy. BE detection appears safe and feasible with a capsule sponge. Corroboration in larger studies is warranted. ClinicalTrials.gov number NCT02560623.
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Affiliation(s)
- Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - William R Taylor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Michele L Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Ramona L Lansing
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Kristyn A Maixner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Tracy C Yab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Julie A Simonson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Mary E Devens
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Seth W Slettedahl
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Douglas W Mahoney
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Calise K Berger
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Patrick H Foote
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Thomas C Smyrk
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - David A Ahlquist
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA. Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA. Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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25
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Abstract
New improved methods are required for the early detection of esophageal adenocarcinoma in order to reduce mortality from this aggressive cancer. In this review we discuss different screening methods which are currently under evaluation ranging from image-based methods to cell collection devices coupled with biomarkers. As Barrett's esophagus is a low prevalence disease, potential screening tests must be applied to an enriched population to reduce the false-positive rate and improve the cost-effectiveness of the program.
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Affiliation(s)
- Maria O'Donovan
- MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Hills Road, Cambridge, CB2 0XZ, UK
- Department of Histopathology, Addenbrooke's Hospital, Cambridge, UK
| | - Rebecca C Fitzgerald
- MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Hills Road, Cambridge, CB2 0XZ, UK.
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26
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Spechler SJ, Katzka DA, Fitzgerald RC. New Screening Techniques in Barrett's Esophagus: Great Ideas or Great Practice? Gastroenterology 2018; 154:1594-1601. [PMID: 29577931 DOI: 10.1053/j.gastro.2018.03.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Stuart J Spechler
- Divisions of Gastroenterology and Hepatology, Baylor University Medical Center at Dallas, Dallas, Texas
| | | | - Rebecca C Fitzgerald
- MRC Cancer Unit, Hutchinson/MRC Research Centre, University of Cambridge, Cambridge, UK
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27
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Abstract
OPINION STATEMENT PURPOSE OF REVIEW: There is a pressing need for effective strategies to halt the increase in both the incidence and mortality of esophageal adenocarcinoma (EAC). Screening for Barrett's esophagus, which is the only known precursor of EAC, remains a ripe area for research, particularly with regard to identifying the target population, screening tools, and management of screen-detected populations. This review aims to explore in depth the rationale for screening for Barrett's esophagus, recent biotechnological advances which may have the potential of making screening feasible, and also highlight the challenges which will have to be overcome in order make screening for BE a realistic prospect. RECENT FINDINGS Imaging techniques such as portable transnasal endoscopy have the advantage of providing an immediate diagnosis of Barrett's esophagus as well as other significant pathologies such as reflux esophagitis and cancer; however, larger studies in non-enriched community screening populations are required to evaluate their feasibility. The capsule sponge is a cell-sampling device coupled with a biomarker, which has been most extensively evaluated with very promising results as regards feasibility, acceptability, accuracy, and cost-effectiveness. Its effectiveness in increasing the detection of Barrett's esophagus in primary care is currently being evaluated. Several Barrett's esophagus risk prediction scores have been developed with variable degrees of accuracy. Several minimally and non-invasive screening techniques have been studied including imaging and cell-sampling devices. Barrett's risk assessment models need to be further validated in independent, relevant screening populations with clear cut-offs for recommending screening to be defined.
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Affiliation(s)
- Sarmed S Sami
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Prasad G Iyer
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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28
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Comparative Assessment of Patient Preferences and Tolerability in Barrett Esophagus Screening: Results From a Randomized Trial. J Clin Gastroenterol 2018; 52:880-884. [PMID: 29369237 PMCID: PMC6056346 DOI: 10.1097/mcg.0000000000000991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
GOALS To determine patient preference for the Barrett esophagus (BE) screening techniques. BACKGROUND Sedated esophagogastroduodenoscopy (sEGD) and unsedated transnasal endoscopy (uTNE) are both potential techniques for BE screening. However, systematic assessment of patient preference for these 2 techniques is lacking. As part of a comparative effectiveness randomized trial of BE screening modalities, we measured short-term patient preferences for the following approaches: in-clinic uTNE (huTNE), mobile-based uTNE (muTNE), and sEGD using a novel assessment instrument. STUDY Consenting community patients without known BE were randomly assigned to receive huTNE, muTNE, or sEGD, followed by a telephone administered preference and tolerability assessment instrument 24 hours after study procedures. Patient preference was measured by the waiting trade-off method. RESULTS In total, 201 patients completed screening with huTNE (n=71), muTNE (n=71), or sEGD (n=59), and a telephone interview. Patients' preferences for sEGD and uTNE using the waiting trade-off method were comparable (P=0.51). Although tolerability scores were superior for sEGD (P<0.001) compared with uTNE, scores for uTNE examinations were acceptable. CONCLUSIONS Patient preference is comparable between sEGD and uTNE for diagnostic examinations conducted in an endoscopy suite or in a mobile setting. Given acceptable tolerability, uTNE may be a viable alternative to sEGD for BE screening.
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29
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Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017; 15:456-466. [PMID: 29142513 PMCID: PMC5683976 DOI: 10.5217/ir.2017.15.4.456] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.
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Affiliation(s)
- Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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30
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Abstract
Barrett's esophagus (BE) predisposes patients to esophageal adenocarcinoma. 3 to 6% of individuals with gastro-esophageal reflux disease are estimated to have BE but only 20 to 25% of BE patients are currently diagnosed. The current gold standard for diagnosis of BE is per-oral upper GI endoscopy. As this is not suitable for large-scale screening, a number of alternative methods are currently being investigated: transnasal and video capsule endoscopy, endomicroscopy, cell collection devices like the cytosponge and biomarkers. Some of these are promising, however, well powered studies carried out in relevant screening populations are needed.
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Affiliation(s)
- Judith Offman
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK.
| | - Rebecca C Fitzgerald
- MRC Cancer Unit, Hutchinson/MRC Research Centre, University of Cambridge, Box 197, Cambridge Biomedical Campus, Cambridge CB2 0XZ, UK
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31
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Blevins CH, Iyer PG. Who Deserves Endoscopic Screening for Esophageal Neoplasia? Gastrointest Endosc Clin N Am 2017; 27:365-378. [PMID: 28577762 DOI: 10.1016/j.giec.2017.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite the availability of safe and effective endoscopic treatment of Barrett's esophagus (BE)-related dysplasia and neoplasia, the incidence and mortality from esophageal adenocarcinoma (EAC) have continued to increase. This likely stems from the large population of patients that develop EAC outside of a BE screening and surveillance program. Identification of BE with screening followed by enrollment in an appropriate surveillance/risk stratification program could be a strategy to address both the incidence of and mortality from EAC. This article summarizes the rationale and challenges for BE screening, the risk factors for BE, and the currently described BE risk assessment tools.
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Affiliation(s)
- Christopher H Blevins
- Division of Gastroenterology and Hepatology, Mayo Clinic Minnesota, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic Minnesota, 200 First Street Southwest, Rochester, MN 55905, USA.
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32
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Crews NR, Gorospe EC, Johnson ML, Wong Kee Song LM, Katzka DA, Iyer PG. Comparative quality assessment of esophageal examination with transnasal and sedated endoscopy. Endosc Int Open 2017; 5:E340-E344. [PMID: 28484734 PMCID: PMC5419847 DOI: 10.1055/s-0042-122008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Unsedated transnasal esophagoscopy (TNE) may offer a less expensive, mobile alternative to sedated esophagogastroduodenoscopy (EGD) for evaluations of reflux related complications. Comparisons of imaging quality by these methods are lacking. Methods Two reviewers evaluated videos of TNE and EGD procedures, performed during a community randomized study comparing endoscopic techniques. Subjects were randomized to EGD, TNE in endoscopy suite, or TNE in mobile research unit. Endoscopic quality was assessed using a validated scoring tool. Results In total, 115 videos (58 EGD, 28 endoscopy suite TNE, and 29 mobile TNE) were reviewed. Overall quality scores for TNE and EGD were excellent without a statistically significant difference (P = 0.30). There were no differences in gastroesophageal junction (GEJ) visualization scores, though EGD scored higher in esophageal passage (P < 0.05) and TNE scored higher in esophageal intubation (P < 0.05). There was no significant difference in any quality score between mobile TNE and gastrointestinal suite TNE. Conclusion Esophageal assessment with TNE or EGD was comparable in overall quality and GEJ visualization. TNE quality was not affected by procedure location. TNE is a feasible option for endoscopic assessment of reflux complications.
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Affiliation(s)
| | - Emmanuel C. Gorospe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michele L. Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - David A. Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,Corresponding author Prasad G. Iyer, MD MS Barrett’s Esophagus UnitDivision of Gastroenterology & HepatologyMayo Clinic200 1st St SWRochesterMNUSA+1-507-255-7652
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33
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Ciocîrlan M. Endoscopic screening for Barrett's esophagus: while we're in, do we also need to see the stomach and the duodenum? Endosc Int Open 2017; 5:E345-E347. [PMID: 28484735 PMCID: PMC5419846 DOI: 10.1055/s-0043-102937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Mihai Ciocîrlan
- Carol Davila University of Medicine and Pharmacy, Fundeni Gastroenterology and Hepatology Center, Bucharest, Romania,Corresponding author Mihai Ciocîrlan Carol Davila" University of Medicine and PharmacyFundeni Gastroenterology and Hepatology Center258 Fundeni StreetBucharest, RO 022328
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34
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Sami SS, Ragunath K, Wilkes EA, James M, Mansilla-Vivar R, Ortiz-Fernández-Sordo J, White J, Khanna A, Coletta M, Samuel S, Aithal GP, Guha IN. The detection of oesophageal varices using a novel, disposable, probe-based transnasal endoscope: a prospective diagnostic pilot study. Liver Int 2016; 36:1639-1648. [PMID: 27125510 DOI: 10.1111/liv.13152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/17/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Screening for oesophageal varices (OV) using conventional oesophagogastroduodenoscopy (C-OGD) is invasive and requires costly monitoring, recovery, and decontamination facilities. We aimed to evaluate the technical feasibility, acceptability and accuracy of a novel, portable and disposable office-based transnasal endoscope (EG Scan™ ) compared to C-OGD as the reference standard. METHODS This was a prospective cohort study. Consecutive adult patients with cirrhosis were invited to participate. All subjects underwent the two procedures on the same day performed by two endoscopists in a blinded design. Patients completed preference and validated tolerability (10-point visual analogue scale (VAS)) questionnaires on day 0 and day 14 post procedures. RESULTS Forty-five of 50 patients (90%) completed both interventions. Mean age was 59 years and OV prevalence was 49%. Patients reported higher preference (percentage) and better experience (mean VAS) with EG Scan compared to C-OGD on day 0 (76.5% vs. 23.5%, P < 0.001; 7.8 vs. 6.8, P = 0.058, respectively) and day 14 (77.8% vs. 22.2%, P < 0.001; 7.0 vs. 5.5, P = 0.0013 respectively). Sensitivity and specificity of the EG Scan for the diagnosis of any size OV were 0.82 (95% confidence interval (CI) 0.60-0.95), and 0.78 (95% CI 0.56-0.93) respectively. Corresponding values for the diagnosis of clinically significant (medium/large) OV were 0.92 (95% CI 0.62-1.0), 0.97 (95% CI 0.84-1.0) respectively. No serious adverse events occurred. CONCLUSIONS EG Scan accuracy was higher for the diagnosis of medium/large OV compared to any size OV. Patients' preference and overall experience of the EG Scan was favourable compared to C-OGD 14 days after procedures.
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Affiliation(s)
- Sarmed S Sami
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Emilie A Wilkes
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Martin James
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Rodrigo Mansilla-Vivar
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Jacobo Ortiz-Fernández-Sordo
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Jonathan White
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Amardeep Khanna
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Marina Coletta
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Sunil Samuel
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Indra Neil Guha
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.
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35
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Chou CK, Lee YC. Transnasal endoscopic gastrostomy for patients whose condition limits standard oral endoscopic intubation. ADVANCES IN DIGESTIVE MEDICINE 2016. [DOI: 10.1016/j.aidm.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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36
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Abstract
OPINION STATEMENT Sedation practices in the endoscopy suite have changed dramatically in the decades since the introduction of routine colonoscopy and esophagogastroduodenoscopy (EGD). Patients initially received moderate sedation (or even no sedation), but now frequently receive monitored anesthesia care (MAC). This significant shift has introduced anesthesiologists to the endoscopy suite along with new sedative medications and safety concerns. Appreciating the ramifications of this change requires an understanding of sedation depth, patient selection, drug use, sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. Furthermore, the changing landscape of healthcare quality and reimbursement challenges us to provide the best possible care for our patients in the most economical way possible. The endoscopy suite is a unique sedation environment, and it is the purpose of this article to review those elements that contribute to a uniquely demanding work environment.
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37
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Tanuma T, Morita Y, Doyama H. Current status of transnasal endoscopy worldwide using ultrathin videoscope for upper gastrointestinal tract. Dig Endosc 2016; 28 Suppl 1:25-31. [PMID: 26792612 DOI: 10.1111/den.12612] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/13/2016] [Accepted: 01/18/2016] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Tokuma Tanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Yoshinori Morita
- Department of Gastroenterology, Kobe University School of Medicine, Kobe, Japan
| | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
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38
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Iyer PG, Chak A. Can endosheath technology open primary care doors to Barrett's esophagus screening by transnasal endoscopy? Endoscopy 2016; 48:105-6. [PMID: 26820077 PMCID: PMC5575807 DOI: 10.1055/s-0034-1393561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Amitabh Chak
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio, United States
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