Transnasal Endoscopy for Children with Eosinophilic Esophagitis

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Currently, the best way to perform disease monitoring in eosinophilic esophagitis (EoE) is through direct visualization of the esophageal mucosa with biopsy via esophagogastroduodenoscopy (EGD). Repeat EGDs requiring sedation can be a potential risk in children, and the authors of this study evaluated the alternative use of transnasal endoscopy (TNE) to monitor disease in children with EoE. The authors of this study looked at a protocol of monitoring EoE in children in which the patients were given a web-based video to watch prior to the procedure. The patients did not eat or drink 2 hours before the procedure. During TNE the patients wore either movie goggles or virtual reality movie goggles. Topical lidocaine or aerosolized benzocaine was applied orally and intranasally. A small bronchoscope or endoscope (size range 2.8 mm to 4.9 mm outer diameter) was placed transnasally based on the patient’s nasal passage size, and esophageal biopsies were obtained via forceps placed through a 1.2 mm or 2 mm operating channel depending on the size of the bronchoscope or endoscope used. Patient demographics, procedure number, completion rate, type of endoscopy, and adverse events were recorded.

There were 300 TNE attempts recorded over a 3-year period, and 294 TNEs were performed successfully (98%). The study population consisted of 190 patients (age range 3 to 22 years). Both operating channel sizes were used throughout the age range. Throughout the 3-year study, the average number of TNE procedures increased every year (48 in 2015; 131 in 2017), and time from procedure check-in to discharge decreased by a small amount as well (maximum time 79 minutes which decreased to 71 minutes by the end of the study period). The total percentage of endoscopies for EoE that were performed via TNE increased as well (15.7% in 2015 to 31.8% in 2017). In 2018, the average cost for TNE with biopsy for EoE was $4393 while the average cost for EGD with biopsy for EoE was $9444.33 (a 53.4% reduction in cost using the transnasal approach). All biopsies obtained by TNE were adequate for examination by a pathologist. Adverse events were rare and only consisted of interventions that included telephone management, reassurance, and supportive care.

This study demonstrates that TNE with video goggles is a safe and effective diagnostic technique to perform in children with EoE. The ability to obtained esophageal tissue with no sedation and with an associated reduction in healthcare costs provides the possibility to expand the use of this procedure throughout pediatric healthcare systems.

Nguyen N, Lavery W, Capocelli K, Smith C, Deboer E, Deterding R, Prager J, Leinwand K, Kobak G, Kramer R, Menard-Katcher C, Furuta G, Atkins D, Fleischer D, Greenhawt M, Friedlander J. Transnasal endoscopy in unsedated children with eosinophilic esophagitis using virtual reality video goggles. Clinical Gastroenterology and Hepatology. 2019; 17: 2455-2462.

John Pohl, M.D., Book Editor, is on the Editorial Board of Practical Gastroenterology

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