trans-nasal endoscopy still sniffing the nhs? · hdtv nbi nbi field of view 140 140 140 140...

Trans-nasal endoscopy – still

sniffing the NHS?

Dr Simon Panter

Consultant gastroenterologist

South Tyneside NHS Foundation Trust

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

Trans-nasal endoscopy – still sniffing

the NHS?

?

TNE

!What it is

How to

do

Role

TNE

TNE – what it is…

Results in less gagging…

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?

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

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

Technical success TNE <5.9mm = cEGD

TNE high patient acceptability and

preference

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

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

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

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

Image quality

High definition

Image enhancement

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

Therapeutic ability

Bleeders – limited – channel for accessories/suction

Reduced cardiovascular stress

Therapeutic ability

Bleeders – limited

“Scouting scope” in high risk individuals

Therapeutic ability

Bleeders – limited

“Assessment” in high risk individuals

Reduced cardiovascular stress

APC

Therapeutic ability

Bleeders – limited

“Assessment” in high risk individuals

Reduced cardiovascular stress

APC

Stents

Narrower scope allows placement of wire

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

Is it better for patients?

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

2 x

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%

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

Barriers?

• Training

• Cost

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

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

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 ?

Thank you for your attention