Researchers in the Oregon Health & Science University Digestive Health Center are first to report that screening people with chronic heartburn or pre-cancer of the esophagus in an office setting using a "skinny scope" is as accurate, less expensive and less risky than a traditional sedated screening in a procedure room — and patients prefer it. The findings are published online and in print in this month's issue of the American Journal of Gastroenterology.
The study, led by principal investigator Blair A. Jobe, M.D., a surgeon in the OHSU Digestive Health Center and member of the OHSU Cancer Institute, found that study participants preferred unsedated, small-caliber upper endoscopy, commonly referred to as the skinny scope, to the standard screening method for upper digestive disease, sedated upper endoscopy.
Study participants in Jobe's Esophageal Care Clinic listed a number of reasons for preferring the skinny scope, including not having to undergo anesthesia, not missing a day of work and not having to arrange for transportation to and from home. But the best benefit, according to at least one study participant, was the ability to watch the entire procedure in real time on a color monitor and receive immediate feedback from the clinician.
"There was no pain. My wife and I watched the entire thing. I found it informative and appreciated not having to wait for the anesthesia to wear off to learn the results," said Dennis Murphy, 58, Tigard, Ore. Murphy was diagnosed with Barrett's esophagus, a precursor to cancer, four years ago. As part of the study protocol, he underwent both procedures on separate occasions. At the end of the study, he said he preferred the skinny scope and would request it at his next checkup.
With approximately 10 million Americans struggling with chronic heartburn, also known as GERD (gastroesophageal reflux disease) — a condition closely associated with the development of one of the most lethal forms of cancer: esophageal cancer — the need for a cost-effective screening and surveillance system was long apparent to Jobe, who also is an associate professor of surgery in the OHSU School of Medicine, Portland Veterans Affairs Medical Center.
"However, given the relative rarity of esophageal cancer compared with the high prevalence of GERD," Jobe explained. "Routine screening within the general population using traditional upper endoscopy would be too costly."
Eager to find an economically viable means of screening and monitoring this patient population, Jobe and colleagues endeavored to devise a method that would reduce the cost, inconvenience and complications associated with sedated endoscopy — and they succeeded.
"This trial has established that unsedated small-caliber endoscopy used in an office setting is technically feasible, well-tolerated and accurate in the screening and diagnosis of Barrett's esophagus. It's a more personal approach and represents the potential to eliminate the infrastructure and costs required for intravenous sedation. It's also more immediate. As soon as you're done, you can tell the patient what you've found."
To perform a sedated upper endoscopy, an endoscope, 9.8 mm in diameter, is passed through the mouth and throat to the esophagus, stomach and small intestine. The procedure requires the resources and infrastructure of an outpatient procedure unit, two assistants, intravenous sedation and post-procedure monitoring, with a total cost in the thousands of dollars. And, as with any procedure for which the patient is sedated, the risk of complications, though rare, is higher.
By comparison, the skinny scope procedure is performed by a single clinician in an office setting and does not require sedation. Patients inhale a topical anesthetic that numbs their nasal passages and throat. The clinician then passes a smaller-caliber endoscope, 4.9 mm in diameter, through the nose, pharynx and throat. The cost for this procedure is in the hundreds of dollars.
Only a handful of centers in the United States routinely employ the skinny scope as part of clinical practice. According to Jobe, this is due in part to the perception that the unsedated skinny scope increases patient anxiety and discomfort. In addition, some endoscopists, unfamiliar with the nasal approach, may lack the skills necessary to perform it. And, up until recently, endoscopes were not long enough to examine the entire upper digestive tract.
One hundred thirty-four men and women with long-standing histories of GERD symptoms and acid-reducing medication use were enrolled in this randomized, cross-over trial. Ninety-eight percent of subjects successfully completed unsedated small-caliber endoscopy (skinny scope) in an office setting. More than 70 percent of participants said they would choose the unsedated skinny scope over the conventional approach on a subsequent endoscopy. The prevalence of Barrett's esophagus discovered by both approaches was equal and there were no undetected cases of cancer.
The National Institutes of Health supported this research.
ABOUT ESOPHAGEAL CANCER
The National Cancer Institute estimates 13,200 Americans will be diagnosed with esophageal cancer this year and 12,500 will die of the malignancy. Of the new cases, 9,200 will occur in men and 3,100 will occur in women. An estimated 25 million Americans have some form of esophageal disease, the most common of which is gastroesophageal reflux disease (GERD). Patients with severe GERD have a 40 times greater risk of developing esophageal cancer than those without GERD symptoms, a risk similar to that of a cigarette smoker developing lung cancer. That said, for one particular individual with GERD, the risk of esophageal cancers is quite low.
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