A randomized trial of topical anesthesia comparing lidocaine versus lidocaine plus xylometazoline for unsedated transnasal upper gastrointestinal endoscopy.

BACKGROUND: The optimal topical anesthesia regimen for unsedated transnasal endoscopy is unknown. The addition of a nasal decongestant, such as xylometazoline (X), to a topical anesthestic may improve patient comfort. OBJECTIVE: To determine the effectiveness of lidocaine (L) versus L plus X (LX) for anesthesia in unsedated transnasal endoscopy. METHODS: Consecutive participants of the Aklavik Helicobacter pylori project were prospectively randomly assigned to receive LX or L for unsedated transnasal 4.9 mm ultrathin endoscopy. The primary outcome was overall procedure discomfort on a validated 10-point visual analogue scale (1 = no discomfort, 10 = severe discomfort). Secondary outcomes included pain, endoscope insertion difficulty, gagging, adverse events and encounter times. Results were presented as mean +/- SD, difference in mean, 95% CI. RESULTS: A total of 181 patients were randomly assigned to receive LX (n=94) and L (n=87). Baseline characteristics between the two groups were similar (mean age 40 years, 59% women). Overall, patient procedural discomfort with LX and L were 4.2+/-2.4 versus 3.9+/-2.1, respectively (0.29; 95% CI -0.39 to 0.96). Transnasal insertion difficulty was significantly lower with LX than with L (2.4+/-2.1 versus 3.2+/-2.8, respectively [-0.80; 95% CI -1.54 to -0.06]). Compared with L, the use of LX was associated with significantly less time needed to apply anesthesia (2.4+/-1.8 min versus 3.5+/-2.2 min, respectively [-1.10; 95% CI -1.71 min to -0.50 min]) and less time for insertion (3.2+/-1.8 min versus 3.9+/-2.2 min, respectively [-0.70 min; 95% CI -1.30 min to -0.10 min]). Epistaxis was rare but occurred less frequently with LX (1.1%) than with L (4.6%) (P=0.19). CONCLUSIONS: LX did not improve patient comfort for transnasal endoscopy compared with L alone. However, LX was associated with less difficulty with endoscope transnasal insertion and reduced insertion time. Further studies on the optimal regimen and dosing of anesthesia are required.

Early experience with unsedated ultrathin 4.9 mm transnasal gastroscopy: a pilot study.

BACKGROUND: Unsedated transnasal gastroscopy is a technique with unverified clinical advantages. OBJECTIVE: To evaluate the efficacy and procedure times with transnasal gastroscopy by physicians with no previous experience in transnasal endoscopy. METHODS: Unsedated transnasal gastroscopy using 4.9 mm ultrathin transnasal gastroscopes with randomization to two different biopsy forceps was prospectively evaluated during a single day in January 2008. The outcomes included patient tolerance (scale: 1, no discomfort; 10, severe discomfort), physician technical assessment (1, excellent; 10, very poor), gastric biopsy quality, adverse events and procedure times. RESULTS: Twenty patients underwent transnasal gastroscopy. Nineteen patients (95%) successfully completed transnasal gastroscopy. The patient-reported mean (+/- SD) overall discomfort level during the procedure was 4.0+/-1.9 compared with a physician-estimated level of 3.2+/-1.7 (P=0.04). Only 10% (n=2) reported they would have preferred sedated over unsedated gastroscopy. Mean total encounter time from anesthesia to discharge was 33.5+/-9.3 min. The time from anesthesia to insertion was 7.0+/-5.3 min and from room exit to discharge 6.2+/-2.9 min. No patients who had gastric biopsies taken (zero of 14) had any of unacceptable quality. The only adverse event was distressing sensations (dyspnea, dizziness) in one patient that started during pre-endoscopy anesthetic application, persisting postendoscopy, but without any abnormalities in vital signs. CONCLUSION: Assuming the adverse event was a rare reaction, early experience with unsedated ultrathin transnasal gastroscopy was an efficient, effective and well-tolerated procedure for evaluation of the upper gastrointestinal tract.