This document discusses unsedated transnasal endoscopy (uTNE) as a potential alternative to conventional sedated endoscopy. uTNE uses slim, transnasal endoscopes to examine the upper GI tract without sedation. It has advantages of being safer, more cost-effective due to lack of sedation costs, and can be performed in an office setting. While it has some limitations like potential nasal discomfort and inability to take standard biopsies, studies show uTNE has comparable diagnostic accuracy and patient tolerability to sedated endoscopy. The document concludes that uTNE has the potential to become a valuable tool for office-based gastroenterologists due to its advantages over conventional sedated endoscopy

1. Kurdistan Board GEH/GIT Surgery weekly J
Club:
Supervised by:
Professor Dr.Mohamed Alshekhani
MBChB-CABM,FRCP,EBGH.
AJG 2016.

2. Introduction:Introduction:
 Sedated trans-oral endoscopy (sEGD) remains the conventional &Sedated trans-oral endoscopy (sEGD) remains the conventional &
most commonly utilized diagnostic tool to directly visualize themost commonly utilized diagnostic tool to directly visualize the
UGI for both diagnostic &therapeutic purposes.UGI for both diagnostic &therapeutic purposes.
 It has become a relatively routine procedure with a favorable riskIt has become a relatively routine procedure with a favorable risk
profile&associated with complications (albeit at a low rate) thatprofile&associated with complications (albeit at a low rate) that
may be prohibitive in certain high-risk populations.may be prohibitive in certain high-risk populations.
 It it is also expensive, making it a less suitable tool for large-scaleIt it is also expensive, making it a less suitable tool for large-scale
applications such as screening for reflux complications as Barrett’sapplications such as screening for reflux complications as Barrett’s
esophagus or complications of cirrhosis such as varices.esophagus or complications of cirrhosis such as varices.
 Th e potential use of unsedated transnasal endoscopy (uTNE) forTh e potential use of unsedated transnasal endoscopy (uTNE) for
these conditions is attractive if proven to be acceptable, safe&these conditions is attractive if proven to be acceptable, safe&
accurate.accurate.
 uTNE can be safe&accurate alternative to sEGD for theseuTNE can be safe&accurate alternative to sEGD for these
indications.indications.

3. Introduction:Introduction:
 Transnasal endoscopes are slimmer than conventional diagnosticTransnasal endoscopes are slimmer than conventional diagnostic
endoscopes with shaft diameters ranging from 5–6 mmendoscopes with shaft diameters ranging from 5–6 mm
 Their working channel (if available) is smaller (2 mm in diameter)Their working channel (if available) is smaller (2 mm in diameter)
&hence cannot accommodate standard-sized biopsy forceps or&hence cannot accommodate standard-sized biopsy forceps or
other through-the-scope tools.other through-the-scope tools.
 Pediatric biopsy cables can be advanced through the therapeuticPediatric biopsy cables can be advanced through the therapeutic
channel to obtain biopsies if needed.channel to obtain biopsies if needed.
 While some have both right-left& up-down controls, those slimmerWhile some have both right-left& up-down controls, those slimmer
than 5 mm only have an up-down control.than 5 mm only have an up-down control.
 Most of these endoscopes are of adequate length to examine theMost of these endoscopes are of adequate length to examine the
stomach / proximal duodenum&need conventional light sourcesstomach / proximal duodenum&need conventional light sources
&disinfection after use.&disinfection after use.

4. Introduction:Introduction:
 Recently an esophagoscope (65 cm in length) has been introducedRecently an esophagoscope (65 cm in length) has been introduced
covered with a disposable sheath &available in two formss with orcovered with a disposable sheath &available in two formss with or
without a biopsy channel.without a biopsy channel.
 This sheath protects the endoscope from coming into contact withThis sheath protects the endoscope from coming into contact with
body fluids &discarded aft er use.body fluids &discarded aft er use.
 The endoscope can then be disinfected with sopropyl alcoholThe endoscope can then be disinfected with sopropyl alcohol
wipes & reutilized with another sheath, without undergoingwipes & reutilized with another sheath, without undergoing
conventional disinfection.conventional disinfection.
 The imaging is not HD, but adequate / comparable toThe imaging is not HD, but adequate / comparable to
conventional endoscopy from a diagnostic standpoint.conventional endoscopy from a diagnostic standpoint.
 A disposable capsule attached to a shaft is also commerciallyA disposable capsule attached to a shaft is also commercially
available for visualization of the esophagus and stomach.available for visualization of the esophagus and stomach.
 It is connected to a controller&processor.It is connected to a controller&processor.
 Both these devices that do not require conventional disinfectionBoth these devices that do not require conventional disinfection
make mobile or in office examinations a possibility.make mobile or in office examinations a possibility.

21. The procedure:The procedure:
 To obtain adequate local anesthesia of the nasopharynx, either aTo obtain adequate local anesthesia of the nasopharynx, either a
topical spray of lidocaine with a vasoconstrictor as oxymetazolinetopical spray of lidocaine with a vasoconstrictor as oxymetazoline
or by introducing a pretreatment swab coated with topicalor by introducing a pretreatment swab coated with topical
anesthetic gel into the nasal pssage for 5 min before introduction.anesthetic gel into the nasal pssage for 5 min before introduction.
 Either nasal passage can be used after documenting the absenceEither nasal passage can be used after documenting the absence
of any anatomic abnormality.of any anatomic abnormality.
 The procedure can be done with the patient in the left lateralThe procedure can be done with the patient in the left lateral
decubitus or seated upright position.decubitus or seated upright position.
 The endoscope is lubricated, introduced into the nasal passage,The endoscope is lubricated, introduced into the nasal passage,
advanced along the floor of the nasopharyngeal space or betweenadvanced along the floor of the nasopharyngeal space or between
the middle&inferior turbinate.the middle&inferior turbinate.
 Following visualization of usual pharyngeal& laryngeal landmarks,Following visualization of usual pharyngeal& laryngeal landmarks,
the endoscope is advanced into the esophagus under vision.the endoscope is advanced into the esophagus under vision.
 Following eso intubation,exam is completed as conventionalFollowing eso intubation,exam is completed as conventional
endoscopy.endoscopy.

22. Advantages:Advantages:
 Greater patient safety due to the lack of conscious sedationGreater patient safety due to the lack of conscious sedation
(particularly in those with medical comorbidities)(particularly in those with medical comorbidities)
 Comparable tolerabilityComparable tolerability
 comparable patient preferencecomparable patient preference
 lower costs due to decreased direct medical costs (lack of sedation,lower costs due to decreased direct medical costs (lack of sedation,
being performed in the office) & indirect costs (lack of loss ofbeing performed in the office) & indirect costs (lack of loss of
work for the patient&the caregiver).work for the patient&the caregiver).
 Incite less sympathetic nervous system activity & stress asIncite less sympathetic nervous system activity & stress as
evidenced by less deleterious cardiovascular effects.evidenced by less deleterious cardiovascular effects.
 Associated with more favorable oxygen saturation during theAssociated with more favorable oxygen saturation during the
procedure with no intravenous access being needed.procedure with no intravenous access being needed.
 Reduce risks for aspiration given less salivary stimulation & moreReduce risks for aspiration given less salivary stimulation & more
favorable in those with dental problems, where placement of afavorable in those with dental problems, where placement of a
mouthpiece may be challenging.mouthpiece may be challenging.
 Safely performed by non-physicians after adequate training.Safely performed by non-physicians after adequate training.

23. Limitations:Limitations:
 Issues surrounding nasal intubation (failure occurs in ~2–6% ofIssues surrounding nasal intubation (failure occurs in ~2–6% of
subjects due to narrow nasal passages),subjects due to narrow nasal passages),
 Nasal pain / epistaxis (1–5%)& usually self-limited)Nasal pain / epistaxis (1–5%)& usually self-limited)
 Potential limited functionality of the endoscope (limited tip deflPotential limited functionality of the endoscope (limited tip defl
ection,limited suction&air insufflation)&the need for someection,limited suction&air insufflation)&the need for some
additional provider training.additional provider training.
 No signifi cant difference in intubation rates between uTNENo signifi cant difference in intubation rates between uTNE
endoscopes <5.9 mm in diameter&conventional endoscopes inendoscopes <5.9 mm in diameter&conventional endoscopes in
addition to excellent tolerability &acceptability.addition to excellent tolerability &acceptability.
 Biopsies taken with a pediatric forceps are smaller, butBiopsies taken with a pediatric forceps are smaller, but provideprovide
adequate diagnosticadequate diagnostic information.information.

24. Costs:Costs:
 Given the lack of need for sedation, uTNE can be performed atGiven the lack of need for sedation, uTNE can be performed at
lower costs in the office, eliminating the need for IV access&post-lower costs in the office, eliminating the need for IV access&post-
procedural monitoring.procedural monitoring.
 Initial equipment costs include the cost of the endoscope (forInitial equipment costs include the cost of the endoscope (for
conventional transnasal endoscopes that will connect with theconventional transnasal endoscopes that will connect with the
regular light sources for transoral endoscopes)& a portable videoregular light sources for transoral endoscopes)& a portable video
system including the light source&display system for thesystem including the light source&display system for the
esophagoscope with Endosheath technology.esophagoscope with Endosheath technology.
 Reimbursement will involve the use of specifi c CPT codes forReimbursement will involve the use of specifi c CPT codes for
uTNE along with facility codes.uTNE along with facility codes.

25. Conclusion:Conclusion:
 While conventional sedated endoscopy remains the most commonWhile conventional sedated endoscopy remains the most common
form of diagnostic upper endoscopy, uTNE will hopefully growform of diagnostic upper endoscopy, uTNE will hopefully grow
due to several advantages listed above.due to several advantages listed above.
 uTNE can provide similar diagnostic information for the clinicianuTNE can provide similar diagnostic information for the clinician
at lower costs, in a shorter time & in a safe manner without theat lower costs, in a shorter time & in a safe manner without the
need for sedation in the office.need for sedation in the office.
 These advantages have the potential to make uTNE a valuableThese advantages have the potential to make uTNE a valuable
tool in the diagnostic armamentarium of the office-basedtool in the diagnostic armamentarium of the office-based
gastroenterologist.gastroenterologist.