Unsedated transnasal EGD with VR procedural disassociation. Conflicts presented here. The background is eosinophilic gastrointestinal disorders of a high and substantial cost of care that can exceed $9,000 per event and has been reported in adults and pediatrics. Here we present a case of a 17-year-old male undergoing transnasal EGD, initially starting with nasal installation of 4% lidocaine, as demonstrated here. This is split into six sprays into alternating nostrils while swallowing and sniffing, as shown here, followed by a dab of lidocaine using a cotton applicator to the nasal meatus. Next, the physician will orient virtual reality to the patient through VR procedural disassociation, making sure he is in a disassociated state. Subsequently, the physician will lubricate the endoscope shaft and prepare for the insertion into the nose while making sure the patient's nose is at the mid-chest level. He will now orient the scope tip and straighten the shaft while making sure the scope handle is facing the patient. He will insert it into the nose, looking at the inferior and middle turbinates and inserting it gently towards the back of the adenoid tissue, making sure to use small motions because of the small caliber nature of the endoscope and to assure patient comfort. You will notice that the scope is parallel to the ground. As he approaches the adenoid, the patient may need to sniff to open up that tissue. After navigating the adenoid tissue, the larynx will be, as shown here, towards the top of the screen. The physician will use gentle motions while inserting the scope into the UES while then facilitating the passage of the scope using a swallow motion by the patient, advancing to the mid-esophagus to avoid excessive gagging after passing through the UES. The physician will now use their hand and or their fingers to adjust the scope using gentle amounts of air or water to lubricate the esophagus and better visualize on the way down to get to the stomach as quickly as possible. While approaching the esophagus, the physician will notice what the esophagus looks like here. After adjustment, the physician will be looking at the lower esophageal sphincter today. As shown here, it looks irritated with some furrows, suggesting active eosinophilic esophagitis. Once approaching the stomach, it is important to keep the scope of the shaft relatively straight for patient comfort while being in the nose. Because of the nature of the ultra-slim nature of the scope, the lighting may be slightly darker in the gastric mucosa and the endoscopist will navigate closer to the gastric mucosa while looking at the gastric body as shown here. Additionally, they will use the dials and or the levers of the scope to navigate towards the gastric antrum following the rugate to get to that area. Because of the small nature of the scope, again, less torque is recommended to avoid the twisting, torquing, or flopping of the scope. As you will notice here, the dials and levers are used to find the pylorus, which is to the right and then to the left, now buried within the gastric secretions. Air, water, and suction can be used to wash away the secretions through the combined channel of this endoscope, as demonstrated here. Now you'll see the incisusura, and below this, the pylorus. The endoscopist will navigate the gastric secretions while then entering the duodenal bulb. Because the patient is awake, peristalsis may be noted, and pauses may need to be done by the endoscopist to find the gastric or the duodenal lumen. Villi can be seen here under the water insufflation or the air insufflation. Again, using gentle motions, the endoscopist will navigate the duodenal mucosa, preparing for biopsies of these tissues, and is now able to visualize the second and third portion of the duodenum. As shown here, the endoscopist sometimes may move the handle of the scope backwards. Additionally, additional motions can be reached to approach even deeper into the duodenal tissues. Noticing here, there may be some erythema or blunting of the villi, as well as some areas that need to be biopsied by the endoscopist. With minimal verbalization, the endoscopist will ask the nurse for the biopsy forceps. Because of the ultra-slim nature of a transnasal endoscope, a standard 2.0 forcep is used for this technique. As you'll notice, the nurse is holding up the forcep above the handle for ease of insertion. Following biopsy, as shown here, the endoscopist will reevaluate the area and take a second piece using these standard needled forceps. You'll notice the patient appears to still be in this disassociated state, and following this, the endoscopist will draw the scope into the stomach, visualize the areas for visualization for the suspected eosinophilic gastrointestinal disorder. Because the stomach may also have peristalsis, it may require some patience, as well as finding the proper area. Two biopsies are obtained here, with washing and or air in between the biopsies. The biopsies are taken by the nurse. The endoscopist may wash the tissues or wash the lens of the camera. Again, because of the nature of the camera, the endoscopist will work closer to the mucosa. It may appear dark if it gets too far away. Suction can be used to facilitate this, as seen here. The endoscopist will now withdraw the endoscope into the esophagus, and while looking at the esophagus, will generally biopsy with the esophagus collapsed, but they are using significant air, which may cause discomfort to the patient. They will use combinations of the dials, air, water, and levers to get to the lumen of the esophagus into view, while then inserting the biopsy forcep to take a picture of the patient. The biopsy forceps will be exiting shortly. You'll notice the peristalsis of the esophagus and the fluid in the esophagus. Here are the forceps working relatively close to the scope tip for maximum maneuverability, and in between this, air can be used to blow up and distend for ERF scores and eosinophic esophagitis. Again, you'll notice a peristalsis noted here. Notice the blood from the biopsy that was recently taken, and another biopsy as well here too. Not all six biopsies were shown during this procedure in this video. Additionally, water is used for patient comfort, as well as to wash the blood from the previous biopsy. As the scope is withdrawn, air is held, and as you can see, the furrow is noted for active eosinophilic esophagitis, while additional biopsies will be taken from those areas. As you can see, the biopsy forceps are inserted again. As the peristalsis goes up and down the esophagus, you'll notice opening and closing of the esophagus, and patient is required to see this. You'll again notice the furrows of active eosinophilic esophagitis. And sure, during the withdrawal, which is a great time to insert air, you can get a better view of those same areas. And then additionally, you'll see the rings and trachealization, as well as the furrows and active eosinophilic esophagitis noted here. There's now withdrawal. During this procedure, the physician and the nurse are commonly reassuring the patient that everything is going to be OK. And now, as the goggles are removed, the patient is noted that he is doing well, getting ready to go home, with great encouragement by the physician and the nurse. The clinical implications of transnasal EGD in pediatrics are the ability to avoid general anextesia or opioid exposure and greater than $6,000 in savings. In conclusion, this is a possible procedure in the pediatric population.

unsedated transnasal esophagogastroduodenoscopy

virtual reality procedural disassociation

eosinophilic gastrointestinal disorders

lidocaine nasal installation

pediatric endoscopy