Transnasal Endoscopy in Unsedated Children With Eosinophilic Esophagitis Using Virtual Reality Video Goggles

Abstract

Background & aims: Evaluation and treatment of children with eosinophilic esophagitis (EoE) requires serial endoscopic, visual, and histologic assessment by sedated esophagogastroduodenoscopy (EGD). Unsedated transnasal endoscopy (TNE) was reported to be successful in a pilot study of children. We evaluated video goggle and virtual reality-based unsedated TNE in children with EoE, collecting data on rates of completion, adverse events, and adequacy of visual and histologic findings.

Methods: We performed a retrospective study of 190 children and young adults (age, 3-22 y) who underwent video goggle or virtual reality-based unsedated TNE from January 2015 through February 2018. We analyzed data on patient demographics, procedure completion, endoscope type, adverse events, visual and histologic findings, estimated costs, and duration in the facility. Esophageal biopsies from the first 173 subjects who underwent TNE were compared with those from previous EGD evaluations.

Results: During 300 attempts, 294 TNEs were performed (98% rate of success). Fifty-four patients (age, 6-18 y) underwent multiple TNEs for dietary or medical management of EoE. There were no significant adverse events. Visual and histologic findings were adequate for assessment of EoE. TNE reduced costs by 53.4% compared with EGD (TNE $4393.00 vs EGD $9444.33). TNE was used increasingly from 2015 through 2017, comprising 31.8% of endoscopies performed for EoE. The total time spent in the clinic (front desk check-in to check-out) in 2018 was 71 minutes.

Conclusions: In a retrospective study of 190 children and young adults (age, 3-22 y) who underwent video goggle or virtual reality-based unsedated TNE, TNE was safe and effective and reduced costs of EoE monitoring. Advantages of TNE include reduced risk and cost associated with anesthesia as well as decreased in-office time, which is of particular relevance for patients with EoE, who require serial EGDs.

Keywords: Adverse Events; Anesthesia; Endoscopy; Eosinophilic Oesophagitis; Transnasal Esophagogastroduodenoscopy; Transnasal Esophagoscopy.

Conflict of interest statement

Disclosures/ Conflicts of Interest: Joel Friedlander is president, chief medical officer, and co-founder of Triple Endoscopy, Inc. Robin Deterding is Vice President, Consultant, and Co-Founder of Triple Endoscopy, Inc. Emily DeBoer is Secretary, Consultant, and Co-Founder of Triple Endoscopy, Inc. Jeremy Prager is Treasurer, Consultant, and Co-Founder of Triple Endoscopy, Inc. Joel Friedlander, Robin Deterding, Jeremy Prager, and Emily DeBoer are listed inventors on University of Colorado patents pending US 62/732,272, US62/680,798, US 15/853,521, US 15/887,438, CA 2,990,182, AU 2016283112, EU 16815420.1, JP 2017–566710 related to endoscopic methods and technologies. Glenn Furuta is co-founder of EnteroTrack. Matthew Greenhawt has served as a consultant for the Canadian Transportation Agency, Thermo Fisher, Intrommune, and Aimmune Therapeutics; is a member of physician/medical advisory boards for Aimmune Therapeutics, DBV Technologies, Nutricia, Kaleo Pharmaceutical, Nestle, and Monsanto; is a member of the scientific advisory council for the National Peanut Board; has received honorarium for lectures from Thermo Fisher and Before Brands.

Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1:

Transnasal endoscopies (TNEs) performed from January 2015- February 2018 and demographics.

Figure 2:

A) Number of transnasal endoscopies (TNE) performed from 2015–2017. B) Number of TNEs performed compared to all diagnostic upper endoscopic procedures. C) Time from patient front desk check-in to patient discharge from office for TNE (minutes) from 2015–2018. D) Average charge per visit for TNE vs Esophagogastroduodenoscopy.

Figure 3:

A) Number of subjects who underwent multiple transnasal endoscopies (TNE) and B) Indication for TNE in the management of Eosinophilic Esophagitis (EoE).

Figure 4:

Adverse Events during transnasal endoscopy (TNE).

Figure 5:

A) Visual findings of the esophagus with transnasal endoscopy (TNE). Representative images from TNE including B) normal esophageal mucosa, C) exudate, edema and linear furrows and D) exudate, edema, and linear furrows.

Figure 6:

A) Percent of esophageal biopsies with full thickness of the epithelium obtained by transnasal endoscopy (TNE) with 1.2mm biopsy forceps (2.8–3.1mm TNE), 2.0mm biopsy forceps (4.0–4.9mm TNE), and by esophagogastroduodenoscopy (EGD) with 2.8mm biopsy forceps. B) Representative images of esophageal biopsies obtained from 1.2mm biopsy forceps, C) 2.0mm biopsy forceps, D) 2.8mm biopsy forceps.