Virtual reality distraction helps in assessment of eosinophilic esophagitis in children
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Unsedated transnasal esophagoscopy with virtual reality distraction may more quickly establish eosinophilic esophagitis treatment, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
Eosinophilic esophagitis, a chronic, inflammatory disease of the esophagus, can be improved by medical treatments and dietary restrictions. Standard of care involves sedated endoscopies at intervals of 6 to 8 weeks or more to test for one to six food allergens.
However, that approach requires many endoscopies — and undergoing repeated sedated procedures leads to costs, risk and time away from school or work — as well as substantial time between food reintroductions.
Thus, researchers conducted a pilot study to evaluate whether serial unsedated transnasal esophagoscopy (TN-Eso) was well-tolerated and could more quickly determine when mucosal eosinophilia develops after reintroducing a single food among five children aged 11 to 18 years.
Study results showed all of the participants opted for TN-Eso at 6 weeks instead of sedated endoscopy following two TN-Eso procedures. Additionally, the researchers observed an eosinophilia return as early as 2 weeks after single food introduction through TN-Eso, which had not been examined in previous pediatric studies.
“Our findings suggest the possibility that the timing of food reintroductions could be shortened by up to 50% to 75% compared with the traditional waiting period, before repeating endoscopies,” Joel A. Friedlander, DO, MA, associate professor of pediatrics–gastroenterology, hepatology and nutrition at University of Colorado School of Medicine, pediatric gastroenterologist at Children’s Hospital Colorado, and president and chief medical officer of EvoEndo, and colleagues wrote.
Healio spoke with Friedlander to learn more about the study results and the use of virtual reality (VR) in examining eosinophilic esophagitis (EoE) among children.
Healio: Can you describe the challenges associated with serial esophageal mucosal assessments among children?
Friedlander: Evaluating the esophagus on a regular basis has been challenging because of the risks and cost of anesthesia and the fears of the parents. There’s been a lot of new technologies — whether it be the string test, the ESO capsule endoscopy or the unsedated endoscopy that we were working on — trying to find a way to see whether or not our therapies are working. So, the question was how to obtain samples — for which the standard of care is biopsies — without those risks and fear of anesthesia.
We also did the study because we didn’t quite know if you have to wait 6 to 8 weeks between procedures, which is the standard cadence used. Usually in pediatrics the wait is longer — 3 to 6 months — because of all the anesthesia risks and costs. We wanted to know if our therapy is working sooner than waiting 2 months because, under dietary therapies, that’s 2 or 3 months without food. That’s a pretty big deal for a kid, especially if it wasn’t going to work. So, we asked if a faster time point would work. Would it be effective and helpful for families? Additionally, if kids did go through it, how would they tolerate it?
This was a small pilot study, but not only did we find that the therapies could be looked for sooner, but the children tolerated unsedated endoscopy every 2 weeks and even preferred that for their third scope.
Healio: How did you come up with the idea of using virtual reality distraction to enable use of unsedated endoscopy?
Friedlander: The concept of unsedated endoscopy came out of a program called aerodigestive medicine, where as a GI doctor, we worked with the ENT doctors and pulmonologists, and we started talking in the operating room one day and I was like, “Hey, pulmonologists, you have really small scopes.” ENT doctors were doing awake scopes, and we had big scopes putting everyone to sleep. Data have been published now for many years on use of unsedated endoscopies in adults using baby scopes, and originally nasal endoscopes.
When we questioned the concept of whether this was possible in pediatrics — because we didn’t know if it was going to work — we had to find a way to try to convince kids to try it, let alone like it and tolerate it. At first we used video goggles in our study on gastrointestinal endoscopy. Although those worked well, the kids always saw us coming because the light bled through underneath the glasses. When VR came out, we realized this is basically the same concept, but blindfolded. So, we made the transition quickly from regular movie goggles to a distraction technique that blindfolded their eyes so all they saw was the VR and the only sensation they had was through their nose.
Healio: Did you find the virtual reality distraction approach effective?
Friedlander: Absolutely. We’ve done about 1,000 unsedated endoscopies at Children’s Hospital of Colorado since we started doing this around 5 years ago. The VR is very helpful for the kids — it keeps them calm and it’s enjoyable. The movies and shows they watch are usually some of their favorite programs, so they’re kind of in their own Zen space.
It’s also helpful for the doctors because I’m used to working on sleepy kids, so this was a new experience for me. We’re able to talk to the kids, and we actually hear music or TV shows playing. At the same time, I can watch the kids and see what’s going on without being in their personal space. I find it helpful from both stances.
Healio: What did your study reveal about the mucosal eosinophilia?
Friedlander: We knew from previous studies in the adult world, and some in the pediatric world, that usually we’d wait about 6 to 8 weeks at a minimum, and usually longer, after a change in dietary or medication therapy. This study evaluated whether we do those biopsies sooner so we would know if the therapies were effective. We found in our pilot study that essentially if you waited 4 weeks, which is 2 weeks sooner, you could actually know if the therapy is working. There were quite a few kids, about half the cohort, who responded at 2 weeks. But. not all of them did, and we think part of that relates to the food that was picked. Because different foods were used for each child, there’s a chance the different foods had different antigenicity, driving the propagation of EoE, let alone the differences from kid to kid.
This study should prompt a larger study to look at if there are differences between egg, milk, soy, wheat or other foods, because there may be different response times for each. Milk may be a strong driver of EoE, so we can get a response within 2 weeks, whereas eggs may take 4 weeks. Determining this requires more statistics from a larger study.
Our originally intended to do a larger study, but COVID-19 hit when we were recruiting patients. We couldn’t ethically bring kids back in on serial time periods in the middle of the pandemic.
Healio: Did any of your findings surprise you?
Friedlander: The 2-week mark did surprise me; I thought it would be at the 4-week mark when we would see response rates. I was really surprised that we had quite a few kids who hit at that 2-week mark. I was really hoping we’d find it sooner and I was excited, and I thought we would, but I didn’t know for sure.
Although we’ve gotten better at the technique of unsedated endoscopy from the time of our first study, I didn’t know what kids would say for the third time in a row after 6 weeks. I thought for sure we’d have some kids say, “Yeah, I’ve had enough of TN-Eso, can I just go back to my regular scope?” One of the kids, the one I’d say had the hardest time with the unsedated endoscopy, even said, “Yeah, I want to pick the unsedated one for the third time, too, I don’t want another sedation for it.” I was really curious as to what would happen after undergoing 2 over a month and what they would pick for the third one, and every kid picked the unsedated scope, which was really exciting for me.
Healio: What research would you like to conduct next in this area?
Friedlander: The next thing would be to go beyond the pilot study. We could look at the patterns we saw in the different response rates for different foods. For example, let’s take milk. If we reintroduce milk, how often does milk really hit at 4 weeks in people who create EoE from milk antigens? A bigger study with different foods can enable us to be more specific and precise, rather than the global approach we use right now.
For more information:
Joel A. Friedlander, DO, MA, can be reached at Digestive Health Institute, Children’s Hospital Colorado, University of Colorado School of Medicine. 13123 East 16th Ave. B290, Aurora, CO 80045; email: joel.friedlander@childrenscolorado.org.