Background
Previous studies report an overall adverse event (AE) rate of 2.6% and a clinically significant AE rate (requiring additional medical care) of 1.7% from esophagogastroduodenoscopies (EGDs) in pediatric patients within the first 72 hours post-procedure. There is increasing interest in unsedated transnasal esophagoscopy (TNE) in pediatrics. Literature has demonstrated TNE to be well tolerated in children, but no large studies have evaluated post-procedure AEs for TNE in children. We hypothesize that TNE has a lower rate of AEs because of smaller endoscopes, minimal gas insufflation, and no sedation. The primary aim of this study was to quantify the number and severity of adverse events with TNE as compared to diagnostic EGD.

Methods
Adverse event data was prospectively collected for all pediatric patients who underwent endoscopies at a tertiary children’s hospital. This study evaluated patients 5-22 years old who underwent outpatient TNE or EGD with biopsies without additional endoscopic procedures on the same day between 1/2015-6/2022. Additional demographic data and procedural factors were collected retrospectively. Adverse event severity grades were defined as grade 1- no intervention; grade II-outpatient evaluation; grade III-hospitalization or repeat endoscopy; grade IV-surgery or intensive care unit admission; and grade V-death. Statistical analysis used chi-squared, Fisher’s Exact test or paired T-test as appropriate. A p-value of ≤ 0.05 was considered statistically significant.

Results
Between 1/2015-6/2022, 10,023 diagnostic EGDs and 927 TNEs were performed. There were 130 grade I, 58 grade II, 8 grade III, 2 grade IV, and 0 grade V AEs. AE rates and cohort details are summarized in table 1. There was no significant difference in age, weight, or mean ASA scores between patients who underwent EGD vs TNE. There were significantly higher rates of AEs after EGD compared to TNEs for all grades (198/10,023 (1.98%) vs 1/927 (0.11%) p = 0.00005) as well as clinically significant AEs grade 2 or higher (0.71% vs 0%). Ninety-three percent (864/927) of TNEs and 16% (1603/10,023) of EGDs were performed for evaluation of eosinophilic esophagitis (EoE). Comparison of AEs for procedures performed for EoE also showed significantly higher AE rates after EGDs compared to TNEs for all AEs (31/1,603 (1.93%) vs. 1/864 (0.12%), p = 0.0001] as well as clinically significant AEs grade 2 or higher (13/1603 (0.81%) vs 0/864 (0%), p = 0.006).

Conclusions
The post-procedure adverse event rate in TNE was significantly lower than the rate with EGD both for overall AEs and clinically significant AEs grade 2 or higher. This lower rate was also observed when evaluating for EoE as the indication. This study suggests that TNE is a safer approach to monitor esophageal pathology than sedated EGD for children and adolescents who can undergo TNE.

Nathalie Nguyen

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