Trans-nasal endoscopy still sniffing the NHS?

Transcription

1 Trans-nasal endoscopy still sniffing the NHS? Dr Simon Panter Consultant gastroenterologist South Tyneside NHS Foundation Trust

2 Disclosures Endoscopy fellow funded by Aquilant 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

3 Trans-nasal endoscopy still sniffing the NHS?? TNE

4 ! What it is How to do Role TNE

5 TNE what it is Results in less gagging

6

7

8

9

10

11 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?

12 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

13 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

14 Technical success TNE <5.9mm = cegd TNE high patient acceptability and preference

15 Fuji Olympus EG- 600WR EG- 580NW2 GIF- H290 GIF- XP290N Image Ultra HD CMOS FICE Super CCD FICE HDTV NBI Field of view Observation range (mm) Distal tip diameter (mm) Insertion diameter (mm) NBI Forceps channel diameter (mm) 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

16 Fuji Olympus EG- 600WR EG- 580NW2 GIF- H290 GIF- XP290N Image Ultra HD CMOS FICE Super CCD FICE HDTV NBI Field of view Observation range (mm) Distal tip diameter (mm) Insertion diameter (mm) NBI Forceps channel diameter (mm) 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

17 Fuji Olympus EG- 600WR EG- 580NW2 GIF- H290 GIF- XP290N Image Ultra HD CMOS FICE Super CCD FICE HDTV NBI Field of view Observation range (mm) Distal tip diameter (mm) Insertion diameter (mm) NBI Forceps channel diameter (mm) 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

18 Fuji Olympus EG- 600WR EG- 580NW2 GIF- H290 GIF- XP290N Image Ultra HD CMOS FICE Super CCD FICE HDTV NBI Field of view mm channel = 320ml/minute flow rate Observation range (mm) Distal tip diameter (mm) mm channel = 500ml/minute flow rate Insertion diameter (mm) NBI Forceps channel diameter (mm) 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

19 Image quality High definition Image enhancement

20 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

21

22 Therapeutic ability Bleeders limited channel for accessories/suction

23 Reduced cardiovascular stress

24 Therapeutic ability Bleeders limited Scouting scope in high risk individuals

25 Therapeutic ability Bleeders limited Assessment in high risk individuals Reduced cardiovascular stress APC

26 Therapeutic ability Bleeders limited Assessment in high risk individuals Reduced cardiovascular stress APC Stents Narrower scope allows placement of wire

27 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

28 Is it better for patients?

29 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 = TNE 10 vs 7 min p= Alexandris et al APT Despott et al Gut (Abstract) 2010

30

31

32

33 2 x

34 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%

35 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

36 Barriers? Training Cost

37

38 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

39 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

40 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?

41 Thank you for your attention