Analysis of cardiopulmonary stress during endoscopy: is unsedated transnasal esophagogastroduodenoscopy appropriate for elderly patients?

BACKGROUND: Transnasal esophagogastroduodenoscopy (EGD) without sedation has been reported to be safe and tolerable. It has recently been used widely in Japan for the detection of upper gastrointestinal disease. Alternatively, transoral examination using a thin endoscope has also been reported to be highly tolerable. OBJECTIVE: To examine the cardiocirculatory effects of transoral versus transnasal EGD in an attempt to determine the most suitable endoscopic methods for patients ≥75 years of age. METHODS: Subjects who underwent monitoring of respiratory and circulatory dynamics without sedation during endoscopic screening examinations were enrolled at the New Ooe Hospital (Kyoto, Japan) between April 2008 and March 2009. A total of 165 patients (age ≥75 years) provided written informed consent and were investigated in the present study. Patients were randomly divided into three subgroups: UO group--thin endoscope; SO group--standard endoscope; and UT group--transnasal EGD. Percutaneous arterial blood oxygen saturation, heart rate and blood pressure were evaluated just before EGD and at five time points during EGD. After transnasal EGD, patients who had previously been examined using transoral EGD with a standard endoscope were asked about preferences for their next examination. RESULTS: There were no statistical differences in the characteristics among the groups. Percutaneous oxygen saturation in the UT group showed a transient drop compared with the SO and UO groups at the beginning of the endoscopic procedure. Heart rate showed no significant differences among the SO, UO and UT groups; Systolic blood pressure in the UO group was lower immediately after insertion compared with the SO and UT groups. The rate pressure product in the UO group was comparable with that in the UT group during endoscopy, and the SO group showed a continuously higher level than the UO and UT groups. More than one-half (54.4%) of patients were 'willing to choose transnasal EGD for next examination'. CONCLUSIONS: For elderly patients, unsedated transnasal EGD failed to show an advantage over unsedated standard endoscopy. Transoral thin EGD was estimated to be safe and tolerable.

Current status and evaluation of transnasal esophagogastroduodenoscopy.

We reviewed the current status of transnasal esophagogastroduodenoscopy (EGD) with regard to tolerance, safety, feasibility and accuracy. Comparison of standard and ultrathin scopes and recently reported endoscopic techniques with transnasal insertion are also described as well as the current status of transnasal EGD in European countries compared with Japan. As several studies concluded that transnasal EGD can facilitate comfortable endoscopy without the need for sedative drugs, it has been tried in countries in which a relatively high number of unsedated EGD are carried out in daily practice. Long-tube intubation of the jejunum with the assistance of transnasal EGD will also be a part of the daily practice in the near future. However, its safety and accuracy should be further investigated. Even a standard scope whose charge-coupled device (CCD) has the same resolution as an ultrathin scope is superior to an ultrathin scope in terms of luminosity and resolution. Given the small number of procedures reported to date, the absolute complication rate of unsedated transnasal EGD is unknown. Methods of nasal anesthesia, as well as informed consent, indications and contraindications for transnasal EGD are not standardized. A guideline of transnasal EGD is under discussion by the Japanese Gastroenterological Endoscopy Society.

Feasibility and tolerance of 2-way and 4-way angulation videoscopes for unsedated patients undergoing transnasal EGD in GI cancer screening.

BACKGROUND: The differences between 2-way and 4-way angulation endoscopes for use in unsedated patients undergoing transnasal EGD have not been elucidated. OBJECTIVE: Our purpose was to evaluate the feasibility and tolerance of 2- and 4-way angulation endoscopes for unsedated transnasal EGD in GI cancer screening of elderly people. DESIGN: A total of 291 patients were randomized to receive unsedated transnasal EGD with a 5.2-mm diameter 2-way angulation endoscope (GIF-N260, Olympus, Tokyo, Japan) (n = 146) or 5.5-mm diameter 4-way angulation endoscope (XGIF-XP240N2, Olympus) (n = 145). The transnasal insertion success rate and incidence of epistaxis were compared. The following parameters were evaluated: overall quality of the examination, ease of passing the endoscope through the pylorus, intubation of the second portion of the duodenum, ability to observe the entire upper GI tract and perform target biopsy, and examination time. Patient tolerance and acceptance were also assessed with regard to nasal pain, choking, gagging, abdominal discomfort, and overall pain and discomfort. SETTING: Matsushita Health Care Center, Moriguchi, Japan. PATIENTS: A total of 291 patients had unsedated transnasal EGD as part of a gastric cancer screening program. RESULTS: Use of the pediatric 4-way angulation endoscope significantly shortened the examination time when biopsy was performed compared with the 2-way angulation instrument, whereas the examination time without biopsy was not significantly different. Other parameters were not significantly different between the 2 endoscopes. CONCLUSION: For unsedated transnasal EGD with biopsy, the 5.5-mm 4-way angulation videoscope shortens examination time while providing easy transnasal insertion and improved patient tolerance.

Initial experience with a new peroral electronic pancreatoscope with an accessory channel.

BACKGROUND: A peroral electronic pancreatoscope was previously developed to improve visualization of the pancreatic duct, but this instrument had no accessory channel. METHODS: A new peroral electronic pancreatoscope (2.6-mm external diameter) with an accessory channel (0.5 mm) was developed. Peroral pancreatoscopy or cholangioscopy was performed with this new instrument in 11 patients with various pancreatobiliary diseases. The clinical utility of the new peroral electronic pancreatoscope was assessed, and visualization with this new instrument was compared with that of the prototype. RESULTS: The resolution of the two instrument systems was nearly equal, with that provided by the new peroral electronic pancreatoscope being slightly better. The new peroral electronic pancreatoscope was inserted successfully into the pancreatic or bile duct in 9 of the 11 patients (82%). Observation of a predetermined target and juice collection with direct visualization was successful in 8 of the 9 patients (89%). CONCLUSIONS: The new peroral electronic pancreatoscope with an accessory channel was useful for clinical diagnosis of various pancreatobiliary diseases. Visualization is excellent. Pancreatic juice and other samples can be collected under direct visualization.

Effect of Helicobacter pylori eradication on gastroesophageal function.

BACKGROUND: To elucidate the cause of possible occurrence of reflux esophagitis after Helicobacter pylori eradication, gastric and esophageal function among H. pylori infected Japanese patients were evaluated both before and after eradication therapy. METHODS: Nine H. pylori-positive patients were studied before and 6 months after successful H. pylori eradication. Studies included gastric emptying, esophageal manometry, gastric and esophageal pH monitoring as well as measuring serum levels of gastrin, pepsinogen I and pepsinogen II. RESULTS: Helicobacter pylori eradication was associated with a significant change in serum gastrin and pepsinogen levels, consistent with the improvement in mucosal inflammation. There was no significant change in gastric emptying, fasting or postprandial lower esophageal sphincter (LES) pressure, esophageal primary peristaltic contractions, frequency of transient LES relaxation, or gastroesophageal reflux, as assessed by 24 h pH monitoring. The percent time of the gastric pH>4 at night decreased significantly. A 41-year-old male developed erosive gastroesophageal reflux disease (GERD) (Los Angeles Classification Grade A) after eradication. Physiological studies showed he had abnormal esophageal motility prior to H. pylori eradication. CONCLUSIONS: With the exception of gastric pH at night, most patients did not experience a significant change in gastric or esophageal function after H. pylori eradication. Development of GERD post H. pylori eradication likely reflects an increase in the acidity of the refluxate superimposed on pre-existing abnormalities in gastroesophageal motility.

Direct cholangioscopy and pancreatoscopy.

Direct cholangiopancreatoscopy has played a minor role in the diagnosis and treatment of pancreaticobiliary disorders, initially because of instrument fragility and suboptimal imaging, and later because of improvements in noninvasive and semi-invasive imaging techniques. Digital scopes provide superior images and hold the promise of increased application and improved durability.

Electronic pancreatoscopy for the diagnosis of pancreatic diseases.

OBJECTIVES: Diagnostic pancreatoscopy was performed in 56 patients using the newly developed peroral electronic pancreatoscope (PEPS). The diagnostic value of the PEPS for pancreatic diseases was evaluated. METHODS: The PEPS (external diameter = 2.1 mm, bidirectional tip deflection) was developed with a minute 50,000-pixel interline charge-coupled device. Pancreatoscopy was performed by means of an endoscopic retrograde approach without sphincterotomy. The cases examined were normal (three), chronic pancreatitis (32), pancreatic cancer (eight), and intraductal papillary mucinous tumors (13). RESULTS: Of the 56 cases, 42 (75%) were adequately seen. In normal cases, fine capillary vessels were clearly visualized on the smooth whitish-pink mucosa. Findings in chronic pancreatitis included protein plugs, calcified stones, rough whitish mucosa, scar formation, edema, erythema, and indistinct capillary appearance. All the stenoses of chronic pancreatitis could be differentiated from those of pancreatic cancer with the PEPS. In the pancreatic cancer cases, all patients had stenoses or duct cutoffs; most cases had friable mucosa with erythema and erosive changes, and a single patient had a compressed pancreatic duct wall covered with normal epithelium. In the cases of intraductal papillary mucinous tumors, papillary tumors were visualized with extreme clarity. In the case of adenocarcinoma, the PEPS revealed oval-shaped tumors with spotty redness or villous tumors with dilation of capillary vessels. Moderate acute pancreatitis was recognized after pancreatoscopy in one of the 56 cases (1.8%). CONCLUSIONS: Electronic pancreatoscopy with the PEPS is feasible in most patients and technically safe, and improves diagnostic yield over conventional pancreatoscopy.