trans-nasal endoscopy still sniffing the nhs? · hdtv nbi nbi field of view 140 140 140 140...
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Trans-nasal endoscopy – still
sniffing the NHS?
Dr Simon Panter
Consultant gastroenterologist
South Tyneside NHS Foundation Trust
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Disclosures
Endoscopy fellow funded by Aquilant -2015
Ad boards/honoraria/travel grants – Astra Zeneca, P&G,
Vifor pharma, Shire, Ferring, Warner Chilcott, Covidien
Reference centre for scope trials and loan equipment
– Olympus, Fuji, Given/Medtronic
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Trans-nasal endoscopy – still sniffing
the NHS?
?
TNE
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!What it is
How to
do
Role
TNE
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TNE – what it is…
Results in less gagging…
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Can we advocate TNE?
Is TNE technically as good as traditional
OGD?
Is it as good for patients?
Is it as good for the NHS?
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Is it…..?
Is TNE technically as good as/better than
traditional OGD? Diagnostic ability
Technical success
Image quality
Views (suction)
Light
Manoeuvrability
Accuracy
Therapeutic ability
Bleeders
Stents
PEG
NJ tube
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Current TNE scopes are NOT….
Limited to 2-way angulation
Limited by inferior optics
Limited by poor illumination
Limited by inadequate biopsy samples
(As) Limited by small biopsy channel
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Technical success TNE <5.9mm = cEGD
TNE high patient acceptability and
preference
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Fuji Olympus
EG-
600WR
EG-
580NW2
GIF-
H290
GIF-
XP290N
Image Ultra HD
CMOS
FICE
Super
CCD
FICE
HDTV
NBI NBI
Field of view 140 140 140 140
Observation range (mm) 2-100 3-100 3-100 3-100
Distal tip diameter (mm) 9.2 5.8 8.9 5.4
Insertion diameter (mm) 9.3 5.9 8.9 5.8
Forceps channel
diameter (mm)
2.8 2.4 2.8 2.2
Angulation Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
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Fuji Olympus
EG-
600WR
EG-
580NW2
GIF-
H290
GIF-
XP290N
Image Ultra HD
CMOS
FICE
Super
CCD
FICE
HDTV
NBI NBI
Field of view 140 140 140 140
Observation range (mm) 2-100 3-100 3-100 3-100
Distal tip diameter (mm) 9.2 5.8 8.9 5.4
Insertion diameter (mm) 9.3 5.9 8.9 5.8
Forceps channel
diameter (mm)
2.8 2.4 2.8 2.2
Angulation Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
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Fuji Olympus
EG-
600WR
EG-
580NW2
GIF-
H290
GIF-
XP290N
Image Ultra HD
CMOS
FICE
Super
CCD
FICE
HDTV
NBI NBI
Field of view 140 140 140 140
Observation range (mm) 2-100 3-100 3-100 3-100
Distal tip diameter (mm) 9.2 5.8 8.9 5.4
Insertion diameter (mm) 9.3 5.9 8.9 5.8
Forceps channel
diameter (mm)
2.8 2.4 2.8 2.2
Angulation Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
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Fuji Olympus
EG-
600WR
EG-
580NW2
GIF-
H290
GIF-
XP290N
Image Ultra HD
CMOS
FICE
Super
CCD
FICE
HDTV
NBI NBI
Field of view 140 140 140 140
Observation range (mm) 2-100 3-100 3-100 3-100
Distal tip diameter (mm) 9.2 5.8 8.9 5.4
Insertion diameter (mm) 9.3 5.9 8.9 5.8
Forceps channel
diameter (mm)
2.8 2.4 2.8 2.2
Angulation Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
Up 210
Down 90
Left 100
Right 100
2.2mm channel = 320ml/minute flow rate
2.4mm channel = 500ml/minute flow rate
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Image quality
High definition
Image enhancement
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Accuracy
TNE as good (?better) at diagnosing GORD related diseases
Recent data suggesting equivalent in diagnosing BO
Equivalent in diagnosing and grading varices
Possibly lower pick up small superficial gastric cancers in proximal stomach
Pick up may be improved with chromoendoscopy
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Therapeutic ability
Bleeders – limited – channel for accessories/suction
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Reduced cardiovascular stress
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Therapeutic ability
Bleeders – limited
“Scouting scope” in high risk individuals
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Therapeutic ability
Bleeders – limited
“Assessment” in high risk individuals
Reduced cardiovascular stress
APC
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Therapeutic ability
Bleeders – limited
“Assessment” in high risk individuals
Reduced cardiovascular stress
APC
Stents
Narrower scope allows placement of wire
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Therapeutic ability
Bleeders – limited
“Assessment” in high risk individuals
Reduced cardiovascular stress
APC
Stents
Narrower scope allows placement of wire
NJ tubes
Significantly quicker and easier
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Is it better for patients?
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Does improved patient tolerability
translate into a better quality endoscopy?
• Procedure time longer for TNE
• TNE 8.8 +/- 3.2 min vs 7.7 +/- 3.4 p = 0.021
• TNE 10 vs 7 min p=0.0042
1. Alexandris et al APT 20142. Despott et al Gut (Abstract) 2010
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2 x
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Is it better for the NHS?
Less staff allocation per room
No need for “head end” nurse
Shorter recovery time
Prep and procedure time longer
Mitigated if nurses do nasal prep
Lidocaine hydrochloride 5% + phenylephrine
hydrochloride 0.5%
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Move out of the endoscopy
department?
Space in endoscopy at a premium
Outpatients
Community setting
Risk with upper GI endoscopy sedation related
Selected, low risk patients having diagnostic endoscopy
www.freedomfromobesity.net
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Barriers?
• Training
• Cost
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Complications/considerations
Failure – rare
Epistaxis – self limiting 2%
Pressure and Naseptin for 1/52
Pack and ENT
Anticoagulants (no good data) – INR<2.5 (?)
Platelet count (no good data) >50 (?)
Slightly higher epistaxis rates (up to 14%)
Nasal fractures – usually not a problem
Frequent epistaxis, HHT contra-indication
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Cost
No robust cost-benefit analysis
Cost savings with fewer nurses
Non sedated
Release space in endoscopy department
vs
Significant investment to provide dedicated TNE list
Switching from PO to TNE scope when opportunity arises
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Summary
Is TNE technically as good as/better than traditional OGD?
Yes
Is it as good/better for patients?
Yes
Is it as good/better for the NHS?
Possibly ?
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Thank you for your attention