Saudi Journal of Gastroenterology
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Year : 2001  |  Volume : 7  |  Issue : 1  |  Page : 26-29
Comparision between per-oral and ultrathin transnasal endoscopy in unsedated patients


Department of Gastroenterology, Armed Forces Hospital, Riyadh, Saudi Arabia

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Date of Submission26-Jun-1999
Date of Acceptance28-Sep-2000
 

   Abstract 

Back ground: This is a prospective study to evaluate the tolerance and acceptability of patients for diagnostic ultrathin transnasal esophagogastroduodenoscopy compared with the standard peroral route. Patients and Methods : Both types of endoscopic procedures were explained to the patients. Sixty patients were included in this study and subsequently, 30 unsedated patients in each group underwent upper gastrointestinal endoscopy. An evaluation and questionnaire form both the endoscopist and the patient was recorded. Out of the 30 patients who had transnasal endoscopy, 15 had previous peroral endoscopy. Oximetry was recorded during the procedure. Results: All patients in both groups tolerated the procedure well and it was successfully completed. In the transnasal group, three patients had mild epistaxis. Desaturation in the transnasal group was the same as compared to the peroral group. From the 30 patients of transnasal group, 21 were willing to repeat the procedure if required and eight patients were willing to repeat the procedure reluctantly. Only one patient expressed preference for the peroral route. The endoscopist's observation revealed that scope insertion in both groups was equally tolerated but lens washing and suction was not optimal in the transnasal approach. Conclusion: Both groups showed good tolerability, but the tranasal approach was found to be more acceptable to the patient. In the tranasal group, the patients found the procedure less distressing and were subsequently more willing for a repeat procedure. Therefore we believe that the tranasnal approach to esophagogastroduodenoscopy in diagnostic and follow up procedures will rapidly acquire increasing popularity.

Keywords: Transnasal, peroral, endoscopy, gastrointestinal, oesophagogastroduodenoscopy.

How to cite this article:
Al Karawi MA, Yasawy MI, Sanai FM, Mohammed AE. Comparision between per-oral and ultrathin transnasal endoscopy in unsedated patients. Saudi J Gastroenterol 2001;7:26-9

How to cite this URL:
Al Karawi MA, Yasawy MI, Sanai FM, Mohammed AE. Comparision between per-oral and ultrathin transnasal endoscopy in unsedated patients. Saudi J Gastroenterol [serial online] 2001 [cited 2020 Dec 3];7:26-9. Available from: https://www.saudijgastro.com/text.asp?2001/7/1/26/33410


With advances in endoscopic technology, the diagnosis and treatment of gastrointestinal disease has significantly improved. Endoscopy has become a popular procedure and quite easily acceptable without the need for any extensive special preparations. However, sedation in some centers is still quite routinely used for patients undergoing esographagogastroduodenoscopy (EGD) [1] . On the other hand, other centers have shown that peroral unsedated endoscopy using standard endoscopes is quite well-tolerated by patients [2],[3] . Unsedated EGD has several advantages over sedated examinations. It avoids cardiopulmonary complications and those directly related to sedation, patient monitoring and cost of the medication itself. The feasibility of unsedated transnasal endoscopy was initially reported by Shaker et al [4] . Various studies have discussed the advantages and the disadvantages of the transnasal method [5],[6],[7],[8] . This study was conducted to evaluate patient tolerance and feasibility, further supported by the endoscopist's evaluation. Of special importance is the fact that this study was performed in unsedated patients using the peroral videoscope of 9.8mm and compared with the ultrathin transnasal videoscope of 6mm diameter.


   Patients and Methods Top


In unsedated patients, upper gastrointestinal endoscopy UGI was performed using either ultrathin transnasal videoscope Pentax 1480 (6mm outer diameter and 2.2mm working chamber) and peroral endoscopy used was E. G. 2901 (outer diameter of 9.8mm and inner diameter of 2.8mm). A total of 60 patients with various presentations of UGI symptomatology were randomly allocated to two different groups of 30 patients each. One group was randomized to transnasal ultrathin (TNEGD) and the other group to peroral (PEGD). The age range in both groups was 18-80 years. The procedure was discussed and explained to all patients and their consent obtained. In the transnsal group, 15 out of 30 patients had previous peroral EGD. All patients had symptoms suggestive of disease of the upper digestive tract.

Excluding criteria constituted evidence of an acute UGI bleeding episode, recent ear, nose or throat surgery or patients previously diagnosed nasal polyp, nasal allergy, or those who were expected to require any therapeutic intervention.

All patients were monitored with pulse oximetry. Peroral EGD was performed in the left lateral position after giving 10% xylocatine gel orally with Pentax-EG 2901. On the other hand, transnasal procedure was performed at a 45° semi sitting position using Pentax 1480 under local anaethesia using nasal xylocatine gel and lubrication by cotton tip swab. Pharyngeal and laryngeal structures were evaluated and the scope was introduced into the oesophagus under direct vision. Examination of the oesophagus and the stomach was carried out including retroflexion. Subsequently, the pylorus, duodenal bulb and the second part of the duodenum were also examined.

At the end of each procedure the endoscopist completed an evaluation form and this included a questionnaire to the patients. The evaluation included impressions of specific adverse events of the procedure, which were graded on a scale 1-5. A score of I indicates that the procedure was unbearable to the extent that it had to be terminated. A score of 2 any category indicated that the aspect being studied was unsatisfactory, but it did not require discontinuation of endoscopy. Other scores were marked with a graded improvement in the aspect being studied, with 5 being the maximum score.


   Results Top


The procedure included 60 patients and successfully completed within the two subgroups containing 30 patients in each. None of the patients in either group had any major complications. Only one patient in the PEGD group could not tolerate the procedure and the endoscopy was discontinued within 15 seconds of the commencement. He subsequently refused the endoscopy. There were no crossovers from either group. In all categories being evaluated, the transnasal group had only a total of 6 patients with a score of 2 or less, while 12 patients in the peroral group had similar readings. In comparison, the number of patients reporting scores of 4 or more when considering the adverse effects of endoscopy were far higher in the TNEGD group than compared to the PEGD group [Table - 1]. In the instance of pain, it was reported excellent or good in 17 patients. (Excellent 14 + good 3) in the PEGD group, while 26 patients in the TNEGD group (excellent 18 + good 8) had such favorable gradings. Gagging was again found to be less troublesome in the TNEGD group with scores of 4 or above in 26 patients while only 20 patients had similar scores in the peroral group. Moreover, three patients felt the gagging to be excessive (unsatisfactory 2, poor 1) in the peroral group. Choking was also found to be less than acceptable in more patients in the peroral group (3 patients), while only one patient in the transnasal group was categorized in this bracket. Discomfort of insertion was most obvious in the peroral group with 5 patients being allocated to this category. In comparison, none of the patients in the transnasal group found insertion unsatisfactory. There was no significant desaturation in either group. Epistaxis occurred in three patients in the transnasal group but did not require any intervention. The technical aspects of the procedure as assessed by the endoscopist were similar in both groups except for `lens washing' and `suction' which recorded more patients with excellent scores for PEGD [Table - 2]. Also the number of patients scoring 5 in these instrument-related technical aspects was also more in the PEGD group. However, when considering scores of 4 and 5 together, both groups were rated the same. In the TNEGD group 21 out of the 30 patients were willing for a repeat endoscopy by the same route, eight were willing but reluctant and only one was unwilling [Table - 3]. Compared to this the peroral route had 12 patients who were willing for PEGD and 12 were willing but reluctant and while six were completely unwilling. In a further breakdown of the results, it was found that from the 30 patients in the TNEGD group, 15 had previously undergone peroral endoscopy. Of these 13 were willing to repeat TNEGD AND two were reluctant.


   Discussion Top


Transnasal intubation performed in the upright or semi recumbent position significantly reduces the risk of gagging, vomiting and possible subsequent aspiration [7] . This position is more suitable for patients with cervical spine problems and cases of multiple fractures especially those involved in road traffic accidents. In such scenarios the patients can not bend their necks or adopt the standard left lateral position of conventional endoscopy. It is also useful in patients who can not hold the mouthpiece due to absent teeth, presence of dentures teeth wiring, lock jaw or dislocation of temporomandibular joints. Moreover, the absence of the mouthpiece may further help by facilitating communication between the patient and the endoscopist.

The transnasal approach to EGD can supply additional information about the higher oesophagus and the pharyngeal region that can prove to be extremely beneficial not only to the endoscopist but also to the ENT surgeon [9] . In our study, we felt that the absence of the mouthpiece also increases the degree of comfort to the patients and makes swallowing easier. Another advantage of this method was that communication could flow more easily between the endoscopist and the patient. The total time for the procedure is not longer than peroral endoscopy and required less nursing aid.

Previous studies have shown that TENGD can make evident all the anatomical areas such as the pharynx, oesophagus, stomach and duodenum [7],[10],[11] . It can be useful in diagnosing nasopharyngeal lesions. Diagnostic TNEGD seems more tolerable than PEGD [11] . It also enables more patients to have the procedure without intravenous sedation. This reduces the risk of drug-related adverse events and considerable cost. Our study has shown that TENGD can be tolerated well and its diagnostic yield was the same as PEGD.

Indeed the insertion of an ultrathin endoscopy transnasally with the requisite level of expertise using xylocaine gel is not very distressing and is as easy as inserting a naso-gastric tube. Epistaxis has been reported in different studies [7],[11] . This may be due to the relative unfamiliarity of the endoscopist to the transnasal route, thus resulting in trauma to the nasal passage. In fact, this complication occurred only in our initial cases, which would imply this particular disadvantage could become a preventable issue with improved skill. Of course, the thin and small endoscopies optical quality and suction are somewhat compromised. These may require improvements in the future.

Although both groups showed good tolerability, the patients in the transnasal group had lesser side effects and showed a higher indication for a repeat procedure by the same route. Transnasal approach to endoscopy can also help in greatly reducing the cost of endoscopy by negating the use of sedatives, in addition to preventing its potential complications. In spite of the disadvantages mentioned, the increased comfort experienced by patients and their easy acceptability might soon make it a popular method as a first step in diagnostic EGD.

 
   References Top

1.Zaman A, Hahn M, Hapke R, Knigge K, Fennerty MB, Katou RM. Randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoscope gastrointest endosc 1999, 49: 279-84.  Back to cited text no. 1    
2.Al Atrakchi HA. Upper gastrointestinal endoscopy without sedation: Aprospective study of 2000 examinations. Gastrointest endosc 1989; 35:79-81.  Back to cited text no. 2    
3.Tan CC, Freeman JG. Throat spray for upper gastrointestinal endoscopy is quite acceptable to patients. Endoscopy 1996; 28:277-82.  Back to cited text no. 3  [PUBMED]  
4.Shaker R. Unsedated transnasal pharyngo­gastroduodenoscopy (TEGD): technique. Gastrointest Enclose 1994; 40: 346-8.  Back to cited text no. 4    
5.Dean R, Dua K, Massey B, Berger W, Hogan WJ, Shaker R..A comparative study of unsedated transnasal oesophagogastrodenoscopy and conventional EGD. Gastrointest Endosc 1996; 44:422-4.  Back to cited text no. 5    
6.Elfant AB, Scheider DM, Bourke MJ, et al. Prospective controlled trial of transnasal endoscopy (TNEGD) vs. peroral endoscopy (PEGD) [abstract]. Gastrointest Endosc 1996; 43:311.  Back to cited text no. 6    
7.Graig A, Hanlon J, Schoeman M. A comaprison of transnasal and transoral endoscopy with small diameter endoscopies in unsedated patients. Gastrointest Endosc 1999; 49:292-6.  Back to cited text no. 7    
8.Saeian K, Townsend WF, Rockling FA, et al. Unsedated transnasal EGD: An alternative approach to documenting Helicobacter Pylori eradication. Gastrointest Endosc 1999; 49: 297-301.  Back to cited text no. 8    
9.Sundokji A, Al Karawi MA. Sanai FM. Transnasal upper gastrointestinal endoscopy in detection of gastroesophageal reflux disease induced vocal cord polyp. Saudi Med J 2000; 21: 780-1.  Back to cited text no. 9    
10.Rey JF, Duforest D, Marker TA. Prospective comparison of nasal versus oral insertion of a thin endoscopy in healthy volunteers Endoscopy 1996; 422-4  Back to cited text no. 10    
11.Dumortier J, Pouchan T, Soazer J-Y, et al. Prospective Evaluation of transnasal oesophagogastroduodenscopy - feasibility and study on performance and tolerance. Gastrointest Endosc 1999; 49: 285-91.  Back to cited text no. 11    

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Correspondence Address:
Mohammed Ali Al Karawi
A-41, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861762

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