Unsedated transnasal small-caliber esophagogastroduodenoscopy in elderly and bedridden patients

Abstract

AIM:To evaluate the safety of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) for elderly and critically ill bedridden patients. METHODS:One prospective randomized comparative study and one crossover comparative study between transnasal small-caliber EGD and transoral conventional EGD was done (Study 1). For the comparative study, we enrolled 240 elderly patients aged > 65 years old. For the crossover analysis, we enrolled 30 bedridden patients with percutaneous endoscopic gastrostomy (PEG) (Study 2). We evaluated cardiopulmonary effects by measuring arterial oxygen saturation (SpO2) and calculating the rate-pressure product (RPP) (pulse rate × systolic blood pressure/100) at baseline, 2 and 5 min after endoscopic intubation in Study 1. To assess the risk for endoscopy-related aspiration pneumonia during EGD, we also measured blood leukocyte counts and serum C-reactive protein (CRP) levels before and 3 d after EGD in Study 2. RESULTS:In Study 1, we observed significant decreases in SpO2 during conventional transoral EGD, but not during transnasal small-caliber EGD (0.24% vs -0.24% after 2 min, and 0.18% vs -0.29% after 5 min, P = 0.034, P = 0.044). Significant differences of the RPP were not found between conventional transoral and transnasal small-caliber EGD. In Study 2, crossover analysis showed statistically significant increases of the RPP at 2 min after intubation and the end of endoscopy (26.8 and 34.6 vs 3.1 and 15.2, P = 0.044, P = 0.046), and decreases of SpO2 (-0.8% vs -0.1%, P = 0.042) during EGD with transoral conventional in comparison with transnasal small-caliber endoscopy. Thus, for bedridden patients with PEG feeding, who were examined in the supine position, transoral conventional EGD more severely suppressed cardiopulmonary function than transnasal small-caliber EGD. There were also significant increases in the markers of inflammation, blood leukocyte counts and serum CRP values, in bedridden patients after transoral conventional EGD, but not after transnasal small-caliber EGD performed with the patient in the supine position. Leukocyte count increased from 6053 ± 1975/L to 6900 ± 3392/L (P = 0.0008) and CRP values increased from 0.93 ± 0.24 to 2.49 ± 0.91 mg/dL (P = 0.0005) at 3 d after transoral conventional EGD. Aspiration pneumonia, possibly caused by the endoscopic examination, was found subsequently in two of 30 patients after transoral conventional EGD. CONCLUSION:Transnasal small-caliber EGD is a safer method than transoral conventional EGD in critically ill, bedridden patients who are undergoing PEG feeding.

Aortoesophageal Fistula after Thoracic Endovascular Aortic Repair Diagnosed and Followed with Endoscopy

“…However, the load of the endoscopic examinations may constitute a risk for rupture of the aortic aneurysm. Transnasal small caliber endoscopy is a safer procedure than transoral conventional endoscopy particularly in terms of cardiopulmonary effects (11,12). Therefore, for the management of patients suspected of having AEFs, transnasal endoscopy is considered after CT.…”

The Usefulness of an Intra-Oropharyngeal U-turn Method using Trans-Nasal Endoscopy for Detecting Superficial Squamous Cell Carcinoma of the Base of the Tongue

“…Trans-nasal endoscopy can usually be performed comfortably due to attenuation of the gag reflex [22]; indeed in Japan, trans-nasal endoscopy is a very common procedure and can be performed without sedation. It has also been reported that trans-nasal endoscopy is less invasive than other techniques with respect to the cardiopulmonary function [23][24].…”

Unsedated small caliber esophagogastroduodenoscopy: Can we trust this technique?

“…In most comparative studies, transnasal EGD was found to have smaller cardiovascular impacts than transoral conventional EGD, and transnasal EGD was found to be safer than conventional EGD for most patients (20,21,29). Transnasal small caliber EGD was reported to be a safer method than transoral conventional EGD in aged hypertensive patients or critically ill, bedridden patients who are undergoing percutaneous endoscopic gastrostomy (PEG) feeding (30,31). The explanation behind these results can be attributed to less sympathetic stimulation induced by transnasal small caliber EGD leading to lesser elevation of blood pressure and pulse (5).…”

“…It is known that the transoral conventional endoscope may stimulate salivary secretion and further increase the risk of aspiration. In one study, unsedated transnasal small caliber EGD in elderly and bedridden patients was found to be much safer than its transoral counterpart with conventional endoscopes with regard to the risk of aspiration pneumonia (31). Application of this technique was also reported to be a safe and tolerable technique in the diagnosis of hypopharyngeal cancer and screening of simultaneous esophageal cancer (26).…”