Transnasal endoscopy: Technical considerations, advantages and limitations

Endoscopic Management of Eosinophilic Esophagitis: A Narrative Review on Diagnosis and Treatment

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by esophageal eosinophilic infiltration, leading to symptoms such as dysphagia and food impaction. Endoscopy is central to both diagnosis and management, allowing for the direct visualization of characteristic features, biopsy collection, and therapeutic interventions. Despite its diagnostic value, up to one-third of patients may present with a normal-appearing esophagus, highlighting the importance of standardized scoring systems and a systematic biopsy approach. This review explores the evolving role of endoscopy in EoE, from traditional diagnostic methods to emerging technologies such as EndoFlip™ for assessing esophageal distensibility, transnasal endoscopy for non-sedated monitoring, and novel dilation techniques for fibrostenotic disease. Additionally, non-invasive biomarkers and minimally invasive tools are reshaping disease monitoring. By integrating endoscopic, histologic, and molecular approaches, future advancements may enhance diagnostic accuracy and optimize personalized treatment strategies for EoE.

Pediatric unsedated transnasal endoscopy: applications, equipment, and future directions

Gastrointestinal (GI) endoscopy is a valuable tool to diagnose and treat GI conditions. Traditional pediatric GI endoscopy uses sedation or general anesthesia, with associated risks of cardiopulmonary compromise and social and economic costs like school or work absence. Unsedated, transnasal endoscopy is an approach that mitigates these disadvantages but provides similar diagnostic benefit to conventional endoscopy. Ongoing advances in the field of pediatric transnasal endoscopy will be driven by an enhanced understanding of current indications, available equipment, procedural comfort strategies, and recent developments in new diagnostic and therapeutic uses.

Transforming transnasal endoscopy services: A multicentre service evaluation pilot project

OBJECTIVES

To assess the impact of pilot transnasal endoscopy (TNE) services on workforce efficiency, allocated procedure times and patient tolerance of procedures. The aim was to also understand the challenges of setting up a TNE service.

METHODS

Six-month data were collected from ten sites. Data captured included productivity, performance, workforce numbers, facilities and quality metrics. A patient survey was done to capture patients' experience. An eight Likert-style and open question survey was designed and used. Pilot sites were visited using a semi-structured interview process.

RESULTS

About 30% of the pilot sites carried out the TNE service outside of the endoscopy unit. There is an overall 25% improvement in workforce efficiency with TNE. Of those patients who had both a TNE and an oesophagogastroduodenoscopy, 78% reported that having the TNE procedure was a better experience. All sites reported that they will continue providing TNE beyond the pilot period. Sites carrying out TNE reported a high satisfaction with the services. Overall satisfaction with the quality of TNE imaging was very high.

CONCLUSIONS

This multicentre pilot project shows evidence that the integration of TNE services has a positive impact in increasing capacity and patient satisfaction. This should set the scene for scaling this up on a wider capacity. TNE services, particularly with an introduction into outpatients, will improve service capacity in endoscopy, patients will tolerate the procedures more, national 2-week wait and Faster Diagnosis Standard targets will improve, and it is potentially more cost efficient overall.

Impact of introducing transnasal endoscopy on expanding diagnostic endoscopy services

INTRODUCTION

Demand for endoscopic services is outstripping capacity in the UK. Transnasal endoscopy (TNE) utilises a narrow calibre endoscope to pass through the nasal passages, thereby reducing retching and discomfort. It is better tolerated compared with standard transoral endoscopy (TOE) but is still rarely used as a diagnostic modality. There is still uncertainty about how well it performs against TOE in diagnostic ability, cost and efficiency.

METHODS

We explored utilising TNE to deal with the growing demand for endoscopy. We compared findings to TOE procedures undertaken during the same time period. We evaluated cost differences, duration/time in the department for procedures as well as quality of procedures (both in terms of performance indicators as well as image quality using the validated POLPREP score).

RESULTS

A total of 241 upper gastrointestinal endoscopy procedures were evaluated (100 TNE and 141 matched TOE) between December 2021 and February 2022. TNE outperformed TOE in obtaining >95% success rate in nationally approved key performance indicators (retroflexion and duodenal intubation, both p=0.026). It also was associated with better image quality in the oesophagus with a POLPREP A3 Score (excellent image quality) in 36/98 available images compared with 26/136 TOE (p=0.028) and was equivalent to TOE in the stomach and duodenum. TNE was identified as having a key role in facilitating complex cases, previously failed via the TOE route with a success rate in 11/12 (91.7%) of such cases. TNE also shows promise in correcting misdiagnoses of short-segment Barrett's oesophagus (39%) compared with TOE (14.8%) (p=0.087).

CONCLUSION

TNE is an emerging endoscopic modality, which shows great promise in replacing TOE in most diagnostic circumstances. In a modern healthcare service, TNE is cheaper, better tolerated and outperforms TOE in multiple domains.

A multifaceted comparative analysis of image and video technologies in gastrointestinal endoscope and their clinical applications

This paper presents a comprehensive exploration of endoscopic technologies in clinical applications across seven tables, each focusing on a unique facet of the medical field. The discourse begins with a detailed analysis of pediatric endoscopes, highlighting their diagnostic capabilities in various conditions. It then delves into the specifications and applications of globally recognized capsule endoscopy devices. Additionally, the paper incorporates an analysis of advanced imaging techniques, such as Narrow Band Imaging (NBI), Flexible Spectral Imaging Color Enhancement (FICE), and i-scan, which are increasingly being integrated into ultrathin gastrointestinal (GI) endoscopes. Factors like technological capabilities, light source, camera technology, and computational constraints are evaluated to understand their compatibility with these advanced imaging techniques, each offering unique advantages and challenges in clinical settings. NBI, for instance, is lauded for its user-friendly, real-time enhanced imaging capabilities, making it effective for early detection of conditions like colorectal cancer and Barrett's esophagus. Conversely, FICE and i-scan offer high customizability and are compatible with a broader range of endoscope models. The paper further delves into innovative advances in movement control for Nasojejunal (NJ) feeding tube endoscopy, elucidating the potential of AI and other novel strategies. A review of the technologies and methodologies enhancing endoscopic procedure control and diagnostic precision follows, emphasizing image and video technologies in pediatric endoscopy, capsule endoscopes, ultrathin endoscopes, and their clinical applications. Finally, a comparative analysis of leading real-time video monitoring endoscopes in clinical practices underscores the continuous advancements in the field of endoscopy, ensuring improved diagnostics and precision in surgical procedures. Collectively, the comparative analysis presented in this paper highlights the remarkable diversity and continuous evolution of endoscopic technologies, underlining their crucial role in diagnosing and treating an array of medical conditions, thereby fostering advancements in patient care and clinical outcomes.

Use of audiovisual devices in transnasal endoscopy without sedation to improve tolerance. A prospective clinical trial

INTRODUCTION AND AIM

Transnasal endoscopy (TNE) has proven its diagnostic utility, but it has not been widely accepted given that it is performed without sedation. There are no previous studies on the use of methods to improve its tolerability. Our aim was to evaluate the tolerability of TNE, when simultaneously performed with an audiovisual device as a distractor.

METHODS

We evaluated 50 patients, 10 of whom did not agree to participate. The performance of the procedure was explained, using an audiovisual device. Before randomization, we applied anxiety and depression scores. Patients were divided into 2 groups: Group I (using an audiovisual device during the procedure) and Group II (without a device). Anxiety and numeric pain rating scales were used, and vital signs were monitored and recorded before, during, and after the endoscopy. An overall procedure satisfaction score was applied at the end of the study and 24 h later.

RESULTS

Mean age was 41.6 years and 35 of the patients were women (87.5%). The most frequent indication for TNE was refractory gastroesophageal reflux disease. There were no severe comorbidities, and none of the patients had a significant anxiety or depression score. One patient in Group II did not tolerate TNE due to nasal pain. There was no statistically significant difference between groups, regarding anxiety, pain, vital signs, and satisfaction scale.

CONCLUSION

Our study showed that TNE was well tolerated and had a high acceptance rate in our patients. The use of distracting audiovisual devices did not increase tolerance to the endoscopic procedure.

Pediatric Unsedated Transnasal Endoscopy

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.

Nasal breathing is superior to oral breathing when performing and undergoing transnasal endoscopy: a randomized trial

BACKGROUND : Transnasal endoscopy presents a technical difficulty when inserting the flexible endoscope. It is unclear whether a particular breathing method is useful for transnasal endoscopy. Therefore, we conducted a prospective randomized controlled trial to compare endoscopic operability and patient tolerance between patients assigned to nasal breathing or oral breathing groups. METHODS : 198 eligible patients were randomly assigned to undergo transnasal endoscopy with nasal breathing or with oral breathing. Endoscopists and patients answered questionnaires on the endoscopic operability and patient tolerance using a 100-mm visual analog scale ranging from 0 (non-existent) to 100 (most difficult/unbearable). The visibility of the upper-middle pharynx was recorded. RESULTS : Patient characteristics did not differ significantly between the groups. Nasal breathing showed a higher rate of good visibility of the upper-middle pharynx than oral breathing (91.9 % vs. 27.6 %; P < 0.001). Nasal breathing showed lower mean [SD] scores than oral breathing in terms of overall technical difficulty (21.0 [11.4] vs. 35.4 [15.0]; P < 0.001). Regarding patient tolerance, nasal breathing showed lower scores than oral breathing for overall discomfort (22.1 [18.8] vs. 30.5 [20.9]; P = 0.004) and other symptoms, including nasal and throat pain, choking, suffocating, gagging, belching, and bloating (all P < 0.05). The pharyngeal bleeding rate was lower in the nasal breathing group than in the oral breathing group (0 % vs. 9.2 %; P = 0.002). CONCLUSIONS : Nasal breathing is superior to oral breathing for those performing and undergoing transnasal endoscopy. Nasal breathing led to good visibility of the upper-middle pharynx, improved endoscopic operability, and better patient tolerance, and was safer owing to decreased pharyngeal bleeding.

Surgical Field Quality in Trans-Nasal Endoscopic Surgeries Using Lignocaine Infusion and Dexmedetomidine Infusion. A Prospective Randomized Control Study

Trans-nasal endoscopic surgery (TNES) is a helpful diagnostic and therapeutic modality in otorhinolaryngology surgeries and requires controlled hypotension for better visualization of the surgical field. Recent literature shows evidence of intravenous Lignocaine infusion to produce the controlled hypotension. The study aims to assess and compare the effects of Lignocaine (LIG) and Dexmedetomidine (DEX) infusion with respect to surgical field quality. 101 Consenting adult patients undergoing elective TNES were double-blinded, randomly allocated in one of the two groups and received either DEX infusion of 0.5ug/kg/hr (n = 51) or LIG infusion of 1.5 mg/kg/h (n = 50) after a loading dose. Surgical field score (SVF) as the primary outcome and secondary outcomes such as variations in hemodynamic parameters, the requirement for rescue agents and total blood loss were recorded. Both the groups were comparable with respect to patient demographics, total duration of anesthesia and surgery. SVF scores were significantly better in the LIG group during the first 105 min of the surgery (p < 0.05). In response to intubation, hemodynamic parameters were lower in LIG group. The requirement of other adjuvant drugs, total blood loss (166.40 ml vs. 251.17 ml) and extubation time were also significantly lower in the LIG group. The study concludes that intravenous Lignocaine gives a better surgical field in the first 105 min of surgery, comparable hemodynamics and decreased blood loss in patients undergoing TNES as compared to Dexmedetomidine infusion. Hence its role as an agent for controlled hypotension during TNES surgery is promising.

Application of Convolutional Neural Networks for Diagnosis of Eosinophilic Esophagitis Based on Endoscopic Imaging

Subjective symptoms associated with eosinophilic esophagitis (EoE), such as dysphagia, are not specific, thus the endoscopic identification of suggestive EoE findings is quite important for facilitating endoscopic biopsy sampling. However, poor inter-observer agreement among endoscopists regarding diagnosis has become a complicated issue, especially with inexperienced practitioners. Therefore, we constructed a computer-assisted diagnosis (CAD) system using a convolutional neural network (CNN) and evaluated its performance as a diagnostic utility. A CNN-based CAD system was developed based on ResNet50 architecture. The CNN was trained using a total of 1192 characteristic endoscopic images of 108 patients histologically proven to be in an active phase of EoE (≥15 eosinophils per high power field) as well as 1192 normal esophagus images. To evaluate diagnostic accuracy, an independent test set of 756 endoscopic images from 35 patients with EoE and 96 subjects with a normal esophagus was examined with the constructed CNN. The CNN correctly diagnosed EoE in 94.7% using a diagnosis per image analysis, with an overall sensitivity of 90.8% and specificity of 96.6%. For each case, the CNN correctly diagnosed 37 of 39 EoE cases with overall sensitivity and specificity of 94.9% and 99.0%, respectively. These findings indicate the usefulness of CNN for diagnosing EoE, especially for aiding inexperienced endoscopists during medical check-up screening.

Unsedated Transnasal Endoscopy: A Safe, Well-Tolerated and Accurate Alternative to Standard Diagnostic Peroral Endoscopy

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.

Diagnostic Accuracy Outcomes of Office-Based (Outpatient) Biopsies in patients with Laryngopharyngeal Lesions: A Systematic Review

Background

In‐office biopsies (IOB) using local anaesthetic for laryngopharyngeal tumours has become an increasingly popular approach since the advent of distal chip endoscopes. Although a wide range of studies advocate use in clinical practice, the widespread application of the procedure is hampered by concerns regarding diagnostic accuracy.

Objective

To assess the diagnostic accuracy of IOB performed via flexible endoscopy. In addition, to analyse modifiable factors that may affect diagnostic accuracy of IOB.

Design

A systematic review following the PRISMA guidelines was conducted. PubMed, EMBASE, the Cochrane Library, Web of Science and CINAHL were used in the literature database search. Quality assessment of included studies was perfomed using the Newcastle‐Ottawa Scale.

Results

A total of 875 studies were identified, 16 of which were included into the systematic review; 1572 successful biopsies were performed using flexible endoscopy; 1283 cases were accurately diagnosed in the outpatient setting (81.6%) and 289 samples did not provide an accurate diagnosis (18.4%). The median sensitivity of IOB was 73%, and the specificity was 96.7%. Analysis of variable factors did not show any significant differences in method of approach, size of equipment (forceps) and additional lighting system or learning curve.

Conclusion

IOB are a viable tool for diagnostic workup of laryngopharyngeal tumours. Clinicians should be wary of reported limitations of IOB when benign or pre‐malignant diagnoses are made. In cases suspicious of malignancy, confirmatory investigation should be conducted.

A Preclinical Feasibility Study of Endoscopic Barostat: A Possible Diagnostic Tool for Visceral Hypersensitivity in Functional Dyspepsia

INTRODUCTION

Diagnosing functional dyspepsia requires excluding organic disease and gastrointestinal function evaluation; however, there are no modalities to evaluate these simultaneously. This preclinical study examined the possibility of an endoscopic barostat.

METHODS

Ultrathin endoscopy and our newly developed pressure-regulated endoscopic insufflator, which insufflates the gastrointestinal tract until the preset pressure is achieved, were used. The actual intragastric pressure was measured using an optical fiber manometer placed in the stomach. Experiment-1: in an ex vivo experiment, we insufflated the isolated stomach and verified whether the intragastric pressure reached the preset pressure. Experiment-2: we inserted the endoscope orally in a porcine stomach, insufflated the stomach, and verified whether the intragastric pressure reached the preset pressure. Finally, we insufflated the stomach at a random pressure to verify the functional tests for proof-of-concept.

RESULTS

Experiment-1: the intragastric pressure reached the preset pressure. After reaching the plateau, the pressure remained stable at the preset pressure (Huber M value: 1.015, regression line: 0.988, 95% confidence interval [CI]: 0.994-0.994). Experiment-2: the intragastric pressure reached the preset pressure. After reaching the plateau, the pressure remained stable at the preset pressure (Huber M value: 1.018, regression line: 0.971, 95% CI: 0.985-0.986). At randomly preset pressures, the transendoscopic theoretical intragastric pressure detected by using the insufflator was correlated with the actual pressure measured by using the pressure manometer.

CONCLUSIONS

This proof-of-concept study shows that a pressure-regulated endoscopic insufflator provides stable intragastric pressure at the preset level, with the potential of an endoscopic barostat to assess the visceral hypersensitivity related to functional dyspepsia.

Diagnostic Ability of High-definition Imaging Using Ultraslim Endoscopes in Early Gastric Cancer

PURPOSE

It is unclear whether high-definition (HD) imaging improves visibility and diagnostic ability in early gastric cancer (EGC) compared with standard-definition (SD) imaging. We aimed to compare the diagnostic performance and visibility scores of HD and SD ultraslim endoscopes in EGC.

MATERIALS AND METHODS

We used HD and SD ultraslim endoscopes to obtain 60 images with similar compositions of gastric environments. Of the 60 images, 30 showed EGC (15 images for each modality) and 30 showed no EGC (15 images for each modality). Seventeen endoscopists evaluated the presence and location of the lesions in each image. Diagnostic ability was compared between modalities. The color difference between a lesion and the surrounding mucosa (ΔE) was measured and compared between the modalities.

RESULTS

The ability of HD to detect EGC was significantly higher than that of SD (accuracy: 80.8% vs. 71.6%, P=0.017; sensitivity: 94.9% vs. 76.5%, P<0.001; positive predictive value, 76.2% vs. 55.3%, P<0.001; and negative predictive value (NPV), 94.1% vs. 73.5%, P<0.001). The ability of HD to determine the horizontal extent of EGC was significantly higher than that of SD (accuracy: 71.0% vs. 57.8%, P=0.004; sensitivity: 75.3% vs. 49.0%, P<0.001; NPV, 72.9% vs. 55.9%, P<0.001; and area under the curve: 0.891 vs. 0.631, P=0.038). The mean ΔE was significantly higher for HD than for SD (10.3 vs. 5.9, P=0.011).

CONCLUSIONS

The HD ultraslim endoscope showed a higher diagnostic performance in EGC than the SD endoscope because it provided good color contrast.

Development of the outer tube through transnasal endoscopy to reduce nasal pain and epistaxis

BackgroundRecently, transnasal endoscopy has become common in Japan. While transnasal endoscopy has many advantages, nasal pain and epistaxis are typical complaints. Consequently, we developed a new tube sheath system for transnasal endoscopy to reduce nasal pain and epistaxis. This new tube sheath system (outer sheath and inner tube) has been named Nasal Slider® and is produced by TOP Corporation, Japan.MethodsA tube sheath longer than the nasal concha is inserted to reduce pain along the nasal turbinate. Since the sheath is left in place, tubes can be passed through the nose multiple times without causing additional pain.A total of 34 consecutive patients (mean age 68.1 years, 22 males and 12 females) who had experienced transnasal endoscopy in the past, would undergo transnasal endoscopy with Nasal Slider® again. After the transnasal endoscopy was completed, patients who gave consent for use of the nasal slider® were interviewed using 3 questionnaires about nasal discomfort, nasal pain and epistaxis.ResultsSince the transnasal endoscope passes inside the sheath, epistaxis can be prevented. Thirty patients for whom trans nasal endoscopy using Nasal Slider® could be carried out. Twenty-seven and 28 patients of all patients used Nasal Slider® expressed feeling less nasal discomfort and pain compared to an examination without Nasal Slider®. No epistaxis was detected in all patients using Nasal Slider®.ConclusionsTo reduce nasal pain and epistaxis, Nasal Slider® for transnasal endoscopy was considerably available. It is currently in use at many hospitals in Japan.

Introduction of Transnasal Endoscopy to a Scottish District General Hospital

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.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Unsedated Transnasal Endoscopy for Preoperative Examination of Bariatric Patients: a Prospective Study

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.

Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis

Introduction

Numerous indications require regular upper gastrointestinal endoscopy (oesophagogastroduodenoscopy; EGD) in outpatients. In most cases, peroral gastroscopy is performed. The aim of this study was to evaluate the need of transnasal gastroscopy (nEGD) in outpatients.

Methods

A questionnaire was used to assess patients’ preferred choice of method, previous experience with EGD, psychological aspects and sociodemographic data. Furthermore, patient satisfaction with and potentially perceived discomfort during the examination as well as preference for a method in regard to future examinations was evaluated.

Results

From September 2016 to March 2017, a total of 283 outpatients at endoscopy of the University Hospital of Leipzig were approached to participate in the study. 196 patients were eligible, of whom 116 (60%) chose nEGD. For 87 patients (87/283, 31%) nEGD had to be excluded for medical reasons. The average age in the total sample was 53 (±17) years. 147 (77%) have had previous experience with peroral EGD (oEGD). Of the nEGD examined patients 83% were fairly up to extremely satisfied with the procedure. Satisfaction significantly predicted the choice of future EGD examinations. Nasal pain experienced during nEGDs was associated with rejection of nEGD in further EGD examinations (p<0.01). Patients who did choose a specific procedure were more likely to select the same procedure as their future preference (χ²= 73.6, df=1, p<0.001); this preference was unaffected by the procedure that had been chosen previously (reselecting nEGD: 84%, oEGD: 89%, p=0.874).

Conclusion

nEGD without sedation is a viable alternative. Patient satisfaction with nEGD is high, and reselection rate for nEGD is similar to that for oEGD. As a result of this study nEGD is now offered as a routine procedure at the University of Leipzig.

Trial registration number

NCT03663491.

Endosheath ultrathin transnasal endoscopy is a cost-effective method for screening for Barrett's esophagus in patients with GERD symptoms

BACKGROUND AND AIMS

Barrett's esophagus (BE) screening is currently not considered to be cost effective in the general population but may be effective in high-risk subgroups, such as 50-year-old white men with chronic reflux disease (GERD). A new modality for screening is unsedated transnasal endoscopy using endosheath technology (uTNE), which has been shown to be safe and effective in clinical practice. In this study, we determined the cost-utility of uTNE in a high-risk subgroup compared with no screening or screening with standard endoscopy.

METHODS

A Markov model was used to simulate screening of 50-year-old white men with symptoms of GERD with either uTNE or standard endoscopy compared with no screening, over a lifetime horizon. Input variables were based on the literature and recent data on uTNE screening for BE. The study was designed from a healthcare payer perspective by using direct costs. Primary outcome measures were costs, quality-adjusted life years (QALYs), and the incremental cost-utility ratio (ICUR) of uTNE and standard endoscopy compared with no screening. Sensitivity analysis was performed for several factors, such as prevalence of BE.

RESULTS

Costs of uTNE, standard endoscopy, and no screening were estimated at, $2495, $2957, and $1436, respectively. Compared with no screening, uTNE screening resulted in an overall QALY increase of 0.039 (95% percentile 0.018; 0.063) and an ICUR of $29,446 per QALY gained (95% confidence interval [CI], 18.516-53.091), whereas standard endoscopy compared with no screening resulted in a QALY increase of 0.034 (95% CI, 0.015-0.056) and an ICUR of $47,563 (95% CI, 31,036-82,970).

CONCLUSION

Both uTNE and standard endoscopy seem to be cost-effective screening methods in a screening cohort of 50-year-old white men with GERD at a willingness-to-pay cutoff of $50,000.

Endoscopic small-capacity forceps increase the pathological diagnosis of gastric indefinite neoplasia

BACKGROUND/AIMS

A definitive biopsy-based diagnosis of gastric cancer is sometimes difficult, and some cases are pathologically diagnosed as gastric indefinite neoplasia (GIN). The most appropriate forceps size for gastric biopsy has yet to be determined. In this study, we investigated the relation between the forceps size and the frequency of GIN diagnosis.

MATERIALS AND METHODS

The records of patients from two historical groups were reviewed. The first group comprised patients evaluated during the period when standard biopsy forceps (StF) were used (April 2010-March 2011), and the second group comprised patients evaluated during the period when small biopsy forceps (SmF) were used (April 2011-March 2013). Patients in whom GIN lesions were diagnosed with biopsy were identified, and pertinent data were compared between the two groups of patients.

RESULTS

Among the 8,420 patients who underwent esophagogastroduodenoscopy (EGD) during the first period, 2,584 (30.7%) underwent gastric biopsy with StF. Among the 15,968 patients who underwent EGD during the second period, 4,204 (26.3%) underwent gastric biopsy with SmF. GIN was diagnosed in a significantly greater number of patients in the SmF group than in the StF group (52 [1.25%] vs. 19 [0.73%]; p=0.048). The mean minor-axis lengths of the biopsy samples were 1.50±0.50 mm and 1.38±0.40 mm in the StF group and the SmF group, respectively, with the SmF group samples tending to be shorter (p=0.088).

CONCLUSION

Because the SmF use may increase the rate of GIN diagnosis, the use of SmF with a standard-caliber endoscope should be avoided.

Emerging optical methods for endoscopic surveillance of Barrett's oesophagus

Barrett's oesophagus is an acquired metaplastic condition that predisposes patients to the development of oesophageal adenocarcinoma, prompting the use of surveillance regimes to detect early malignancy for endoscopic therapy with curative intent. The currently accepted surveillance regime uses white light endoscopy together with random biopsies, but has poor sensitivity and discards information from numerous light-tissue interactions that could be exploited to probe structural, functional, and molecular changes in the tissue. Advanced optical methods are now emerging that are highly sensitive to these changes and hold potential to improve surveillance of Barrett's oesophagus if they can be applied endoscopically. The next decade will see some of these exciting new methods applied to surveillance of Barrett's oesophagus in new device architectures for the first time, potentially leading to a long-awaited improvement in the standard of care.

Alternatives to Traditional Per-Oral Endoscopy for Screening

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.

Feasibility of transnasal endoscopy in screening for esophageal and gastric varices in patients with chronic liver disease

BACKGROUND AND STUDY AIMS

 Screening for esophageal and gastric varices is indicated for patients with portal hypertension or cirrhosis. Typically, conventional endoscopy is used; however, the need for sedation increases the costs and risks, especially in cirrhotic patients. Use of transnasal endoscopy with an ultrathin endoscope enables study of the upper gastrointestinal tract without the need for sedation. The objective of this study is to evaluate the feasibility of transnasal endoscopy in screening for esophageal and gastric varices in patients with chronic liver disease.

PATIENTS AND METHODS

This was a prospective study in which transnasal endoscopy was carried out in patients with cirrhosis or portal hypertension who had indications for screening of esophageal and gastric varices. The following variables were evaluated: demographical data, duration of procedure, patient tolerance and acceptance, adverse events (AEs), endoscopic findings and interobserver agreement related to portal hypertension alterations ( kappa index).

RESULTS

A total of 50 patients entered the study. The most common cause of liver disease was chronic viral hepatitis (66 %). Among the cirrhotic patients, most of the patients were Child-Pugh A (74 %). In 5 patients (10 %), nasal intubation was not possible. Two patients (4 %) experienced minor epistaxis. Tolerance was excellent or good in 92 % according with a visual analogic scale. In 16 patients (32 %), esophageal varices were detected and in 2 patients (4 %) gastric varices were detected. The mean duration of the procedure was 7 minutes.

CONCLUSIONS

Transnasal endoscopy is feasible, effective and well tolerated for screening of esophageal and gastric varices in patients with chronic liver disease. It can be performed in outpatient clinics safely and without the use of sedation.

Ultrathin unsedated transnasal gastroscopy in monitoring eosinophilic esophagitis

BACKGROUND

Ultrathin unsedated transnasal gastroscopy (UTEG) has a number of advantages applicable to eosinophilic esophagitis (EoE) and has not been evaluated for this condition.

AIM

The aim of the study is to determine the feasibility of UTEG in patients with EoE and the acceptability of histological specimens obtained at biopsy.

METHOD

All patients with a diagnosis of EoE presenting to the outpatients department of two hospitals (Box Hill Hospital and The Alfred Hospital, Melbourne Australia) were asked to participate in the study. UTEG was performed on consenting individuals. Feasibility was determined by the success of nasal intubaton, patient perception according to post procedural survey, and adequacy of esophageal biopsies was assessed.

RESULTS

Ninety-six consecutive patients with EoE were offered UTEG, and 24 agreed to participate in the study. Seventy-four UTEGs were performed over a period of 26 months (September 2012 to December 2014). Nineteen patients had repeat procedures. Successful nasal intubation occurred in 97% (72 of 74 procedures), and 21 of 24 (86%) described high satisfaction with the procedure and minimal discomfort, and would choose UTEG for future procedures. Mean duration was 5 min. Adverse events of epistaxis (three cases) and vomiting of liquid contents during the procedure (two cases) were recorded, cardiorespiratory parameters remaining normal in all patients. All completed procedures produced adequate histological samples.

CONCLUSION

In those who decide to undergo UTEG, it is a safe and well-tolerated procedure.

An Ultrathin Endoscope with a 2.4-mm Working Channel Shortens the Esophagogastroduodenoscopy Time by Shortening the Suction Time

Background/Aims:

Poor suction ability through a narrow working channel prolongs esophagogastroduodenoscopy (EGD). The aim of this study was to evaluate suction with a new ultrathin endoscope (EG-580NW2; Fujifilm Corp.) having a 2.4-mm working channel in clinical practice.

Methods:

To evaluate in vitro suction, 200 mL water was suctioned and the suction time was measured. The clinical data of 117 patients who underwent EGD were retrospectively reviewed on the basis of recorded video, and the suction time was measured by using a stopwatch.

Results:

In vitro, the suction time with the EG-580NW2 endoscope was significantly shorter than that with the use of an ultrathin endoscope with a 2.0-mm working channel (EG-580NW; mean ± standard deviation, 22.7±1.1 seconds vs. 34.7±2.2 seconds; p<0.001). We analyzed the total time and the suction time for routine EGD in 117 patients (50 in the EG-580NW2 group and 67 in the EG-580NW group). In the EG-580NW2 group, the total time for EGD was significantly shorter than that in the EG-580NW group (275.3±42.0 seconds vs. 300.6±46.5 seconds, p=0.003). In the EG-580NW2 group, the suction time was significantly shorter than that in the EG-580NW group (19.2±7.6 seconds vs. 38.0±15.9 seconds, p<0.001).

Conclusions:

An ultrathin endoscope with a 2.4-mm working channel considerably shortens the routine EGD time by shortening the suction time, in comparison with an endoscope with a 2.0-mm working channel.

Magnetic resonance enterography in refractory iron deficiency anemia: A pictorial overview

AIM: To highlight magnetic resonance enterography (MRE) for diagnosis of patients with refractory iron deficiency anemia and normal endoscopy results.

METHODS: Fifty-three patients diagnosed with iron deficiency anemia refractory to treatment and normal gastroscopy and colonoscopy results were admitted to this prospective study between June 2013 and December 2013. All patients underwent a standardized MRE examination with a 1.5 Tesla magnetic resonance imaging system using two six-channel phased-array abdominal coils. Adequate bowel distention and fast imaging sequences were utilized to achieve diagnostic accuracy. All segments of the small bowel, duodenum, jejunum, and ileum were examined in detail. All cases were examined independently by two radiologists with > 5 years of experience in abdominal magnetic resonance imaging. A consensus reading was performed for each patient following image examination. Both radiologists were blinded to patient history, laboratory findings, and endoscopy results.

RESULTS: Twenty (37.7%) male and 33 (62.3%) female patients were included in the study. The mean age of the patients was 52.2 ± 13.6 years (range: 19-81 years, median 51.0). The age difference between the male and female patient groups was not statistically significant (54.8 ± 16.3 years vs 50.7 ± 11.7 years). MRE results were normal for 49 patients (92.5%). Four patients had abnormal MRE results. One patient with antral thickening was diagnosed with antral gastritis in the second-look gastroscopy. One patient had focal wall thickening in the 3^rd and 4^th portions of the duodenum. The affected areas were biopsied in a subsequent duodenoscopy, and adenocarcinoma was diagnosed. One patient had a fistula and focal contrast enhancement in the distal ileal segments, consistent with Crohn’s disease. One patient had focal wall thickening with luminal narrowing in the mid-jejunum that was later biopsied during a double-balloon enteroscopy, and lymphoma was diagnosed.

CONCLUSION: MRE is a non-invasive and effective alternative for evaluating possible malignancies of the small intestines and can serve as a guide for a second-look endoscopy.