Transnasal esogastroduodenoscopy & EBM

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  • 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.
  • Transnasal esogastroduodenoscopy & EBM

    1. 1. Transnasal EGD & Evidence-Based Medicine Samir Haffar M.D. Associant Professor of Gastroenterology
    2. 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. 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. 4. I personally prefer to perform an UGI endoscopy in this patient using an ultrathin gastroscope But what are the evidences?
    5. 5. Unsedated transnasal EGD  Feasibility  Safety  Accuracy & quality of biopsies  Tolerance  2 way or 4 way angulations  Self-training  Cost savings
    6. 6.  Feasibility of t-EGD
    7. 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.
    8. 8.  Safety of t-EGD
    9. 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. 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. 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.
    12. 12.  Accuracy & biopsy quality of t-EGD
    13. 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. 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. 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.
    16. 16.  Tolerance of t-EGD
    17. 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. 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. 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. 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
    21. 21.  2-way or 4-way angulations?
    22. 22. 2-way or 4-way angulation? • 291 patients randomized: 5.2-mm (2-way angulations) 5.5-mm (4-way angulations) • Evaluated parameters: insertion rate, epistaxis, overall quality of examination, passing through pylorus, D2 intubation, observe entire upper GIT, perform biopsy, examination time, tolerance & acceptance (nasal pain, choking, gagging, overall pain & discomfort) • 4-way angulation videoscope shortens examination time, provides easy insertion & improves tolerance Tatsumi Y et al. Gastrointest Endosc 2008 ;67 : 1021 – 7.
    23. 23.  Self-training of t-EGD
    24. 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
    25. 25.  Cost savings of t-EGD
    26. 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. 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. 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. 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. 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. 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
    32. 32. Thank You

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