Table 3.

Potential advantages and foreseeable challenges of establishing a TNE service in a COVID-19 era

	Features of a TNE service	Potential benefits applicable to a post-COVID-19 era	Potential challenges
Pre-procedure considerations	Utilisation of space otherwise not used for endoscopic procedures, which may be inside or outside the endoscopy unit footprint (eg, bowel preparation rooms, capsule endoscopy rooms, physiology rooms, outpatient clinics, etc)	Increased capacity for patient procedures without significant restrictions to other services	Not all hospitals will have a suitable area to repurpose. If operating outside the endoscopy unit, a larger inventory of scopes may be required to ensure sufficient equipment to run the list. This financial outlay for this and other resources may be offset by the increased productivity from using previously unused areas for TNE.
	Twilight/evening endoscopy timings	Extended timings without large staffing requirements	May not fall within the existing job plans of all endoscopy departments. May be met by appropriate restructuring of resources as ultimately less staff are needed for a TNE list.
	Shallow learning curve to training of new operators14	Ability to expand services to both medical and non-medical endoscopists and build resilience in staffing and general departmental skillset	ENT support needed within the training phase. There may be a transient drop-off in procedure completion rates as new endoscopists are trained up that should improve once procedural independence has been achieved.
Intraprocedural considerations	Single nurse assistant	Ability to expand endoscopy services without significant increase in staffing requirement	Nursing staff require initial training to assist with TNE procedures.
	TNE procedure associated with less coughing/gagging	Theoretical reduction in aerosols7 8	Reduced ventilation and air exchange in some outpatient areas, although can be counteracted by robust pre-procedural COVID-19 testing; use of face mask to cover the patient’s mouth may provide further aerosol reduction.8
	Unsedated procedure	Total patient interaction time likely to be shorter, thereby improving turnaround time and patient flow	There may be the occasional need to convert a failed nasal intubation to the oral route in a patient who hasn’t received sedation. This is generally more comfortable than c-OGD without sedation, and ENTONOX can be used adjunctively.
	Improved patient tolerability when compared with unsedated conventional transoral endoscopy	Theoretical improved lesion detection rate in comfortable patients	Some patients will still find the procedural uncomfortable. This can be ameliorated by adjunctive use of ENTONOX as noted above.
Post-procedure considerations	Better patient tolerability	Improved compliance and attendance for repeat procedures (surveillance, etc)	As above
	Immediate discharge from endoscopy procedure room	No requirement for social distancing in endoscopy recovery or interference with other endoscopy department patient flow	None significant foreseen

c-OGD, conventional oesophagogastroduodenoscopy; TNE, transnasal endoscopy.