Reply to Dr. Lapeyre: Duration of Esophagogastroduodenoscopy Procedures

We very much appreciate the letter from Dr. B. Lapeyre, stating his view that the duration of unsedated esophagogastroduodenoscopy (EGD) procedures has an important impact on patients’ tolerance of them. Our data do not support this hypothesis. As we reported, sedation became necessary in 44 % of all conventional EGD procedures. In 86.4 % of these cases (19 of 22 patients), sedation was administered at the patient’s request shortly after insertion of the endoscope. Only 13.6 % of the patients (three of 22) received sedation for the first time at a later stage of EGD [1].

The differences between our results and those reported in the study by Birkner et al. [2] appear to have a different basis. One striking difference is that we excluded 19.4 % of the study population when obligatory sedation for EGD was requested. The corresponding rate was 58.7 % (352 of 600) in the study by Birkner et al., suggesting a stronger selection of patients with a high tolerance for unsedated interventions.

The time required for EGD probably does not depend on the examiners’ level of expertise in endoscopy, which was high in both groups. In contrast to Birkner et al., we routinely took at least six biopsies per patient, which prolonged the procedure. A procedure time of 3 min for EGD, frequently reported by Western endoscopists, is sufficient to look for obvious reasons for symptoms - e. g., reflux esophagitis, ulcers, or elevated lesions. From our point of view, considerably more time is needed if we follow the strategies used by endoscopists in the Far East, which additionally include a careful search for type O-II lesions or small tongues of Barrett’s epithelium, chromoendoscopy of suspicious areas, and biopsy studies - e. g., to determine the type of gastritis present. In addition, high-quality digital imaging documentation of the esophagogastric junction, all parts of the stomach, and the proximal duodenum, as suggested by the European Society of Gastrointestinal Endoscopy, takes additional time. If an EGD examination is being conducted, the opportunity should be taken to detect or exclude early neoplastic lesions or their precursors - and an average of 9 min does not seem to be too long to do this.

References

• 1 Preiss C, Charton J P, Schumacher B, Neuhaus H. A randomized trial of unsedated transnasal small-caliber esophagogastroduodenoscopy (EGD) versus peroral small-caliber EGD versus conventional EGD.  Endoscopy. 2003;  35 641-646
• 2 Birkner B, Fritz N, Schatke W, Hasford J. A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose?.  Endoscopy. 2003;  35 647-651