Increased gagging and choking associated with the ultrathin device suggests that its deployment will require techniques to reduce gagging. Transnasal upper endoscopy appears to cause less gagging and choking,8,9,11,14-17,19 but has not been studied in the family practice setting. Other techniques to determine pharyngeal sensitivity are needed.20,21 One study10 found that ultrathin EGD was tolerated better than conventional EGD for unsedated examinations; investigators22 identified younger age and higher levels of pre-endoscopic anxiety as predictors of patient intolerance of unsedated endoscopy.
Although the success rate of retroflexion and duodenal intubation has not been reported in other studies6-9,11,12,14-17,19,23 of ultrathin EGD, we could not perform retroflexion in 15% of subjects in the ultrathin EGD group. Inability to retroflex was secondary to patient intolerance and increased instrument flexibility. In these patients, the endoscopist might switch to a normal diameter scope; however, in a large national study using a standard diameter endoscope, retroflexion was not performed in 7% of patients.24 The most frequent contribution of retroflexion is the identification of a dysfunctional lower esophageal sphincter. In our experience, a small fundal polyp and a large diverticulum in the cardia would be missed in the absence of this maneuver. In contrast, we were unable to intubate the duodenum in 3% of patients undergoing ultrathin EGD. Rodney and colleagues24 cited in their national study that with use of the standard endoscope, duodenal intubation was not achieved in 7% of patients. With increased experience with the ultrathin device, endoscopists may be able to develop techniques to overcome the increased flexibility (eg, using the biopsy forceps in the accessory channel to increase rigidity).
Although we found no significant differences in the proportion of clinical findings between the 2 groups, the findings may have been different had we been able to retroflex the scope in the ultrathin EGD group. The diagnostic accuracy,11,17 image quality,11,23 and adequacy of the smaller biopsy specimen for pathologic diagnosis9,25,26 for ultrathin EGD have been reviewed and consistently determined to be clinically acceptable. Image quality of the 2 techniques is comparable (Figure 2). Although the biopsy specimens obtained with the ultrathin endoscope were smaller than samples of tissue obtained with the conventional device, CLO test positivity did not differ between the groups.
Conventional EGD required more recovery time and was associated with significantly higher anxiety. It is possible that the relatively higher anxiety experienced by patients in the conventional EGD group can be explained by fear of loss of control, fear about risks related to sedation, or a combination of psychosocial factors. One limitation in the conventional EGD group was the potential bias of the seda-tion when patients responded to the postrecovery surveys. Future studies may control for this sedation-effect bias by repeated measures over a period of a few days. Another limitation of our study was that the verbal reassurance offered to patients before and during endoscopy was nonscripted and may have influenced tolerance scores. A third limitation was that the patient questionnaire was given to patients by the endoscopist, thereby possibly introducing a social desirability bias. Finally, the small sample size limited the ability to detect differences that may be clinically meaningful.
Ultrathin EGD costs less, provides similar results, and has acceptable tolerability compared with conventional EGD. Once they are EGD credentialed, clinicians do not require further training or skills to perform the procedure with the ultrathin device. As more family physicians feel comfortable performing EGD in an outpatient setting, more patients will have access to this important procedure.
FIGURE 2
View of gastric ulcer with GIF-N230 (A) and GIF-130 (B)
Acknowledgments
The investigators acknowledge Olympus for the use of a GIF-N230 gastrointestinal videoscope, which was used for the ultrathin procedures. We also acknowledge Staff Sergeant Ron O’Dell for his photograph of the endoscopes.