A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin video endoscope

Background: Potential advantages of unsedated endoscopy include prevention of side effects or morbidity related to sedation, less intensive patient monitoring, and less expense. There has been recent interest in unsedated oral and transnasal endoscopy with ultrathin endoscopes. Aim: Compare transnasal (T-EGD) with peroral (P-EGD) unsedated endoscopy (Olympus 6mm N230 ultrathin video (UT) instrument) with respect to patient tolerance and acceptance. Method: All endoscopists were trained in transnasal approach by ENT staff. Patients undergoing upper endoscopy for UGI symptoms were eligible. Exclusions include GI bleeding, dysphagia, history of sinus surgery or recent sinusitis. Patients were randomized to T-EGD or P-EGD. T-EGD patients received nasal spray (1% Phenylephrine/4% Lidocaine) and P-EGD patients received oral 20% Benzocaine spray. If the initial route of insertion failed, the patient was crossed over to the other route. If this also failed then the patient received a sedated exam with the UT. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where 0 is none/well tolerated and 10 is severe/poorly tolerated). Results: 50 of 85 recruited patients consented to undergo unsedated endoscopy. Reasons for unwillingness included not interested 7, fear of gagging 10, fear/anxiety 14, fear of T-EGD 4. There were 17 males and 8 females (mean age 46 yrs) in the P-EGD group and 12 males and 13 females (mean age 46 yrs) in the T-EGD group. All 25 P-EGD patients completed an unsedated exam. 22 of 25 (88%) T-EGD patients had a complete exam. 3 T-EGD exams failed due to severe pain on insertion. 2 of these 3 patients when crossed over to the P-EGD route had a successful exam. The third patient failed both routes. (Table: mean values ± SD, and*is p<0.05) Preprocedure Anxiety Discomfort on Insertion Discomfort During Exam Gagging Overall Tolerance P-EGD 3.5 ± 2.6 2.3 ± 2.7*2.0 ± 2.3*5.6 ± 2.8*2.2 ± 1.9*T-EGD 3.5 ± 2.9 5.0 ± 3.6 3.5 ± 3.4 3.3 ± 3.0 3.6 ± 3.6 23 of 25 (92%) P-EGD patients and 19 of 25 (76%), p>0.05. were willing to undergo future unsedated endoscopy. Conclusion: Unsedated endoscopy using either the transnasal or peroral route is generally well tolerated and was completed in 49 of 50 patients. Except for gagging, patients had less discomfort and better tolerance for P-EGD than T-EGD. More patients were willing to undergo repeat unsedated P-EGD than T-EGD.