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Grave’s disease is a clinical syndrome consisting of hypermetabolism, diffuse thyroid enlargement and exophthalmos. Which has ocular complications. Due to the high incidence of these complications and the risk of blindness special attention is needed. Many therapeutic methods including medical surgical and radiotherapy for ocular complications are suggested. In cases of medical therapy failure, surgery is recommended. One of its methods is orbital decompression and if needed optic nerve decompression by transnasal endoscopy. A Graves’ patient with bilateral exophthalmos and severe visual loss was operated. With this method. After surgery in addition to return of normal eye appearance and eye movements, visual acuity of left eye improved significantly. This article describes this method, its results and complications.

Aim Ezetimibe inhibits cholesterol absorption by blocking Niemann- Pick C1-like 1 proteins ( NPC1L1) expressed in the small intestine. Because NPC1L1 is also expressed in human liver, ezetimibe conceivably alters biliary lipid compositions. Here, we performed a clinical trial investigating the effect of ezetimibe on biliary lipids using transnasal endoscopy for bile collection. Methods Eight patients with dyslipidemia enrolled in this study completed blood and bile sampling before and at 3 months after ezetimibe treatment (10 mg/day), and the samples are analyzed. Results Endoscopic bile sampling was performed safely and painlessly. Serum sterol-based biomarkers declared decreased cholesterol absorption and increased synthesis. On analysis of biliary lipids, four of the eight patients showed relative decrease of cholesterol and increase of bile acids with improved lithogenicity while the remainder exhibited the symmetrical changes. Conclusion Our data suggests that biliary lithogenicity is not worsened by ezetimibe. The regulation of biliary cholesterol is presumably multifactorial such as body cholesterol pool size and biliary cholesterol reabsorption by NPC1L1 in the liver. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the efficacy of transoral or transnasal endoscopic-guided adenoidectomy compared with endoscopic nasopharyngeal inspection at the end of curettage adenoidectomy. A prospective case series of patients who had adenoidectomy. A total of 27 girls and 34 boys (age range 2.5-18 years) in whom adenoidectomy with or without tonsillectomy procedure was planned were included in the study. The cases were divided into three groups. Group 1 Transoral endoscopic-guided adenoidectomy performed patients. Group 2 Transnasal endoscopic-guided adenoidectomy performed patients. Group 3 Transnasal endoscopic nasopharyngeal exploration performed at the end of the conventional curettage adenoidectomy. The study was completed on 61 children. Mean age and sex frequency were not significant different between the groups. Mean operative time were 11.6 ± 2.9, 15.6 ± 4.4 and 9.7 ± 2 min, respectively ( p > 0.05). On the other hand, significant differences were observed in operative time between group 1 and group 2 ( p < 0.05), and between group 2 and group 3 ( p < 0.05). Transnasal endoscopic examination at the end of curettage adenoidectomy is an appropriate method to assess the residual adenoid tissue after conventional curettage adenoidectomy. Also, operative time of this method is shorter than transoral or transnasal endoscopic-guided adenoidectomy. We recommend transnasal endoscopic inspection in all patients after conventional curettage adenoidectomy. [ABSTRACT FROM AUTHOR]

Background and Aim: Newly developed ultrathin transnasal endoscope, the GIFXP290N, makes possible a resolving power similar to the GIF-H260 at a distance of 3 mm. We conducted surveillance of subjects with Barrett's esophagus using this ultrathin transnasal endoscopy. In Japan the lower margin of the lower esophageal palisade vessels is defined the gastroesophageal junction in deep inspiration. We diagnose Barrett's esophagus if columnar epithelium is present on the oral side of the gastroesophageal junction. Methods and Results: Barrett's esophagus was confirmed in 116 out of 135 subjects (85.9%), with 17 cases of short-segment Barrett's esophagus (SSBE) and 99 of ultra-shortsegment Barrett's esophagus. Close observation of the Barrett's esophagus mucosal structural pattern using narrow band imaging revealed 29 cases with an oval or round pattern, 29 with a long straight pattern, 47 with a villous pattern, 8 with a cerebriform pattern, and 6 with an irregular pattern according to Goda classification. Mucosal biopsies from all subjects with SSBE are examined. Histological examination revealed intestinal metaplasia in only eight subjects. We grouped the oval/round and long straight patterns as closed type, and the villous, cerebriform, and irregular patterns as open type. Analysis of the relationship between these mucosal patterns and background factors revealed a significant correlation between intestinal metaplasia and the open-type pattern. Conclusion: We consider this new ultrathin transnasal endoscopy to be a useful technique for surveillance of Barrett's esophagus, especially SSBE. [ABSTRACT FROM AUTHOR]

Background and Aim The new developed ultrathin transnasal endoscope, the GIF- XP290 N, makes possible a resolving power similar to the GIF- H260 at a distance of 3 mm. In this study, using the GIF- XP290 N, we evaluated whether endoscopic diagnosis (discrimination between benign and malignant) of gastric lesions is possible using nonmagnified narrow-band imaging ( NBI) endoscopy. Methods The subjects were 255 consecutive patients who underwent screening of the gastrointestinal tract using new ultrathin transnasal endoscopy. Their average age was 65.2 ± 11.4 years. The male-female ratio was 2.5:1. All cases were examined using conventional white-light imaging ( WLI) and nonmagnified NBI. When a depressed lesion was detected in the stomach, it was examined using WLI, then NBI close examination (at about 3 mm). We observed the mucosal structure of the lesion using close visualization with NBI. Concerning mucosal structural changes, we looked for a clear demarcation line between the lesion and the surrounding mucosa, and loss, irregularity, or nonuniformity of the lesion mucosal microsurface pattern. Results A total of 52 depressed lesions were examined. The histological diagnosis was cancer for 8 lesions, and noncancer for 44 lesions. WLI examination yielded a sensitivity of 50.0% (4/8), specificity of 63.6% (28/44), and accuracy 61.5% (32/52). On the other hand, NBI close examination yielded a sensitivity of 87.5% (7/8), specificity of 93.2% (41/44), and accuracy of 92.3% (48/52), significantly higher. Conclusion NBI close examination using ultrathin transnasal endoscopy enables mucosal diagnosis even without magnification and was considered to be an effective technique for improving endoscopic diagnosis. [ABSTRACT FROM AUTHOR]

Background: Screening for Barrett's esophagus (BE) and adenocarcinoma (EAC) is controversial, but interest remains in finding the optimal method. Attitudes on screening within the community are unknown. We aimed to assess these attitudes via a survey. Study: A mixed-mode survey was conducted in adults >50 years to assess awareness regarding BE, willingness to participate in screening, and preferences regarding method of screening. Methods evaluated were sedated endoscopy (sEGD), unsedated transnasal endoscopy (uTNE) and video capsule (VCE). Results: A total of 136 from 413 (33 %) adults responded [47 % males, mean (SD) age 63 (10.2) years], and 26 % of responders knew of BE at baseline. After reading the information on BE, 72 % were interested in screening. A history of undergoing screening tests and GI symptoms were predictive of interest. Unsedated techniques were preferred by 64 % (VCE: 56 % and uTNE: 8 %) versus sEGD (36 %). Conclusions: The majority of adults were willing to undergo screening for BE/EAC, with a preference for unsedated techniques. [ABSTRACT FROM AUTHOR]

Background/Purpose: Differences in patient tolerance, acceptance, and satisfaction of esophagogastroduodenoscopy (EGD) between transnasal (TN) and peroral (PO) routes using a 5-mm video endoscope. Methods: A total of 220 enrolled patients were assigned randomly to two groups undergoing EGD—110 patients each for TN and PO. The successful rate, procedure time, and adverse events were recorded. After the procedure, patients answered a validated questionnaire of tolerance, acceptance, and satisfaction. Results: There were 6 failures (5.7%) of nasal intubation and two nasal bleeding (2%) among 105 TN-EGD procedures. All PO patients (n =102) completed EGD successfully without adverse event. Compared to PO, the procedure of TN achieved lower successful rate (94% vs. 100%, p =0.01), was complicated with epistaxis (2% vs. 0%) and took longer (mean±SD 19.9±6.1min vs. 16.8±6.4min, p =0.0001). The patients undergoing TN-EGD indicated less discomfort during passing pharynx (scores of 2.1±2.0 vs. 3.1±2.6, p =0.011) but more pain during inserting scope (scores of 2.2±1.6 vs. 1.5±1.8, p =0.0001). Eventually, there were no significant differences between TN and PO regarding the overall procedure discomfort (scores of 10.7±6.6 vs. 11.1±7.8 scores, p =0.9), satisfaction (scores of 41.2±4.2 vs. 41.3±4.6, p =0.91), and acceptability (87.8% vs. 94.2%, p =0.91). Conclusion: PO intubation seems an excellent alternative method when using a 5-mm ultrathin endoscopy because it achieves comparable patient tolerance, acceptance, and satisfaction as TN intubation, takes less time and causes lower intubation failure and epistaxis. [ABSTRACT FROM AUTHOR]

Background & Aims: Both unsedated transoral endoscopy (TOE) and sedated TOE have some drawbacks in clinical practice. Unsedated transnasal endoscopy (TNE) has been suggested as an alternative to both methods. This study aimed to determine the advantages of TNE in patients who have previously undergone unsedated conventional TOE. Methods: Patients who had received an unsedated TOE in the last 12 months and were scheduled for a second upper endoscopy were included. They were randomized to undergo either unsedated TOE, using a standard endoscope, or unsedated TNE, using an ultrathin endoscope. Post-procedure, patients were asked to complete a questionnaire to assess pain, discomfort and acceptability of the procedure, and to compare the current procedure with their previous unsedated TOE. Endoscope insertion rate, procedure duration, and side-effects were recorded. Results: Each group included 50 patients. With the exception of nasal pain, the tolerability and acceptance were significantly greater in the unsedated TNE group. Significantly more TNE patients (82%) found the current endoscopic procedure to be better than their previous TOE when compared with patients who had received a second TOE (12%). A repeat procedure was significantly more acceptable for TNE patients when compared to the TOE group (68% vs.16%). The duration of endoscopy was significantly shorter in TOE than in TNE (p<0.05). Endoscope insertion failed in 4% and mild epistaxis was observed in 4% of TNE patients. Conclusion: Unsedated TNE was better tolerated in endoscopy experienced patients when compared with unsedated TOE. The majority of patients found TNE more acceptable and preferable to TOE, suggesting that TNE should become a more common practice in clinics when applicable. [ABSTRACT FROM AUTHOR]

Conclusions: Hemorrhage within the ethmoid and/or sphenoid sinus and an interval between the time of injury and the time of operation exceeding 3 days are the risk factors for the visual prognosis of traumatic blindness. Objectives: To investigate the therapeutic efficacy of endoscopic optic nerve decompression in the treatment of traumatic blindness and to evaluate the relevant prognostic factors. Methods: Eighty-five cases of traumatic blindness were analyzed retrospectively. Univariate analysis and multiple logistic regression were performed to evaluate potential prognostic factors. Results: The overall rate of vision acuity improvement was 44.7% (38 of 85). Univariate analysis indicated that hemorrhage within the ethmoid and/or sphenoid sinus was significantly associated with unrecovered visual acuity. However, multiple logistic regression analysis identified that an interval between the time of injury and the time of operation exceeding 3 days, and hemorrhage within the ethmoid and/or sphenoid sinus were significantly correlated with the efficacy of treatment of traumatic blindness. [ABSTRACT FROM AUTHOR]

Abstract: The use of unsedated transnasal esophagogastroduodenoscopy (UT-EGD) is a milestone in gastrointestinal endoscopy. Although the image quality, suction, air insufflation, and lens washing in UT-EGD have been reported to be inferior to those in conventional peroral EGD (P-EGD), the former procedure is associated with reduced gag reflex and is better tolerated than the latter. Several large studies have shown that transnasal endoscopy is safe, well tolerated, and less risky than P-EGD, which requires sedation in most western countries. Moreover, UT-EGD induces less sympathetic stimulation and less oxygen desaturation compared with P-EGD. Use of an ultrathin endoscopy, an alternative choice to endoscopic retrograde cholangiography, is helpful in patients with gastrointestinal stenosis and is a convenient method for postpyloric feeding tube placement. However, nasal anesthetic methods, techniques of scope insertion and withdrawal from the delicate nasal cavity, and therapeutic applications may be difficult to learn without proper training, even for an experienced endoscopist. [Copyright &y& Elsevier]

In the past decade, surgical treatment of skull base pathologies has greatly advanced through the advent of the endoscope and later of the high definition endoscope. Recently a new type of three dimensional (3D) scope has been introduced to permit the surgeon a real stereoscopic vision of the operating field and to overcome the limitations of the 2D endoscopic set up. As with all new technologies a formalized adaptation period is essential for the surgeon to secure steady outcomes and low complications. To determine the subjective difficulties that one may encounter during this sensitive period we therefore devised and analyzed a questionnaire that evaluated the first ten procedures with the 3D device of junior and senior ENT and neurosurgeons. 52 consecutive patients were treated with purely 3D transnasal endoscopy for skull base pathologies. Sensation of strain or dizziness, difficulties in anatomical orientation and difficulties in performing the surgical gesture were assessed for each surgeon. The learning curve and difficulties of junior and senior surgeons are discussed and strategies to overcome the initial problems are devised. Our results confirm that after only few procedures, the advantages of the 3D endoscopic system including better visualization and depth perception are able to outweigh the inconveniences that go hand in hand with the learning of a new skill set. [ABSTRACT FROM AUTHOR]

Background and Aim Endoscopic biliary drainage ( BD) is an effective palliative treatment for acute cholangitis. Transnasal endoscopy ( TNE) using an ultraslim endoscope can be less stressful and has limited hemodynamic effects compared with endoscopic retrograde cholangiography using a conventional duodenoscope. Here, we evaluate the clinical usefulness of direct BD by TNE in critically ill patients with acute cholangitis who had undergone endoscopic sphincterotomy ( ES) previously. Methods Twenty-three patients with severe-to-moderate acute cholangitis who had undergone ES previously were enrolled prospectively. BD was achieved by TNE, using an ultraslim upper endoscope with a 5- Fr nasobiliary drainage catheter and/or a plastic stent. The technical and clinical success, as well as the safety, of the procedure were investigated. Results A total of 23 patients were enrolled, including 17 with bile duct stones. The severity of the cholangitis was severe in nine (39.1%) and moderate in 14 patients (60.9%). The technical success rate was 95.7% (22/23). Nasobiliary drainage was performed in 15 patients, a plastic stent was placed in three, and both treatments were used in four patients. In three patients, direct BD by TNE was achieved in the intensive care unit without fluoroscopy. Direct cholangioscopy for distal common bile duct was performed in nine patients (40.9%), and three patients underwent immediate stone extraction under endoscopic visualization. Clinical improvement was achieved in 20/23 (87.0%) of patients. No significant procedure-related complications occurred. Conclusion Direct BD by TNE may be useful in critically ill patients with severe-to-moderate acute cholangitis who had undergone ES previously. [ABSTRACT FROM AUTHOR]

Objectives: We clarify and demonstrate the utility of our new method of voice prosthesis insertion using puncture from the esophageal lumen. Methods: Our new reverse puncture method using a flexible endoscope can be performed in an outpatient clinic under local anesthesia. We conducted a clinical trial with patients with head and neck cancer between April 2010 and February 2012. Our study focused on the following three points: 1) the percentage of patients for whom the procedure was successful; 2) the duration of the operation; and 3) any adverse effects. Results: The puncture was performed successfully for 21 of 22 patients (95%). The mean duration of the operation, excluding the time for local anesthesia, was only 11.6 minutes. All patients began voice rehabilitation and attained peroral intake immediately after the operation. None of the patients suffered complications from the procedures. Conclusions: Most patients were treated with our new method with ease and at low risk. The high success rate and the absence of complications demonstrate the benefits of our method. We conclude that our method can be recommended for secondary reverse tracheoesophageal puncture. [ABSTRACT FROM AUTHOR]

Aim: One of the prohibiting factors in achieving complete small bowel capsule endoscopy is slow gastric transit of the capsule. The present study retrospectively investigated the success rate of, and the time required for, transnasal endoscope-assisted capsule placement to assess its clinical utility. Methods: In 24 of 27 patients who underwent capsule placement assisted by a transnasal endoscope, the capsule was successfully transported to and released in the duodenum (capsule placement group). For each patient in the capsule placement group, three age- and sex-matched patients who underwent conventional capsule endoscopy were assigned as controls ( n = 72). Gastric transit time, small bowel transit time, and rate of capsule arrival at the cecum within 8 h were compared between the two patient groups. Results: Among the 27 patients in whom capsule placement was carried out, the capsule was successfully placed in the duodenum in 24 patients (88.9% success rate). In the capsule placement group, gastric transit time was significantly shorter (10.5 vs 46.2 min, P = 0.0021), small bowel transit time was significantly longer (354.7 vs 301.3 min, P = 0.0134), and completion rate (capsule arrival at the cecum within 8 h) was significantly higher (83.3 vs 61.1%, P = 0.0455) than in the control group. There were no procedural accidents associated with capsule placement. Conclusion: Transnasal endoscope-assisted capsule placement appears to be a safe and reliable procedure, achieving complete small bowel capsule endoscopy, and is considered clinically useful. [ABSTRACT FROM AUTHOR]

Aim: The present prospective observational study investigates the safety of transnasal percutaneous endoscopic gastrostomy (T-PEG) carried out by a single physician using an ultrathin endoscope. Methods: A single endoscopist attempted the unsedated transnasal insertion of a 20-Fr PEG tube using a pull-method in 31 dysphagic patients: 11 females and 20 males aged 76.5 ± 10.6 (46-96) years, using a 5-mm-diameter endoscope. The indications for PEG, cardiopulmonary function before and after T-PEG, operation time, success or failure, and any immediate adverse events that occurred during each procedure were recorded. Complications, including peristomal infection, systemic infection, tube lifespan, and patient mortality were monitored throughout the post-T-PEG follow-up period. Results: Thirty (96.8%) of the transnasal PEG insertions were successful. The mean operation time was 14.7 ± 2.9 (10-20) min, and cardiopulmonary function did not change before and after T-PEG. Complications included three (10%) cases of epistaxis, eight (26.6%) cases of minor Pseudomonas wound infection and two cases of Foley-related urinary tract infection (UTI). No self-extubation was observed, and the mean lifespan of the PEG tubes was 10.7 ± 2.2 months. Four patients died from pneumonia 10 months after T-PEG insertion. Conclusion: Unsedated T-PEG insertion carried out by a single physician is a feasible and safe procedure. No major complications or mortality were observed following the procedures; only minor Pseudomonas aeruginosa wound infections were noted. It is an alternative method for dysphagic patients when transoral insertion of endoscopy is impossible. [ABSTRACT FROM AUTHOR]

ABSTRACT Simulation of endoscopic navigation in the narrow nasal cavity poses important challenges to the computation of adequate and near-realistic collision response and haptic feedback because extensive multidirectional contact and massive tissue deformations are inevitable. We present a virtual coupling algorithm that provides stable collision response as well as intuitive and smooth haptic interaction in all phases of the simulation. In each iteration, continuous collision detection between the point shell representing the surface of the virtual patient anatomy and the endoscope, represented by a cylinder, is performed. This allows for rolling back the instrument movement to the point in time the first collision occurred. Subsequently, a relaxation process locally optimizes the position and orientation of the instrument. A novel method of applying contact forces to colliding tissues and thus triggering appropriate deformations improves the fluency of navigation. This paper describes the algorithm and presents experimental results. © Her Majesty the Queen in Right of Canada 2012. Reproduced with the permission of the Minister of Medical Devices, National Research Council Canada. [ABSTRACT FROM AUTHOR]

A 65-year-old woman, a case of cranio-vertebral junction anomaly, presented with a sudden onset of quadriparesis, dysphagia, and breathing difficulty and required emergency surgery. She underwent image-guided endoscopic transnasal odontoidectomy followed by occipito-cervical decompression and stabilization. She recovered well, with immediate improvement of respiratory function. Burning paresthesias disappeared and the upper limbs function normalized. [ABSTRACT FROM AUTHOR]

Objective To clarify the usefulness of transnasal esophagogastroduodenoscope ( N- EGD) with all flexible imaging color enhancement ( FICE) patterns (0-9) for the diagnosis of esophageal varices ( EV). Methods A total of 50 patients with EV were examined during the same period by N- EGD without sedation and by peroral endoscopy ( O- EGD) with sedation. The visibility of treatment scars, microvessels, recurrent EV and red color sign ( RCS) were measured. Visibility was evaluated by five blinded observers (poor-good: 0-10), and the effect of both endoscopic examinations on the cardiorespiratory function of the patients was measured. Results The image scores for O- EGD and N- EGD with ordinary mode and N- EGD with FICE were 7.3 ± 1.2, 6.1 ± 1.0 and 6.9 ± 1.0 for treatment scars; 7.2 ± 1.4, 6.2 ± 1.2 and 7.3 ± 1.0 for microvessels; 7.2 ± 1.2, 6.1 ± 1.0 and 7.1 ± 1.0 for recurrent EV and 7.2 ± 1.3, 6.1 ± 1.3, and 7.2 ± 1.2 for RCS, respectively (intraclass correlation coefficients > 0.6). When FICE patterns 2, 6 and 9 were used, visibility was much improved. Ten minutes after insertion, the double product values in the N- EGD with the FICE group were significantly better ( P < 0.05). Conclusions N- EGD with FICE is very useful for the diagnosis of EV and can improve the visibility of N- EGD on each lesion to the same level as that of O- EGD. N- EGD with FICE does not require sedation and may reduce the risk of hepatic encephalopathy. [ABSTRACT FROM AUTHOR]

Aim: Although frequent vomiting reflexes during esophagogastroduodenoscopy (EGD) causes suffering in patients, very few studies have investigated the characteristics of subjects who frequently develop vomiting reflexes. This study examined the incidence of the vomiting reflex and related factors, especially upper gastrointestinal symptoms, among individuals undergoing transoral EGD. Methods: Subjects included 488 consecutive adults (mean age, 56.1 ± 8.9 years) who underwent transoral EGD for gastric cancer screening between February 2010 and March 2011. All procedures were performed by an endoscopist with 15 years of experience. Based on a questionnaire survey using the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG), symptoms (dyspepsia and acid reflux symptoms) and the number of vomiting reflexes during EGD were recorded. Results: Of the 488 subjects, 271 (56%) developed vomiting reflexes (mean, 4.2 times). This reflex-positive group was younger (54.3 ± 9.5 years) than the reflex-negative group (58.3 ± 7.7 years, P < 0.001). The number of subjects in the reflex-positive group with a high FSSG dyspepsia score (2.27 ± 2.57 vs 1.23 ± 1.84; P < 0.001), acid reflux symptom score (1.96 ± 2.22 vs 1.34 ± 2.14; P < 0.01) or an esophageal hiatal hernia (14.8% vs 4.6%; P < 0.001) was significantly higher than in the reflex-negative group. Multivariate analysis also showed a significant correlation between these four factors and the occurrence of vomiting reflexes. Using an FSSG dyspepsia score of 1 as the cut-off offered 68% sensitivity and 57% specificity for predicting the occurrence of vomiting reflexes. Conclusion: Based on FSSG questionnaire responses on upper gastrointestinal symptoms, dyspepsia symptoms, in particular, are related to presence of vomiting reflexes during EGD. [ABSTRACT FROM AUTHOR]

Background and Aim: Biopsy specimens are taken during transnasal esophagogastroduodenoscopy with 1.8 mm forceps. The aims of this study were to compare the concordance of the Campylobacter-like organism (CLO) test and histological diagnoses between biopsies taken with 1.8 mm and 2.2 mm forceps and to determine whether the concordance of the CLO test could be improved by increasing the number of specimens using 1.8 mm forceps. Methods: A total of 200 patients were enrolled. We first performed the CLO test twice using each sample taken with both forceps in 100 patients. The CLO test was conducted three times again after confirming the difference in the CLO test between two forceps: (i) one sample with 1.8 mm forceps; (ii) two with 1.8 mm; and (iii) one with 2.2 mm in the other 100 patients. Additionally, each specimen was taken from the same gastric lesions in 200 patients for the histological diagnosis using both forceps types. Results: The concordance rate of the CLO test between each sample with 1.8 mm and 2.2 mm forceps was 83% (κ-value, 0.64), and that between two samples with 1.8 mm and one with 2.2 mm was 92% (κ-value, 0.83). The concordance rate of the histological diagnosis with 1.8 and 2.2 mm was 97% (κ-value, 0.84). Conclusions: At least two samples using 1.8 mm forceps might be needed to obtain similar results on the CLO test using 2.2 mm. But, the size difference between two forceps did not influence the histological diagnosis. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Asymptomatic subjects volunteering for research studies are generally stratified as healthy based on a questionnaire, medical interviewing, and physical examination. The aim of this study was to evaluate the prevalence of upper gastrointestinal (GI) abnormalities in healthy asymptomatic volunteers using unsedated transnasal esophagogastroduodenoscopy (T-EGD) with an ultrathin endoscope as an additional screening tool. Study Design: A prospective study from one academic medical center with extensive experience in T-EGD. Methods: Consecutive 150 subjects volunteering for research studies were initially screened by using a gastroesophageal reflux disease (GERD) questionnaire, interviewing, and examination. Based on these, they were stratified as healthy asymptomatic volunteers or with GERD. Unsedated T-EGD was then performed by a faculty member who was blinded to the results of the initial assessment. Results: On initial assessment using GERD questionnaire, medical interviewing, and physical examination, of the total 150 consecutive research volunteers, 83 (average age 33 ± 16 years; 46 females, 37 males) subjects were healthy asymptomatic volunteers and 67 (average age 36 ± 15 years; 35 females, 32 males) had symptoms of GERD. On T-EGD, GI pathology was found in 15 of 83 (18%) healthy asymptomatic volunteers as compared to 24 of 67 (36%) stratified as having GERD ( P < .01). The esophageal abnormalities found in healthy asymptomatic volunteers were esophagitis (13.3%), Barrett's esophagus (2.4%), hiatus hernia (2.4%), and gastritis (2.4%). Conclusions: A small but significant number of asymptomatic subjects have abnormal upper GI findings. Hence, transnasal unsedated endoscopy can be considered as a screening tool to stratify subjects as healthy, especially when considering them for research studies. Laryngoscope, 2012 [ABSTRACT FROM AUTHOR]

Abstract: We performed a trial investigation of transnasal endoscopy for post-mortem examinations to assess its efficacy in superficial post-mortem examinations. Transnasal endoscopy proved capable of permitting detailed visual inspections of the respiratory and the upper gastrointestinal tract, equal to direct viewing, on an LCD digital display. In 18 (40.9%) of 44 cases, findings obtained by post-mortem transnasal endoscopy (PMTNE) provided valuable clues regarding cause of death. The cases examined included seven deaths by fire, four by hypothermia, four by asphyxia (three involving death by mechanical asphyxia, the other by choking), two by drowning and one case of lung cancer. In two cases, PMTNE also led to informative findings not directly related to the cause of death. Under Japan''s current systems, we are required to diagnose the cause of death for over 80% of all the unnatural death cases based solely on superficial post-mortem examinations, in the absence of an autopsy. Introducing PMTNE to superficial post-mortem examinations will undoubtedly provide much more information on the cause of death than relying solely on superficial post-mortem examinations. [Copyright &y& Elsevier]

OBJECTIVE: To evaluate the feasibility and efficacy of small-caliber transnasal esophagogastroduodenoscopy for the placement of nasoenteric feeding tubes (NET) in patients with severe upper gastrointestinal (GI) diseases. METHODS: Between January 2007 and March 2010, 51 patients underwent transnasal endoscopy for the placement of NET in Peking University Third Hospital. Indications for NET included esophageal stricture or gastric outlet obstruction because of corrosive esophagitis or gastritis, partial obstruction due to malignancy, stenosis in stoma or efferent loop, gastroparesis, metallic stent in upper GI tract, tracheoesophageal fistula, severe acute pancreatitis, anorexia nervosa and intensive care patients. The tubes were endoscopically placed using the guidewire technique. The position of the tube was confirmed by the immediate second endoscopy or abdominal X-ray. If the initiate placement was not correct, an adjustment or a second placement was conducted immediately. RESULTS: Initial post-pyloric placement of NET was achieved in 43 of 51 patients (84.3%), but the total success rate reached 98.0% (50/51) after the second placement. The time required for the procedure ranged from 10 to 35 min, with a median time of 20.4 min. Epistaxis occurred in 2 patients. There were no complications of hemorrhage, perforation or aspiration. CONCLUSION: The transnasal endoscopic placement of NET was feasible in patients with upper GI diseases, especially in those with changed anatomy. [ABSTRACT FROM AUTHOR]

Background and Aim: Ultrathin transnasal endoscopy, used extensively in Japan, is considered to have inferior image quality and suction performance, and questionable diagnostic performance. So the aim of the present study was to compare the diagnostic performance of white light (WL) examination and non-magnified narrow-band imaging (NBI) examination in screening for esophageal disorders with ultrathin transnasal endoscopy. Methods: A prospective case study of 105 consecutive patients screened for upper gastrointestinal disorders at a single clinic in Tokyo Medical University Hospital. All subjects were diagnosed using WL, NBI and Lugol-staining examinations. Areas ≥ 5 mm clearly not a Lugol-staining lesion were defined as esophageal disorders and the rates of detection of the two examination methods (WL vs NBI) were compared. Results: For WL examination, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy (concordance rate) for esophageal disorders were 19.6%, 98.1%, 90.9%, 55.4%, and 59.2%, respectively, versus 60.8% 96.2%, 93.9%, 71.4%, and 78.6% for NBI. Conclusion: A useful level of diagnostic performance for esophageal disorders can be achieved with non-magnified narrow-band NBI ultrathin transnasal endoscopy. [ABSTRACT FROM AUTHOR]

Background and Aim: Low-dose aspirin (LDA), and Helicobacter pylori (HP) infection are considered the two primary causes of peptic ulceration. The interaction between HP infection and non-steroidal anti-inflammatory drugs is, however, a matter of considerable discussion and controversy. In this study, we investigated possible synergistic or negative interactions between HP infection and LDA in gastric mucosal lesions, according to lesion site. Methods: The subjects were 120 patients attending the Cardiology Outpatients Department (average age, 67.1 ± 8.9 years; male : female ratio 2.9:1). Endoscopic findings were graded using the Modified Lanza score. Lesions were scored for the antral, body and fundal regions. Ulcers were defined as mucosal defects ≥ 5 mm in size. Results: There were 55 HP-positive and 65 HP-negative subjects, and 91 subjects on LDA therapy. The gastric antral Lanza scores were HP(−) LDA(−): 0.2 ± 1.6, HP(−) LDA(+): 1.8 ± 1.5, HP(+) LDA(−): 0.3 ± 0.7, and HP(+) LDA(+): 0.5 ± 1.0. The gastric body and fundal Lanza scores were 0.0 ± 0.0, 0.8 ± 0.9, 0.4 ± 1.1, and 1.0 ± 1.5, respectively, and 0.1 ± 0.3, 0.5 ± 0.9, 0.1 ± 0.3, and 0.1 ± 0.3, respectively. Variance analysis of the correlation between HP infection and LDA by regional Lanza scores identified both HP infection and LDA use as factors that significantly influence the antral Lanza score. However, LDA was an aggressive factor, and HP infection a protective factor. In the gastric body, LDA was a non-significant, and HP infection a significant, aggressive factor. In the gastric fundus, neither HP infection nor LDA was a significant factor (LDA was an aggressive factor, and HP infection a protective factor). Conclusions: LDA had aggressive effects in all gastric lesions; on the other hand, HP infection had protective effects in the antrum and fundus in the stomach, and aggressive effects in the body in the stomach. [ABSTRACT FROM AUTHOR]

A challenge facing the field of speech-language pathology is how to equip students at the university level with the transnasal endoscopy skills needed to perform fiberoptic endoscopic evaluation of swallowing (FEES). The use of simulation has the potential to allow students to gain transnasal endoscopy experience with repetitive practice without compromising patients. The present study examined the effects of two different forms of simulation training on multiple transnasal endoscopic passes on healthy volunteers by graduate student clinicians as measured by procedure duration and confidence ratings. Eighteen speech-language pathology graduate student clinicians were randomly assigned to groups that utilized either a human patient simulator (HPS) or a non-lifelike simulator for transnasal endoscopy training. Using a flexible nasal endoscope, each clinician performed seven training passes on a simulator and one pass on two different volunteers. Each volunteer was endoscoped two times, once by a clinician trained using a HPS and once by a clinician trained using a non-lifelike simulator. There was no difference in pass times on volunteers between clinicians trained using the HPS and clinicians trained on the non-lifelike simulator. Both training groups were faster and more confident on the second endoscopy on a volunteer than on the first. [ABSTRACT FROM AUTHOR]

Background: Early gastric cancer located from the pyloric ring to inside the duodenal bulb (DB) is not easily treated by endoscopic submucosal dissection (ESD). The endoscope needs to be reversed inside the DB to set the resection line at a safe distance from the anal side. Because of the space limitations and limited flexibility of conventional endoscopy (CE), there have been increasing possibilities of complications. Here we report a new ESD technique using a transnasal endoscope (TN-E) that is reversed inside the DB. Methods: The subjects were 5 patients with early gastric cancer or adenoma, at locations ranging from the pyloric ring to inside the DB, who were all treated by ESD. We compared results in these patients (TN-E group) with results in five patients with similar disease characteristics who were treated by ESD before July 2008, when the TN-E treatment method was introduced (CE group). In the TN-E group, after marking by CE, we switched the endoscope to the TN-E, and performed the reversing procedure insidethe DB, and cut the anal side of the lesion in a semicircle. We switched back to CE to dissect the remaining half on the oral side. We compared the average resection time, en-bloc resection rate, and safety margin between the TN-E and CE groups. Results: Reversing inside the DB and the anal-side procedures proved easy and there were no complications. No bleeding or perforation occurred. The average resection times and en-bloc resection rates were not different between the two groups. All the resections by the TN-E were more than 5 mm away from the tumor margin, whereas a resection rate with a safety margin of more than 5 mm was 80% by CE. Conclusions: In conclusion, the TN-E was safe and effective for use inside the DB. ESD using the TN-E contributed to accurate pathological diagnosis, because the size of the resected specimen was sufficient to prevent the burning effect caused by the ESD. [ABSTRACT FROM AUTHOR]

The endoscopic appearance of gastric antral vascular ectasia (GAVE) can be easily misinterpreted as inflammatory changes of gastric mucosa. We report on a case of GAVE that had been missed by conventional transnasal endoscopy but was diagnosed by flexible spectral imaging color enhancement (FICE) with a transnasal endoscope. A 45-year-old woman with severe anemia presented with a 1-month history of increasing fatigue. She was previously diagnosed as having acute antral gastritis by conventional transnasal endoscopy (EG 530N2) because of the presence of reddish mucosal changes on the entire antral rugal fold. However, the FICE images produced using a combination of new processor system (VP4450) and new small-caliber endoscope (EG 530NW), did not show reddish mucosal changes on the entire rugal fold, but gave a clear image of dilated vessels associated with GAVE distinct from the surrounding normal mucosa on the same fold. These findings are useful to differentiate GAVE from ordinary gastritis. The lesions of GAVE were managed with a combination of focal pulse and spray-painting techniques to obliterate the bulk of the disease in two sessions of argon plasma coagulation therapy. Three months later, the patient recovered from iron deficiency anemia with an oral medication of iron tablets. [ABSTRACT FROM AUTHOR]

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Background and Aim: Although duodenal hypersensitivity has been suggested as one of the causes of functional dyspepsia (FD), a practical method to clarify this has not yet been established. The aim of this study was to evaluate whether patients with FD have duodenal hypersensitivity to acid, using transnasal endoscopy. Methods: In all, 44 patients with FD and 16 healthy volunteers were enrolled, and all the subjects received transnasal endoscopy in the morning after overnight fasting. After ordinary transnasal endoscopy, an infusion tube was introduced into the duodenal bulb by transnasal endoscopy and acid (20 mL, 0.1 N HCl, 20 mL/min, 36.5°C) was injected via the infusion tube. The severity of 12 symptoms was assessed by each subject using a 100-mm visual analogue scale. The maximum severity scale was defined as the maximum score of the symptom severity scale. The total score was defined as the aggregate score of the maximum severity scale of the 12 symptoms. The maximum severity scales and the total scores between patients with FD and healthy volunteers were evaluated. Results: The maximum severity scales of nine symptoms increased significantly more after acid infusion in patients with FD than in healthy volunteers ( P < 0.05). There were significant differences in the total scores (patients with FD vs healthy volunteers 233.8 ± 37.8 vs 63.9 ± 14.6, mean ± standard error of the mean, P < 0.001). Conclusions: Duodenal acidification using transnasal endoscopy enabled the evaluation of duodenal hypersensitivity to acid in healthy volunteers and patients with FD. [ABSTRACT FROM AUTHOR]

We performed a randomized prospective trial to compare unsedated endoscopy via transnasal and transoral routes using a small-caliber endoscope. Two hundred patients referred for diagnostic esophagogastroduodenoscopy (EGD) were randomly allocated to two groups: those undergoing transnasal (TN) and transoral (TO) endoscopy. We examined the insertion rate, examination duration, nasal pain, pharyngeal pain, number of occurrences of pharyngeal reflex, severity of discomfort throughout the examination, and rate of adverse events. Patients were asked to rate the severity of their pain or discomfort on a 10-cm visual analog scale (VAS). We identified statistically significant differences between the TN and TO groups in rate of insertion (95% versus 100%, respectively, P < 0.05) and examination duration (9.7 +/- 3.0 min versus 8.4 +/- 2.7 min, respectively, P < 0.005). Severity of discomfort throughout the examination was comparable in the TN and TO groups (3.0 +/- 1.8 versus 2.9 +/- 2.3, NS). Nasal bleeding occurred as an adverse event in 4.1% of patients in the TN group. Patients in the TO group were more likely than those in the TN group to prefer the present method in the subsequent endoscopic examination (99.0% versus 82.1%, P < 0.00005). These results indicated that transoral insertion is superior to transnasal insertion in endoscopy procedures performed with small-caliber endoscope. [ABSTRACT FROM AUTHOR]

Although different pathophysiological mechanisms have been suggested to be involved in functional dyspepsia, a practical method to clarify them has not been established. The aim of this study was to evaluate dyspeptic symptoms and gastric motility induced by duodenal acidification using transnasal endoscopy. Fourteen healthy volunteers (mean age, 32 years) were enrolled. Transnasal endoscopy was performed on all fasting volunteers. Dyspeptic symptoms and antral contractions were evaluated before and after duodenal infusions of pure water (20 ml/min for 5 min) and acid (0.1 N HCl, 20 ml/min for 5 min). The severity of various symptoms was assessed by each subject using a 10-cm visual analog scale every 2 min. The maximum severity scale was calculated as the mean of the individual maximum values. The motility number was defined as the mean number of antral contractions in 1 min. The maximum severity score for a heavy feeling in the stomach and other symptoms significantly increased after the acid infusion compared with after the pure water infusion. During pure water infusion, there were no changes in the motility number. On the other hand, the motility number significantly decreased after duodenal acidification (before vs. after, 2.93 ± 0.12 times vs. 1.11 ± 0.23 times, P < 0.0001). Duodenal acid exposure induces dyspeptic symptoms and inhibits antral motility. Transnasal endoscopy enabled us to evaluate both dyspeptic symptoms and gastric motility simultaneously. [ABSTRACT FROM AUTHOR]

Background. Transnasal esophagogastroduodenoscopy (EGD) using an ultrathin endoscope is less stressful to the cardiovascular system with less elevation of systolic blood pressure (BP) than oral procedures. To elucidate the mechanism of such beneficial cardiovascular responses, we performed a prospective patient-centered randomized study in which BP and pulse rate (P), as well as autonomic nervous functions, were estimated during transnasal EGD compared with those in oral procedures using the same ultrathin endoscope. Methods. The study involved 781 patients, among whom 55 and 56 cases were assigned to transnasal and oral EGD groups, respectively. The autonomic nervous responses were determined employing power spectral analysis (PSA) of heart-rate variations on electrocardiogram. PSA data were based on two peaks in lowfrequency (LF) and high-frequency (HF) ranges. HF power and the ratio of LF power/HF power represented parasympathetic and sympathetic nervous activities, respectively. Results. Our study confirmed the lesser elevation of BP and P in patients undergoing transnasal EGD than in those undergoing oral procedures. PSA revealed a lower increase in LH power/HF power in transnasal EGD than in oral EGD. However, both endoscopic procedures equally suppressed HF power. Significant correlations were found between the parameters of cardiovascular response (P and BP) and autonomic functions (LF power/HF power ratio and HF power). Conclusions. This is the first study demonstrating less sympathetic stimulation in patients undergoing transnasal EGD, leading to lesser elevation of BP and P. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients. Methods: A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD ( n = 64) or peroral EGD ( n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0–10 scale where ‘0’ represents no discomfort/well tolerated and ‘10’ represents severe discomfort/poorly tolerated). Results: Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 ± 0.2 vs 2.6 ± 0.3, P = 0.003), discomfort during insertion (2.3 ± 0.3 vs 4.3 ± 0.3, P = 0.001), and overall tolerance during procedure (1.6 ± 0.2 vs 3.8 ± 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients ( P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis. Conclusion: For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD. [ABSTRACT FROM AUTHOR]

Background: The utility of transnasal esophagogastroduodenoscopy (EGD) using ultrathin endoscopy has previously been described by analyzing subjective information and comparing it to conventional oral EGD. Limited information is available regarding the advantageous use of nasal EGD when assessed by reliable objective data. Methods: A total of 927 patients undergoing unsedated EGD between June 2004 and May 2005 were enrolled. We used a partially randomized patient-centered study design in order to exclude a bias of the patient’s preference. Patients were divided into four groups. Patients who preferred oral or nasal EGD underwent endoscopy according to their preference (preferred group). Patients without preference were randomly assigned to oral and nasal EGD (randomized group). Pulse, blood pressure (BP) and peripheral blood oxygen saturation (SpO2) were monitored during the procedure. Acceptability of EGD was also assessed by an acceptance score and the rate of willingness to repeat the same procedure. Results: Oral and nasal EGD were performed in 325 and 387 patients, respectively, in the preferred group, and 81 and 77 cases, respectively, in the randomized group. Nasal EGD was incomplete in 57 patients. Increases in BP were significantly lower in nasal EGD than in oral endoscopy in both the randomized and preferred groups, whereas no significant difference was found in the increment of pulse between the groups. Changes in SpO2 were minimal in either procedure. Analyses of patient acceptability showed favorable evaluation of nasal EGD in both randomized and preferred groups. Conclusions: Nasal EGD appears to be less stressful to the cardiovascular system. Patient’s acceptability also supports its usefulness unless difficulties in transnasal insertion are encountered. [ABSTRACT FROM AUTHOR]