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Transnasal esogastroduodenoscopy & EBM
1. Transnasal EGD & Evidence-Based Medicine
Samir Haffar M.D.
Associant Professor of Gastroenterology
2. Introduction
• 1994 t-EGD proposed by Shaker in 1994 to improve
tolerance & to allow unsedated procedure
• 2002 Developments in endoscopic technology made
ultrathin videoscopes of improved quality
• There are still concerns on t-EGD regarding
Inferior image quality
Smaller biopsy channel diameter
Maneuverability
Shaker R. Gastrointest Endosc 1994 ; 40 : 346 – 348.
3. Characteristics of t-EGD & C-EGD
Characteristics Transnasal Conventional
Insertion tube (mm) 4.9 – 6.0 8.0 – 10.9
Biopsy channel (mm) 2.0 2.4 – 3.2
Field of view 120 – 140 120 – 140
Working length (mm) 1030 – 1100 1030 – 1100
Tip flexion: Up/Down
Left/Right
180 – 210 / 90 –120
100 – 120
210 /90 –120
100 – 120
2-way angulations (Up/down) 210 /120 210 /90 –120
Optical magnification Not available Up to 115
High definition Not available Available
Dumonceau JM et al. Dig Liver Dis 2008 ; 40 : 776 – 783.
4. I personally prefer to perform an
UGI endoscopy in this patient
using an ultrathin gastroscope
But what are the evidences?
5. Unsedated transnasal EGD
Feasibility
Safety
Accuracy & quality of biopsies
Tolerance
2 way or 4 way angulations
Self-training
Cost savings
7. Feasibility of t-EGD
• Endoscope diameter Main success factor
90-100 % of cases if ≤ 5.3 mm
78-100% with larger endoscopes
• Gender (female) Associated with higher failure rate
• Age (<35 years) Associated with higher failure rate
If insertion through both nostrils fails, the unsedated
peroral route can be used with the same endoscope
Hu CT. Am J Gastroenterol. 2008 ; 103 : 1 – 8.
Dumortier J et al Gastrointest Endosc. 2003 ; 57 : 19 – 204.
9. Complication rates of t-EGD
Absolute complication rate unknown
• Epistaxis1 Most frequent (0 – 5%)
Usually mild & self-limited
Lower in thinner endoscope
• Nasal pain 1.6%
• Vaso-vagal reaction 0.3%
• Withdrawal difficulty2 0.12% (13.000 cases)
• Esophageal perforation3 1 case
1 Technology committee of ASGE. Gastrointest Endosc 2000 ; 51 : 786 – 9.
2 Tatsumi Y et al . J Gastroentrol Cancer Screen 2009 ; 47: 217 – 26 (in Japanese).
3 Zaman A et al. Gastrointest Endosc 1999 ; 49 : 279 – 84.
10. Methods to resolve withdrawing difficulty
Change the position of mandible
Rotate the scope
Extra lubrication to shaft of the scope & insert
tip into upper esophagus to lubricate nasopharynx
Tatsumi Y et al . J Gastroentrol Cancer Screen 2009 ; 47: 217 – 26 (in Japanese).
11. Contraindications to t-EGD
• Technology committee of ASGE*
- Prior nasal trauma
- Prior nasal surgery
- Coagulopathy
- Use of anticoagulants
• Japanese Gastroenterological Endoscopy Society
Under discussion
*Technology status evaluation report: Ultrathin endoscopes EGD – March 2000.
Gastrointest Endosc 2000 ; 51 : 786 – 9.
13. Accuracy of t-EGD
• Diagnostic yield of t-EGD is similar to c-EGD:
HP diagnosis & eradication1
EV detection & grading2
Barrett’s metaplasia & dysplasia3
• Superficial gastric neoplasms4
Lower sensitivity & specificity compared to HR endoscopy
Especially in proximal stomach
Improvements in optical quality & chromoendoscopy
1 Saeian K et al. Gastrointest Endosc 1999 ; 49 : 297 – 301.
2 Saeian K et al. Am J Gastroenterol 2002 ; 97 : 2246 – 9.
3 Saeian et al. Gastrointest Endosc 2002 ; 56 : 472 – 8.
Toyoizumi H et al. Gastrointest Endosc 2009 ; 70 : 240 – 5.
14. Superficial gastric neoplasia
Ultrathin endoscopeHR endoscope
Toyoizumi H et al. Gastrointest Endosc 2009 ; 70 : 240 – 5.
White subtle elevation on gastric corpus
Pathological diagnosis after ESD was gastric adenoma
15. Adequacy of biopsy specimens in t-EGD
RCT of t-EGD vs c-EGD
• 300 procedures 109 t-EGD – 191c-EGD
• 1035 biopsies 783 untargeted
352 targeted to focal lesions
• Mean size 1.8 mm in t-EGD – 2.1 mm in c-EGD
• No significant difference in diagnosis from targeted
or nontargeted biopsies for both endoscopes
Walter T et al. J Clin Gastroenterol. 2010 ;44 : 12 – 7.
17. Tolerance of t-EGD
• t-EGD versus unsedated c-EGD1-5
4 out of 5 RCTs evaluated patient tolerance using visual
analogue scales reported better tolerated of UT-EGD
Symptoms best prevented included nausea & choking
• t-EGD vs sedated c-EGD
Discordant results
1 Preiss C et al. Endoscopy. 2003;35:641-6.
2 Campo R et al. Endoscopy 1998 ; 30 : 44 – 52.
3 Birkner B et al. Endoscopy 2003 ; 35 : 647 – 51.
4 Trevisani L et al. World J Gastroenterol 2007 ; 13 : 906 – 11.
5 Mori A et al. Dig Endosc 2006 ; 18 : 282 – 7.
18. CV tolerance of t-EGD versus c-EGD
Trial taking into account patient preference
Ultrathin endoscope with 5.9 mm diameter for both routes
Topical anesthesia only
Mori A et al. Dig Endosc 2008 ; 20 : 79 – 83.
19. CV tolerance of t-EGD versus c-EGD
RCT of 149 patients
* SpO2: peripheral blood oxygen saturation
Mori A et al. Dig. Endosc 2008 ; 20 : 79 – 83.
Blood pressure Pulse SpO2*
Before scope insertion
2 min after scope insertion
3 min after terminating endoscopy
20. Acceptance score of t-EGF & c-EGD
Box-and-whiskers plot
Mori A et al. Dig Endosc 2008 ; 20 : 79 – 83.
Visual analog scale: from 0 (unbearable) to 10 (comfortable)
Values represent means, interquartiles & 10 – 90% quantities
24. Self-training in t-EGD
150 patients
Maffei M et al. Gastrointest Endosc 2008 ; 67 : 410 – 8.
Beginners in t-EGD Trainee 17.0 (15.0-21.0) min
Skilled 11.0 (9.0-13.0) min
Skilled in t-EGD 12.0 (9.8-13.5) min
26. Direct cost savings of t-EGD
• No surveillance in recovery room (70% procedure time)
Suppression of sedation-related morbidity
• 20 - 36% cost reduction as compared to sedated EGD1-2
• Cost savings per procedure of 151-202 CHF3
Switzerland 91.849 sedated EGD/year
13-19 million CHF/year
France 77.7 67sedated diagnostic EGD/year
117-152 million CHF/year
1 Gorelick AB et al. J Clin Gastroenterol 2001 ; 33 : 210 – 4.
2 Garcia RT et al. Gastroenterology 2003 ; 125 : 1606 – 12.
3 Maffei M et al. Swiss Med Wkly 2008 ; 138 : 658 – 664.
27. Japanese status of t-EGD
• Beginning in 2002 t-EGD increasingly carried out,
mainly in private clinics & health check-up institutes
• In 2006, almost 50% of UGI endoscopes sold in Japan
were small caliber scopes < 5.9 mm in diameter
• Several excellent textbooks with DVD videos have
been published for self-training
24th European workshop on gastroenterology & endotherapy, Brussels, 2006.
Dumonceau JM et al. Dig Liver Dis 2008 ; 40 : 776 – 83.
28. European status of t-EGD
Survey at 24th European workshop, Brussels, 2006
Dumonceau JM et al. Dig Liver Dis 2008 ; 40 : 776 – 83.
624 attending endoscopists
Majority from European countries
297 respondents
92 practiced t-EGD (31%)
68 practiced t-EGD
in < 20% of cases
29. Percentages of endoscopists who practice
UT-EGD in different European countries
Survey of 297 endoscopists attending live course
on digestive endoscopy in Brussels 2006
Dumonceau JM et al. Dig Liver Dis 2008 ; 40 : 776 – 783.
30. European status of UT-EGD
Survey at 24th European workshop, Brussels, 2006
Dumonceau JM et al. Dig Liver Dis 2008 ; 40 : 776 – 83.
624 attending endoscopists
Majority from European countries
Poll before & after live cases:
Would UT-EGD be useful to you?
P = 0.006
297 respondents
92 practiced t-EGD (31%)
68 practiced t-EGD
in < 20% of cases
131 answers
before live cases
Yes
55 (42.0%)
after live cases
Yes
72 (55.0%)
31. Conclusion
t-EGD
Feasible in 95 – 100% of patients
Safe
Accurate with good quality of biopsies
Better toleration than o-EGD
No need of special training for a skilled endoscopist
Costs less money
According to several reports, the diagnostic yield of transnasalunsedated upper EGD has been found to be similar toconventional sedated EGD. For UTE to be used as an alternative modality for dg of superficial gastric neoplasms, improvements in optical quality and the incorporation of additional procedures, including close-range observations and chromoendoscopy, are required to enhance visualization.
choking: اختناق6- Preiss C, Charton JP, Schumacher B, Neuhaus H. A randomized trial of unsedatedtransnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD. Endoscopy. 2003;35:641-6.9- Campo R, Montserrat A, Brullet E. Transnasal gastroscopy compared to conventional gastroscopy: a randomized study offeasibility, safety and tolerance. Endoscopy. 1998 ;30:448 -52.12- Birkner B, Fritz N, Schatke W, Hasford J. A prospective randomized comparison of unsedated ultrathin versus standardesophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose? Endoscopy 2003;35:647-51.14- Trevisani L, Cifalà V, Sartori S, Gilli G, Matarese G, Abbasciano V. Unsedated ultrathin upper endoscopy is better thanconventional endoscopy in routine outpatient gastroenterology practice: a randomized trial. World J Gastroenterol 2007;13:906-11.27- Mori A, Fushimi N, Asano T, Maruyama T, Ohashi N, Okumura S, et al. Cardiovascular tolerance in unsedated upper gastrointestinalendocsopy: prospective randomized comparison between transnasal and conventional oral procedures. Dig Endosc 2006;18 :282-7.
Trial with comprehensive cohort design
The present study confirmed less cardiovascular stress using nasal EGD than oral endoscopy when compared using the same ultrathin scope.
Endoscopists who had no experience in UT-EGD and who were not supervised were technically competent in this technique from theirfirst attempts. Procedure duration was the only parameter affected by the learning process, and its lengthening (compared with procedures performed by an endoscopist skilled in UT-EGD) was marginal for a skilled endoscopist and more significant for a trainee who had recently achieved competency in conventional EGD. This had no impact on examination quality, patient tolerance, and acceptance of repeat procedures, which were in the upperrange of previous reports.
Indirect costs Less time off work no need for a driver with, possibly, additional lost work dayReferences:Gorelick AB, Inadomi JM, Barnett JL. Unsedated small-caliber esophagogastroduodenoscopy (EGD): less expensive and less time-consuming than conventional EGD. J ClinGastroenterol 2001;33(3):210-4.Garcia RT, Cello JP, Nguyen MH, Rogers SJ, Rodas A, Trinh HN. Unsedated ultrathin EGD is well accepted when compared with conventional sedated EGD: a multicenter randomized trial. Gastroenterology 2003;125:1606-12.
