Total enteroscopy with a nonsurgical steerable double-balloon method

Rebleeding Rate and Risk Factors for Rebleeding after Device-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study

Introduction: The impact of device-assisted enteroscopy (DAE) on long-term rebleeding in patients with obscure gastrointestinal bleeding (OGIB) exhibiting detectable small-bowel lesions remains unclear. We investigated the long-term rebleeding rate and predictive factors for DAE in patients with OGIB. Method: Patients with OGIB with small bowel lesions detected through DAE were enrolled at three Korean tertiary hospitals. Predictive risk factors associated with rebleeding were analyzed using the Cox regression analysis. Results: From April 2008 to April 2021, 141 patients were enrolled, including 38 patients (27.0%) with rebleeding. The rebleeding rates at 1, 2, and 3 years were 25.0%, 29.6%, and 31.1%, respectively. The Cox regression analysis revealed that multiple small-bowel lesions (hazard ratio [HR]: 2.551, 95% confidence interval [CI]: 1.157–5.627, p = 0.020), the need for more than five packed red blood cells (RBC) transfusions (HR: 2.704, 95% CI: 1.412–5.181, p = 0.003), and ulcerative lesions (HR: 1.992, 95% CI: 1.037–3.826, p = 0.039) were positively associated with rebleeding. Therapeutic interventions for patients with detectable lesions, overt bleeding (vs. occult bleeding), comorbidities, and medications were not associated with rebleeding. Conclusion: More than 25% of patients with OGIB having detectable small-bowel lesions had rebleeding. Patients with multiple lesions, a requirement of more than five packed RBC transfusions, and ulcerative lesions were associated with a higher risk of rebleeding.

Position Statement. Recommendations of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on the treatment of strictures in Crohn's disease

Despite pharmacological advances, strictures in Crohn's disease (CD) continues to be an important problem that leads in a high percentage of patients to undergo endoscopic and/or surgical treatments. There are currently no clinical scores or diagnostic tools that allow predicting which patients will develop this complication, and when a stricture is diagnosed, it is usually already well established and clinically relevant. The current role of pharmacological treatment is limited to treat inflammation and once there is significant fibrosis, the only therapeutic options are endoscopic and/or surgical. To establish a correct therapeutic algorithm and based on the current scientific evidence available, the Spanish Group Working on Crohn's Disease and Ulcerative Colitis (GETECCU) has decided to conduct this position statement on the treatment of strictures in CD. This document embraces the three mentioned therapeutic approaches, medical, endoscopic and surgical. Recommendations and therapeutic algorithms are established to help us to choose the most appropriate option based on the characteristics of the stricture and the patient.

Multiple intestinal lymphangiomas with episodic hemorrhage requiring partial laparoscopic resection: a case report

Background

Lymphangioma is a non-epithelial tumor marked by aggregates of abnormally dilated lymphatics. Mesenteric occurrences account for < 1% of all cases, and < 0.05% involve the gastrointestinal tract. Most are confined to children, rarely affecting adults.

Case presentation

Herein, we describe an elderly Japanese woman with anemia, hypoalbuminemia, and episodic bleeding due to multiple intestinal lymphangiomas. Abdominal computed tomography revealed multiple low-density defects of mesentery, with areas of intermediate (T1 images) or high (T2 images) signal intensity similarly dispersed in magnetic resonance scanning sequences. Single-balloon enteroscopy was undertaken, enabling identification and tattooing of a small intestinal bleeding source. Laparoscopy-assisted resection at this site served to control related hemorrhage, removing a histologically confirmed hemolymphangioma. Having recovered uneventfully, the patient remained stable 2 months postoperatively.

Conclusions

Although rare in adults, mesenteric or gastrointestinal lymphangiomas must be considered in a setting of anemia and hypoalbuminemia. Complete resection is advantageous to improve patient symptoms, but limited resection of multiple lesions may be equally effective.

Small bowel obstruction due to Roux-en-Y enterolith 13 years following deceased donor liver transplantation: a case report

Primary sclerosing cholangitis (PSC) is a progressive, cholestatic liver disease, and liver transplantation (LT) is considered the only therapeutic option for patients with end-stage liver disease secondary to PSC. Intestinal obstruction in adults after LT surgery is a rare complication with diverse clinical presentations. The most common etiology is intestinal adhesions, but this can also result from other rare causes such as enterolith. We describe the first case report of small bowel obstruction secondary to biliary stone formation in the common limb of Roux-en-Y hepaticojejunostomy 13 years after the deceased donor LT. The patient failed initial conservative management and developed peritonitis, requiring urgent surgical exploration to remove the enterolith and resect the involved small bowel. In conclusion, small bowel obstructions due to enteroliths are unusual clinical complications following LT, which require a high degree of suspicion in patients who develop a bowel obstruction in the setting of a previous hepaticojejunostomy.

Single-centre empirical analysis of double-balloon enteroscopy in the diagnosis and treatment of small bowel diseases: A retrospective study of 466 cases

BACKGROUND AND OBJECTIVE

The diagnosis and treatment of small bowel diseases (SBDs) has always been a challenge. The purpose of this study was to evaluate the value of double-balloon enteroscopy (DBE) in the diagnosis and treatment of small bowel diseases.

METHOD

The clinical data of 466 patients who underwent double-balloon enteroscopy (DBE) in the Endoscope Center of Gastroenterology Department of the First People's Hospital of Yunnan Province from Jan. 2015 to Dec. 2020 were analysed retrospectively. The factors included age, sex, indications, endoscopic treatment results, pathological results, discharge diagnosis and so on.

RESULTS

A total of 370 patients underwent 466 double-balloon enteroscopies, among whom 274 underwent one examination and 96 received two-way examinations (oral and transanal approaches). Abnormalities were detected in 299 cases, with a detection rate of 80.81% (299/370). The common indications were occult gastrointestinal bleeding (OGIB) (30.8%, 114/370) and abdominal pain (28.3%, 105/370). The diagnosis rates were 64.9% and 77.1%, respectively. The common positive findings included nonspecific inflammation/erosion (60 cases), ulcers (34 cases), diverticulum (32 cases), polyps (26 cases) and Crohn's disease (CD) (24 cases). The common tumours were lymphoma(12 cases), adenocarcinoma(11 cases) and stromal tumour(8 cases). Lymphoma was mostly located in the ileum, while stromal tumours and adenocarcinoma were mostly located in the duodenum and jejunum. The main endoscopic intervention measures were haemostasis and polypectomy, including haemostatic clip, argon plasma coagulation (APC), endoscopic mucosal resection (EMR), endoscopic trap resection, endoscopic foreign body extraction and other operations, without serious complications.

CONCLUSION

DBE has a high success rate in the diagnosis and treatment of some SBDs, and it is a safe and effective management method.

Clinical Outcomes of Negative Balloon-Assisted Enteroscopy for Obscure Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

Background

For patients with obscure gastrointestinal bleeding (OGIB), finding the bleeding site is challenging. Balloon-assisted enteroscopy (BAE) has become the preferred diagnostic modality for OGIB. The long-term outcome of patients with negative BAE remains undefined. The present study aimed to evaluate the long-term outcomes of patients with negative BAE results for OGIB and to clarify the effect of further investigations at the time of rebleeding with a systematic review and meta-analysis of the available cohort studies.

Methods

Studies were searched through the PubMed, EMBASE, and Cochrane library databases. The following indexes were analyzed: rebleeding rate after negative BAE, rebleeding rate after different follow-up periods, the proportion of patients who underwent further evaluation after rebleeding, the percentage of patients with identified rebleeding sources, and the percentage of patients with rebleeding sources in the small intestine. Heterogeneity was assessed using the I² test.

Results

Twelve studies that involved a total of 407 patients were included in the analysis. The pooled rebleeding rate after negative BAE for OGIB was 29.1% (95% CI: 17.2–42.6%). Heterogeneity was significant among the studies (I² = 88%; p < 0.0001). The Chi-squared test did not show a difference in rebleeding rates between the short and long follow-up period groups (p = 0.142). The pooled proportion of patients who underwent further evaluation after rebleeding was 86.1%. Among the patients who underwent further evaluation, rebleeding sources were identified in 73.6% of patients, and 68.8% of the identified rebleeding lesions were in the small intestine.

Conclusion

A negative result of BAE in patients with OGIB indicates a subsequently low risk of rebleeding. Further evaluation should be considered after rebleeding.

Water exchange-assisted versus carbon dioxide-insufflated single-balloon enteroscopy: a randomized controlled trial

BACKGROUND

Single-balloon enteroscopy (SBE) is a valuable but difficult modality for the diagnosis and treatment of small-bowel disease. The water exchange method has the advantage of facilitating intubation during colonoscopy. Here, we evaluated the effects of water exchange on procedure-related variables related to SBE.

METHODS

This randomized controlled trial was conducted in a tertiary-care referral center in China. Patients due for attempted total enteroscopy were randomly allocated to undergo water exchange-assisted (water exchange group) or carbon dioxide-insufflated enteroscopy (CO₂ group). All patients were planned to undergo both anterograde and retrograde procedures. The primary outcome was the total enteroscopy rate. Secondary outcomes included the maximal insertion depth, positive findings, procedural time, and adverse events.

RESULTS

In total, 110 patients were enrolled, with 55 in each group. Baseline characteristics between the two groups were comparable. Total enteroscopy was achieved in 58.2 % (32/55) of the water exchange group and 36.4 % (20/55) of the control group (P = 0.02). The mean (standard deviation) estimated intubation depth was 521.2 (101.4) cm in the water exchange group and 481.6 (95.2) cm in the CO₂ group (P = 0.04). The insertion time was prolonged in the water exchange group compared with the CO₂ group (178.9 [45.1] minutes vs. 154.2 [27.6] minutes; P < 0.001). Endoscopic findings and adverse events were comparable between the two groups.

CONCLUSIONS

The water exchange method improved the total enteroscopy rate and increased the intubation depth during SBE. The use of water exchange did not increase the complications of enteroscopy.

[Results of motorized spiral enteroscopy in 83 consecutive patients]

INTRODUCTION

For motorized spiral enteroscopy, only limited data are available. We report about our early experiences with the motorized spiral enteroscopy in a retrospective case series. The present worldwide study reported the results of motorized spiral enteroscopy in 68 patients with small bowel diseases and in 15 patients with ERCP and surgically altered anatomy.

PATIENTS AND METHODS

This retrospective single-centre study was performed between 01/2020 and 09/2021 in 83 consecutive patients. Indications were known or suspected small bowel diseases or diseases of the bile or pancreatic duct after surgical altered anatomy with Roux-Y anastomosis.

RESULTS

In 68 patients (38 m/30 f; mean age 66.4 years) with an indication for small bowel enteroscopy, diagnostic and therapeutic yield was 86.8% and 41.2%, respectfully. The average depth of maximum insertion was 279 cm with an average insertion time of 64.3 min. In 13 patients (19.7%), complete panenteroscopy was achieved. In patients without prior abdominal surgery, the rate of complete enteroscopy was 46.2%.In 15 patients (9 m; 6 f; mean age 61.8 years) with surgically altered anatomy and Roux-Y anastomosis (the papilla resp.), the biliodigestive anastomosis could be reached in 60%.In the entire case series, the total complication rate was 15.7%. There were no severe complications, such as perforation or major bleeding.

DISCUSSION

The present case series shows a high rate of panenteroscopies with a short examination time. To confirm these data, further comparative studies for ERCPs in patients with surgically altered anatomy are necessary.

Achieving Total Enteroscopy by Consecutive Bidirectional Double-balloon Enteroscopy Procedures

OBJECTIVE

To investigate the feasibility and safety of achieving total enteroscopy by consecutive bidirectional double-balloon enteroscopy (DBE) procedures.

METHODS

The demographic data, indication, initial insertion route, examination time for each insertion and the entire procedure, total enteroscopy rate, diagnostic yield and adverse events of patients who attempted to achieve total enteroscopy by consecutive bidirectional DBE procedures from January 2014 to December 2019 were retrospectively analyzed.

RESULTS

A total of 189 patients were included, and the total enteroscopy rate was 87.3%. Initiating the DBE procedure via the retrograde approach as the initial insertion route achieved a higher total enterosocpy rate (90.9% vs. 78.9%, P=0.023), with shorter overall examination time (134.2±36.2 vs. 156.9±47.6 min, P=0.017) and shorter examination time for the opposite insertion route (23.8±19.9 vs. 53.1±27.6 min, P=0.000) compared with anteograde approach as the initial insertion route. The overall diagnostic yield was 37.6%. The diagnostic yield for successfully achieving total enteroscopy was higher, when compared to the yield for not successfully achieving total enteroscopy (39.4% vs. 25%, P=0.029). The overall rate of adverse events was 2.1% (4/189). There was no significant difference in adverse event rate between the overall examination time ≥2 h group and <2 h group (2.1% vs. 2.0%, P=0.593).

CONCLUSION

Consecutive bidirectional DBE procedure is an effective and safe strategy for achieving total enteroscopy with a considerable success rate. This may be a promising option and alternative to traditional methods, and helpful to more promptly establish a definite diagnosis. The retrograde approach, as the initial insertion route, is preferred in clinical practice.

Efficacy and factors affecting procedure results of short-type single-balloon enteroscopy-assisted ERCP for altered anatomy: a multicenter cohort in Japan

BACKGROUND AND AIMS

Although single-balloon enteroscopy (SBE)-assisted or short-type SBE (short SBE)-assisted ERCP has been reported as useful in patients with surgically altered anatomy, most studies had small sample sizes or single-center designs. This study aimed to evaluate the efficacy and factors affecting the procedure results of short SBE-assisted ERCP in patients with surgically altered anatomy.

METHODS

This multicenter, retrospective study was conducted at 8 tertiary referral care centers in Japan. The data of patients who underwent ERCP-related procedures using short SBE between September 2011 and August 2019 at each facility were analyzed.

RESULTS

Overall, 1318 patients were included in this analysis. The enteroscopy (reaching the target site), cannulation, and total procedural success rates were 87.9% (95% confidence interval [CI], 86.1%-89.6%), 87.0% (95% CI, 84.9%-88.8%), and 74.9% (95% CI, 72.5%-77.2%), respectively. Adverse events occurred in 7.7% of patients (95% CI, 6.4%-9.3%). Multiple logistic regression analysis indicated that age (≥75 years), Roux-en-Y reconstruction, pancreatic indication, and malignancy were factors affecting the total procedural failure.

CONCLUSIONS

This large-scale study proved that short SBE-assisted ERCP in patients with surgically altered anatomy was effective. Moreover, it clarified factors affecting procedure results. Proficiency with alternative treatment techniques is required in difficult cases. (Clinical trial registration number: UMIN00004045.).

Clinical impact of videocapsule and double balloon enteroscopy on small bowel bleeding: Results from a large monocentric cohort in the last 19 years

BACKGROUND

Suspected small bowel bleeding (SSBB) is the main indication for videocapsule endoscopy (VCE) and double balloon enteroscopy (DBE). We assessed the impact of both modalities in a large cohort of SSBB patients in a European tertiary center.

METHODS

We retrospectively evaluated consecutive patients with SSBB undergoing VCE and/or DBE from March 2001 to July 2020. Demographic/clinical parameters, anticoagulant therapies, technical characteristics and adverse events were collected, as well as diagnostic yield (DY), VCE-DBE concordance, hemoglobin (Hb) values before and after DBE, and complications.

RESULTS

807 VCEs and 407 DBEs were performed in 751 patients. The DY was significantly higher in DBE compared with VCE (68.8% vs 57.7%), with the highest (75%) yield for overt active SB bleeding. The agreement between VCE and DBE was generally suboptimal (k = 0.059). This improved in cases where both procedures were done within 1-5 days of the other (k = 0.323). Post-procedural Hb values were significantly higher. In patients treated with direct oral anticoagulants (DOACs), there were no differences in DY, complications or Hb values compared with non-DOAC patients.

CONCLUSION

VCE and DBE play a pivotal role in the diagnostic and therapeutic approach to SSBB, having a high clinical impact even in patients treated with DOACs.

Breaking the Barrier in Endoscopy

In this narrative review, invited by the Editors of the Journal of Digestive Endoscopy, we summarize recent advances in the field of gastrointestinal endoscopy with regard to reaching the earlier inaccessible areas in the gut by newer methods and technology. This article primarily discusses recent advances in the past few years in the following headings: (1) reaching redundant small bowel via enteroscopy (primarily motorized spiral enteroscopy), (2) reaching the thin pancreaticobiliary ducts via cholangioscopy and pancreatoscopy, (3) going out of the gut wall: third-space endoscopy (primarily peroral endoscopic myotomy: POEM). A thorough literature review was performed on each topic describing how the advances were evolving.

Reduction of acute gastric volvulus in a 3-year-old using a balloon-attached endoscope combined with gel immersion endoscopy

When performing endoscopic reduction in patients with gastric volvulus, it is important to maintain a low level of intragastric pressure and to fix the endoscope in the duodenum. Gel immersion endoscopy is a new method for securing the visual field by injecting clear gel. The balloon-attached endoscope makes it easier to fix the tip in the duodenum without mucosal damage. We report successful reduction of a mesenteroaxial gastric volvulus using an endoscope with a balloon in combination with gel immersion endoscopy. A 3-year-old Japanese male developed gastric volvulus. Since gastric decompression using a nasogastric tube failed to reduce the volvulus, endoscopic reduction was performed under general anesthesia. After aspiration of intragastric gas, clear gel was injected through the accessory channel which secured the visual field in the stomach even with residue while maintaining low intragastric pressure. After reaching the descending portion of the duodenum, the balloon attached to the tip of the endoscope was inflated and fixed in the duodenum. The volvulus was successfully reduced by pulling back the endoscope with clockwise torque. Acute mesenteroaxial gastric volvulus has the potential to cause ischemia and perforation which can be life-threatening, so most patients are treated with surgical intervention. Gel immersion endoscopy is safe and effective to secure the visual field, even in children. Endoscopic reduction may be a viable treatment option for reducing gastric volvulus in non-emergent patients.

Endoscopic Therapy of Small Bowel Polyps by Single-Balloon Enteroscopy in Patients with Peutz-Jeghers Syndrome

BACKGROUND

Little is known about the efficacy and safety of single-balloon enteroscopy (SBE) in patients with Peutz-Jeghers syndrome (PJS). The aim of this study was to assess the efficacy and safety of SBE for the treatment of small bowel polyps in patients with PJS.

METHODS

We conducted a single-center observational study, which included all patients diagnosed with PJS who underwent SBE for polypectomy between January 2018 and March 2021. Complete treatment was defined as the absence of polyps ≥10 mm after SBE resection. The clinical records were retrospectively reviewed.

RESULTS

102 patients (including 40 men and 62 women) with a mean age of 28.7 years (range 13-55 y) were enrolled in our study. The intubation depth via the oral approach of patients with a history of laparotomy was significantly shorter than that of the patients without a history of laparotomy ([241.6 ± 64.2] cm vs [280.9 ± 40.2] cm, P=0.008). The maximum size of the resected polyps via anus during the second hospitalization was significantly smaller than that during the first hospitalization ([2.25 ± 1.29] cm vs [4.26 ± 3.51] cm, P=0.032). For patients with total enteroscopy, the complete treatment rate was 98% (49/50). For patients without total enteroscopy, all polyps larger than 10 mm in the examined segment of small bowel were resected successfully. Complications occurred in 10 of 129 hospitalizations (delayed bleeding in 4, perforation in 3, and acute pancreatitis in 3).

CONCLUSIONS

SBE is effective and safe for resection of small bowel polyps in patients with PJS.

Video Capsule Endoscopy and Device-Assisted Enteroscopy

Mark Hanscom Courtney Stead Harris Feldman Neil B. Marya David Cave.

Meckel's diverticulum diagnosed by double‐balloon enteroscopy: A single‐center retrospective study in Taiwan

Background and Aim

Meckel's diverticulum (MD) is a common congenital abnormality of the gastrointestinal (GI) tract. Although a few patients with MD present symptoms, preoperative diagnosis of MD is a clinical challenge because of its endoscopic inaccessibility. The aim of the present study was to investigate patients with MD diagnosed by double‐balloon enteroscopy (DBE) in Taiwan.

Methods

We conducted a retrospective study in a tertiary referral center in middle Taiwan. The clinical characteristics, endoscopic features, histopathological findings, treatment methods, and outcomes of patients with MD diagnosed by DBE were analyzed.

Results

A total of 14 male patients with MD diagnosed by DBE were enrolled. The mean age of all patients was 32.3 years. GI bleeding (78.6%) accounted for the major indication of DBE, followed by abdominal pain and Crohn's disease follow‐up. The mean distance between the ileocecal valve and MD was 68.9 cm. The average length of 12 patients with surgically resected MD was 5.2 cm. The diagnostic yields of the other modalities excepting DBE are as follows: capsule endoscopy, 50%; Meckel's scan, 11.1%; computed tomography, 16.7%; small bowel series, 0%; and angiography, 33.3%. MD presented as a large ostium in 13 patients (92.9%), a small ostium in 1 patient (7.1%), and bleeding signs in 10 patients (71.4%). Twelve patients (85.7%) underwent surgical treatment and 2 patients (14.3%) received conservative treatment. Heterotopic gastric tissue was identified in 4 patients (28.6%).

Conclusion

The present study showed that DBE is a more powerful modality in detecting MD than the other conventional modalities in Taiwan.

Meckel's Diverticulum Diagnosed by Balloon-Assisted Enteroscopy: A Multicenter Report from the Taiwan Association for the Study of Small Intestinal Diseases (TASSID)

Background and Aims

Patients with Meckel's diverticulum (MD) are difficult to preoperatively diagnose because of its endoscopic inaccessibility. Balloon-assisted enteroscopy (BAE) allows endoscopic access to the entire small intestine. The aim of the current study was to investigate patients with MD diagnosed by BAE in Taiwan.

Methods

We conducted a retrospective, multicenter study of patients with MD who were diagnosed by BAE in Taiwan. The clinical characteristics, endoscopic features, histopathological findings, treatment methods, and outcomes were analyzed.

Results

A total of 55 patients with MD were enrolled (46 males and 9 females). The mean age at diagnosis was 34.1 years. Overt gastrointestinal bleeding (87.3%) was the primary indication for BAE, followed by abdominal pain (9.1%), suspected small bowel tumor (1.8%), and Crohn's disease follow-up (1.8%). The mean distance between the ileocecal valve and MD was 71.6 cm (regarding diagnostic yields: BAE—100%, capsule endoscopy—40%, Meckel's scan—35.7%, computed tomography—14.6%, small bowel series—12.5%, and angiography—11.1%; regarding endoscopic features of MD: a large ostium—89.1%, a small ostium—7.3%, and a polypoid mass—3.6%). Surgical treatment was performed in 76.4% patients, and conservative treatment was performed in 23.6% patients. The mean length of MD in 42 patients who underwent surgical resection was 5.2 cm (in 43 patients of MD with available histopathology: heterotopic gastric tissue, 42.4%, heterotopic gastric and pancreatic tissues, 7%; heterotopic pancreatic tissue, 4.7%; heterotopic colonic tissue, 2.3%; and a neuroendocrine tumor, 2.3%).

Conclusions

The current study showed BAE is a very useful modality for detecting MD compared with other conventional modalities.

Endoscopic ultrasound-guided antegrade procedures for managing bile duct stones in patients with surgically altered anatomy: Comparison with double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (with video)

BACKGROUND AND STUDY AIM

Management of bile duct stones (BDSs) in patients with surgically altered anatomies (SAAs) remains challenging. An endoscopic ultrasound-guided antegrade (EUS-AG) procedure and double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (DB-ERC) have been used to remove BDSs from patients with SAAs. However, few comparative data have been reported. Therefore, we compared the efficacy and safety of the techniques.

METHODS

This was a single-center retrospective study. Patients with SAA who underwent the EUS-AG procedure or DB-ERC to remove intra- or extra-BDSs between November 2010 and March 2020 were included. The primary outcome was the technical success rate, defined as stent insertion or stone removal during the initial session. The secondary outcomes were the procedure time, incidence of adverse events (AEs), and complete stone removal rate.

RESULTS

Of the 54 patients enrolled, 23 underwent the EUS-AG procedure and 31 DB-ERC. The technical success rates of EUS-AG and DB-ERC were 87.0% and 64.5%, respectively (P = 0.11). The procedure time was significantly shorter in the EUS-AG group than in the DB-ERC group (51.9 ± 15.4 vs 72.6 ± 32.2 min; P = 0.01), and the early AE rates were 26.1% and 12.9%, respectively (P = 0.71). The complete stone removal rates in patients who underwent previous stone removal were 94.1% in the EUS-AG group and 85.7% in the DB-ERC group (P = 0.61).

CONCLUSION

The EUS-AG afforded technical success and complete stone removal rates comparable with those of DB-ERC, but the former procedure was shorter. The AE rate was acceptable.

Status of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: Systematic review and meta-analysis on biliary interventions

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is still challenging. Usefulness of single-balloon enteroscopy (SBE)-assisted ERCP has been increasingly reported. Short SBE is considered beneficial with a 152-cm working length and a 3.2-mm working channel. This has increased the variety of devices that can be used during ERCP procedures. The aim of this pooled analysis was to evaluate the efficacy of SBE-assisted ERCP in patients with surgically altered anatomy and elucidate the current status.

METHODS

This systematic review only involved biliary interventions which excluded pancreatic cases. Studies involving SBE-assisted ERCP in patients with Roux-en-Y gastrectomy, hepaticojejunostomy with Roux-en-Y, pancreaticoduodenectomy (Whipple or Child procedure), or Billroth II gastrectomy were analyzed. Enteroscopy, biliary cannulation, and procedural success were assessed by pooling data in a random-effect model, according to the degree of heterogeneity, to obtain a proportion with 95% confidence interval (CI). The outcomes observed for conventional and short SBE cases were also reported.

RESULTS

Overall, 1227 SBE-assisted ERCP procedures from 21 studies were included. The pooled enteroscopy, biliary cannulation, and procedural success rates were 86.6% (95% CI, 82.4-90.3%), 90% (95% CI, 87.1-92.5%), and 75.8% (95% CI, 71.0-80.3%), respectively. Adverse events occurred in 6.6% (95% CI, 5.3-8.2%) of the procedures. Although good outcomes were reported for short SBE-assisted ERCP, these should not be directly compared to the outcomes observed for conventional SBE, as they assume different backgrounds and include confounding variables.

CONCLUSIONS

Single-balloon enteroscopy-assisted ERCP in patients with surgically altered anatomy on biliary interventions is effective.

Factors Affecting Route Selection of Balloon-Assisted Enteroscopy in Patients with Obscure Gastrointestinal Bleeding: A KASID Multicenter Study

Balloon-assisted enteroscopy (BAE) is an important diagnostic modality for ongoing obscure gastrointestinal bleeding (OGIB). However, it is difficult to determine the optimal insertion route. We retrospectively analyzed the records of patients with OGIB contained in a multicenter enteroscopy database of 1108 balloon-assisted enteroscopy (BAE) procedures (875 patients) to find out factors affecting BAE route selection in patients with OGIB. A total of 603 BAE procedures in 512 patients were investigated: there were 392 (65.0%) bidirectional and 211 (35.0%) unidirectional procedures. Overt OGIB was more frequent in the latter group (p = 0.024). Computed tomography (CT) was more frequently performed in the unidirectional group (p < 0.001). Capsule endoscopy and a small bowel barium study were performed more frequently in the bidirectional group (p < 0.001 and p = 0.039, respectively). Multivariate analysis showed that occult OGIB, capsule endoscopy and a small bowel barium study were independently associated with use of the bidirectional approach (p = 0.011, p = 0.013 and p = 0.046, respectively). Conversely, CT was associated with use of the unidirectional approach (p < 0.001). Conclusion: CT can aid the selection of an optimal insertion route in OGIB patients. However, capsule endoscopy and small bowel barium study are unhelpful.

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn's disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.

Use, Yield, and Risk of Device-assisted Enteroscopy in the United States: Results From a Large Retrospective Multicenter Cohort

INTRODUCTION

Since 2001, device-assisted enteroscopy (DAE) has revolutionized the diagnostic and therapeutic capabilities for managing small bowel pathology. Though commonly performed, there have been no recent large studies to assess the use, yield, and risks of DAE and none that include all 3 DAE modalities. We hypothesized that DAE is safe with high diagnostic and therapeutic yields achieved within reasonable procedure duration and here we present a large retrospective multicenter US study evaluating the use, yield, and complications of DAE.

METHODS

After obtaining institutional review board approval, electronic records were used to identify all DAE's performed for luminal small bowel evaluation in adult patients at 4 US referral centers (Duke University Medical Center, New York University Langone Medical Center, Louisiana State University Health Sciences Center, and University of Massachusetts Medical Center) from January 1, 2014 to January 1, 2019. Electronic medical records were reviewed to collect and analyze a variety of procedure-related outcomes. Using the data pooled across centers, descriptive statistics were generated for the patient and procedure-related characteristics and outcomes; relationships between characteristics and outcomes were explored.

RESULTS

A total of 1787 DAE's were performed over this 5-year period (392 at Duke University Medical Center, 887 at Louisiana State University Health Sciences Center, 312 at New York University Langone Medical Center, and 195 at University of Massachusetts Medical Center). Of these, there were 1017 (57%) double-balloon, 391 (29%) single-balloon, and 378 (21%) spiral enteroscopies. The mean age of patients undergoing DAE was 66 years and 53% of examinations were performed on women; 18% of patients in the cohort underwent >1 DAE over this time span. A total of 53% of examinations were performed for suspected small bowel bleeding, 31% were directly guided by video capsule endoscopy findings and 8% were performed for abnormal imaging. A total of 85% of examinations used an antegrade approach and DAE took a mean of 45 minutes to complete; 76% of examinations revealed abnormal findings, with vascular, inflammatory, and neoplastic findings seen in 49%, 17%, and 15% of the cohort, respectively. Older age was significantly associated with any abnormal finding, including arteriovenous malformations (P<0.0001); 50% of examinations included a therapeutic maneuver, most commonly argon plasma coagulation/cautery (43%). There were complications in 16 examinations (0.9%) including 2 perforations (0.1%), 6 cases with bleeding (0.3%) and 1 episode of pancreatitis (0.1%).

CONCLUSIONS

DAE is most commonly performed to evaluate suspected small bowel bleeding and is commonly directed by video capsule findings. DAE is safe, has a high diagnostic yield, with 76% of examinations showing abnormal findings, and frequently features therapeutic maneuvers. Advancing age is associated with abnormal findings on DAE.

The role of small-bowel endoscopy in inflammatory bowel disease: an updated review on the state-of-the-art in 2021

The impact of small-bowel (SB) capsule endoscopy and device-assisted enteroscopy on clinical practice, since their introduction 2 decades ago, has been remarkable. These disruptive technologies have transformed the investigation and management of SB pathology and now have a firmly established place in guidelines and clinical algorithms. Furthermore, recent years have witnessed innovations, driven by the demand of new goals in the management of inflammatory bowel disease (IBD), such as mucosal healing and evolving strategies based on tight monitoring and accelerated escalation of care. These developments in SB endoscopy have also been paralleled by refinement in dedicated radiological SB imaging technologies. This updated review highlights the current state of the art and more recent innovations with a focus on their role in IBD.

Recent advances of endoscopic retrograde cholangiopancreatography using balloon assisted endoscopy for pancreaticobiliary diseases in patients with surgically altered anatomy: Therapeutic strategy and management of difficult cases

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic modality established for diagnosis and treatment of pancreaticobiliary diseases. However ERCP in patients with surgically altered anatomy (SAA) has been difficult, and more invasive therapies have been primarily selected. The development of balloon assisted endoscopes (BAEs) innovatively facilitated ERCP in such patients. Recent advances of BAEs and other devices greatly contributed to increasing success of ERCP using BAEs (BAE-ERCP). Furthermore, interventions using Endoscopic Ultrasound (EUS-intervention) have been reported to be useful for pancreaticobiliary diseases in patients with SAA, which provide more options for endoscopic therapies and are also expected as a rescue therapy for difficult cases of BAE-ERCP. In order to thoroughly complete endoscopic treatment for pancreaticobiliary diseases with SAA, it is important to standardize the BAE-ERCP procedures based on the features of respective endoscopes and to establish a strategy for endoscopic treatment which includes analysis of BAE-ERCP difficult cases and selection of cases for rescue therapy. In addition, it is essential to be acquainted with the characteristics of possible adverse events of the procedure and to be able to deal with them for safe accomplishment of endoscopic treatment.

The Efficacy and Safety of Balloon Enteroscopy-Assisted Endoscopic Retrograde Cholangiography in Pediatric Patients with Surgically Altered Gastrointestinal Anatomy

Balloon enteroscopy-assisted endoscopic retrograde cholangiography (BEA-ERC) is useful and feasible in adults with pancreatobiliary diseases, but its efficacy and safety have not been established in pediatric patients. We compared the success rate and safety of BEA-ERC between adults and pediatric patients. This single-center retrospective study reviewed 348 patients (pediatric: 57, adult: 291) with surgically altered gastrointestinal anatomies who underwent BEA-ERC for biliary disorders from January 2007 to December 2019. The success rate of reaching the anastomosis or duodenal papilla was significantly lower in pediatric patients than in adult patients (66.7% vs. 88.0%, p < 0.01). The clinical success rate was also significantly lower in pediatric patients (64.9% vs. 80.4%, p = 0.014). The rate of adverse events was significantly higher in pediatric patients than in adults (14.2% vs. 7.7%, p = 0.037). However, if the anastomotic sites were reached in pediatric patients, the treatment was highly successful (97.3%). The time of reaching target site was significantly longer in pediatric patients than in adult patients. This study shows that BEA-ERC in pediatric patients is more difficult than that in adult patients. However, in patients where the balloon enteroscope was advanced to the anastomosis, clinical outcomes comparable to those in adults can be achieved.

Review of ERCP Techniques in Roux-en-Y Gastric Bypass Patients: Highlight on the Novel EUS-Directed Transgastric ERCP (EGDE) Technique

PURPOSE OF REVIEW

Hepatobiliary complications are common in Roux-en-Y gastric bypass (RYGB) patients. Despite development of multiple surgical and endoscopic access techniques over the years, ERCP using standard duodenoscope remains challenging in these patients due to the altered anatomy.

RECENT FINDINGS

Limited success with enteroscope-assisted and laparoscope-assisted ERCP led to the evolution of the novel EUS-directed transgastric ERCP (EDGE) procedure, with variations of this technique termed as Gastric Access Temporary for Endoscopy (GATE), EUS-guided TransGastric ERCP (EUS-TG-ERCP), EUS-guided GastroGastrostomy-assisted ERCP (EUS-GG-ERCP), and EUS-directed transgastric intervention (EDGI). EDGE has high technical (100%) and clinical success rates (60-100%), lower adverse event rate (1.5-7.6%), and up to 20% access stent migration rate; without any significant weight changes. EDGE has significantly shorter procedure time (73vs184min), post-procedural hospital stays (0.8vs2.65 days) and is more cost effective compared to other modalities. EDGE technique addresses the challenges of RYGB anatomy as a minimally invasive, clinically successful, fully endoscopic, and cost-effective option. We present a literature review of the EDGE technique from its inception to current, in addition to reviewing other access techniques, their advantages, disadvantages and outcomes.

A Soft Robotic Sleeve for Safer Colonoscopy Procedures

Colonoscopy is the gold standard for colorectal cancer diagnosis; however, limited instrument dexterity and no sensor feedback can hamper procedure safety and acceptance. We propose a soft robotic sleeve to provide sensor feedback and additional actuation capabilities to improve safety during navigation in colonoscopy. The robot can be mounted around current endoscopic instrumentation as a disposable "add-on", avoiding the need for dedicated or customized instruments and without disrupting current surgical workflow. We focus on design, finite element analysis, fabrication, and experimental characterization and validation of the soft robotic sleeve. The device integrates soft optical sensors to monitor contact interaction forces between the colon and the colonoscope and soft robotic actuators that can be automatically deployed if excessive force is detected, to guarantee pressure redistribution on a larger contact area of the colon. The system can be operated by a surgeon via a graphic user interface that displays contact force values and enables independent or coordinated pressurization of the soft actuators upon demand, in case deemed necessary to aid navigation or distend colon tissue.

Total motorized spiral enteroscopy: first prospective clinical feasibility trial

BACKGROUND AND AIMS

Motorized spiral enteroscopy (MSE) was recently introduced into clinical practice and shown to be safe and effective for antegrade enteroscopy. The aim of the current trial was to prospectively study the efficacy and safety of MSE for visualization of the entire small bowel.

METHODS

All consecutive patients with indications for complete enteroscopy meeting the inclusion criteria were enrolled in a prospective observational bicentric trial, starting with antegrade MSE; a retrograde approach was performed if MSE remained incomplete from antegrade. The primary objective was to ascertain the total enteroscopy rate (TER); secondary objectives were diagnostic yield, procedural success, time, depth of maximum insertion (DMI), therapeutic yield, and adverse events (AEs).

RESULTS

Thirty patients (16 women, 14 men; median age 64 years [range, 37-100]) were enrolled. Technical success rate of antegrade MSE (advancement beyond the ligament of Treitz) and retrograde MSE (advancement beyond the ileocecal valve [ICV]) were 100% and 100%, respectively. Overall TER was 70%: 16.6% antegrade approach alone and 53.4% bidirectional approach. Median antegrade DMI distal from the ligament of Treitz was 490 cm (range, 160-600); median insertion time 26 minutes (range, 15-110). The median retrograde DMI beyond the ICV was 120 cm (range, 40-600), and median insertion time was 17 minutes (range, 1-68). Overall diagnostic and therapeutic yields were 80% and 86.7%, respectively. Overall AE rate was 16.7%. No serious AEs occurred.

CONCLUSIONS

This prospective study showed that complete enteroscopy is feasible with MSE, either from antegrade alone or bidirectionally, with high success rates and short procedural duration. These results justify further evaluation of MSE in a large prospective multicenter study, preferably with inclusion of a control group. (Clinical trial registration number: NCT03438695.).

Clinical Features of Ischemic Enteritis Diagnosed by Double-Balloon Endoscopy

INTRODUCTION

Ischemic enteritis (IE) is a relatively rare small bowel disease that is diagnosed via double-balloon endoscopy (DBE), although the lack of established diagnostic criteria can make it difficult to confirm the diagnosis. This study aimed to describe the clinical characteristics, endoscopic imaging features, and treatments for IE at our center. Patients and Methods. We retrospectively searched the DBE database (1,521 patients) at Nagoya University Hospital for patients with IE and collected data regarding endoscopic findings, clinical background, and histological findings. The cases were categorized according to whether they involved transient or stenotic IE.

RESULTS

The DBE database included 24 patients (14 men) with IE. Transient IE was identified in 9 patients, and stenotic IE was identified in 15. Half of the patients had a history of cerebrovascular and cardiovascular disease. A granular structure at the ulcer base was the most frequently observed DBE finding at the stenotic site. Enterography using the contrast medium revealed that transient IE had a similar stenotic lesion length, relative to stenotic IE, although stenotic IE had a significantly higher stenosis ratio (81% vs. 63%, P=0.033). Small bowel enteroclysis revealed the "lead pipe" sign (11 patients), thumbprinting (3 patients), and the serrated lumen sign (1 patient). Only 1 patient with stenotic IE experienced recurrence after conservative treatment.

CONCLUSION

During DBE, IE was characterized by cannular stenosis with extended and variable ulceration types, which spread over the edge of the stenosis, and a granular appearance at the ulcer base. These findings may help guide the diagnosis of IE.

Recent Advances of Interventional Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound for Patients with Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) is considered to be the gold standard for diagnosis and interventions in biliopancreatic diseases. However, ERCP in patients with surgically altered anatomy (SAA) appears to be more difficult compared to cases with normal anatomy. Since the production of a balloon enteroscope (BE) for small intestine disorders, BE had also been used for biliopancreatic diseases in patients with SAA. Since the development of BE-assisted ERCP, the outcomes of procedures, such as stone extraction or drainage, have been reported as favorable. Recently, an interventional endoscopic ultrasound (EUS), such as EUS-guided biliary drainage (EUS-BD), has been developed and is available mainly for patients with difficult cases of ERCP. It is a good option for patients with SAA. The effectiveness of interventional EUS for patients with SAA has been reported. Both BE-assisted ERCP and interventional EUS have advantages and disadvantages. The choice of procedure should be individualized to the patient’s condition or the expertise of the endoscopists. The aim of this review article is to discuss recent advances in interventional ERCP and EUS for patients with SAA.

Role of Video Capsule Endoscopy as a Prelude to Deep Enteroscopy

Video capsule endoscopy and device-assisted enteroscopy are complementary technologies. Capsule endoscopy is a highly acceptable technology with high diagnostic yield that can guide a subsequent enteroscopy approach. This article aims to focus on the role of video capsule endoscopy as a prelude to deep enteroscopy with a focus on the strengths and limitations of either approach.

Technical and Clinical Aspects of Diagnostic Single-Balloon Enteroscopy in the First Decade of Use: A Systematic Review and Meta-Analysis

Background/Aims

Single-balloon enteroscopy (SBE) has been widely used in diagnosing small bowel disease. We conducted this study to systematically appraise its technical and clinical performance.

Methods

Studies on SBE published by September 2018 were systematically searched. Technical and clinical performance data were collected and analyzed with descriptive or meta-analysis methods.

Results

In total, 54 articles incorporating 4,592 patients (6,036 procedures) were included. Regarding technical parameters, the pooled insertion depths (IDs) for anterograde and retrograde SBE were 209.2 cm and 98.1 cm, respectively. The pooled retrograde ID in Asian countries was significantly greater than that in Western countries (129.0 cm vs 81.1 cm, p<0.001). The pooled anterograde and retrograde procedure times were 57.6 minutes and 65.1 minutes, respectively. The total enteroscopy rate was 21.9%, with no significant difference between Asian and Western countries. Clinically, the pooled diagnostic yield of SBE was 62.3%. Obscure gastrointestinal bleeding (OGIB) was the most common indication (50.0%), with a diagnostic yield of 59.5%. Vascular lesions were the most common findings in Western OGIB patients (76.9%) but not in Asian ones (31.0%). The rates of severe and mild adverse events were 0.5% and 2.5%, respectively.

Conclusions

SBE is technically efficient and is clinically effective and safe, but total enteroscopy is relatively difficult to achieve with this technique. Etiologies of OGIB in Asian countries differ from those in Western countries.

The diagnostic and treatment values of double-balloon enteroscopy in children's Meckel's diverticular bleeding

The diagnostic and treatment values and safety of preoperative double-balloon enteroscopy (DBE) for Meckel's diverticula (MD) bleeding in children by retrospective review and analyses.The clinical data were collected and analyzed from 10 cases of children with MD receiving preoperative DBE examination and postoperative pathological confirmation. The diagnostic and treatment values and safety were assessed through the comparison of the DBE results and intra-operative observations and subsequently postoperative pathological results.Total cases are 10, 7 males and 3 females. The male to female ratio is 2.3 to 1. The youngest patient is 3.3 years old and oldest 12.1, the average age is 7.4 ± 3.0. The lowest body weight is 12.6 kg and the average is 32.5 ± 18.9 kg. The hematochezia was the main clinical manifestation in all patients with anemia and moderate to severe anemia were common (9/10, 90%). All patients had and tolerated the DBE procedures via anal route with 100% success rate. There were no observable complications during the examinations and post operations. All patients were diagnosed with MD by DBE. Exploratory laparoscopy and surgical operations were subsequently performed. All surgical samples were confirmed by pathology as bleeding MD. The postoperative follow-ups up to April 2019 (from 3 to 12 months) do not show any bleeding sign. Pathological examinations found ectopic gastric mucosa in 9 patients (90%) and one case had both ectopic gastric mucosa pancreatic tissue (10%). The distance of MD to ileocecal valve was from 60 to 100 cm (average 81.0 ± 16.0 cm) by DBE examinations. Surgery showed similar findings from 30 to 100 cm (average 71.0 ± 18.5) consistently to DBE. There is no statistical significance between 2 methods (Ζ = 1.715, Ρ = .086).DBE examination proves to be a safe method for diagnosing children's MD disease and can reliably determine the bleeding lesions in children's MD, providing valuable guidance for surgical treatment of children's MD bleeding.

Malignant Melanoma of the Gastrointestinal Tract: Symptoms, Diagnosis, and Current Treatment Options

Malignant melanoma (MM) has become the fifth most frequent cancer in the UK. It is the most common carcinoma to metastasize to the gastrointestinal (GI) tract. MM particularly has an affinity to spread to the small bowel, which is followed by the involvement of the stomach and large intestine. Excellent endoscopic options including video capsule endoscopy and enteroscopy are available for a precise diagnosis of GI involvement by a metastatic MM. The complete surgical resection of GI metastatic MM in carefully selected patients not only provides symptom control, but has also been associated with an increase in overall survival. The approval of BRAF-targeted therapies and immune checkpoint inhibitors has transformed therapeutic approaches for patients with metastatic MM over the past decade. Currently, the overall survival of patients with advanced metastatic MM who have been treated with a combination of immunotherapeutic agents reaches 52% at five years. The role of surgery for patients with the metastatic involvement of the GI tract with MM is evolving in the era of effective systemic treatments.

Usefulness of self-expandable metal stents for malignant biliary obstruction using a short-type single-balloon enteroscope in patients with surgically altered anatomy

OBJECTIVES

To evaluate the efficacy and safety of self-expandable metal stent (SEMS) placement for unresectable malignant biliary obstruction (MBO) using a short-type single-balloon enteroscopy (short SBE) in patients with surgically altered anatomy (SAA).

METHODS

The technical success rate, clinical success rate, recurrent biliary obstruction (RBO), time to RBO (TRBO), procedure related adverse events, and reintervention after RBO were evaluated from September 2011 to June 2020.

RESULTS

Thirty-seven patients (11 patients with distal MBO and 26 with hilar MBO) who underwent SEMS placement were included in the analysis. The technical and clinical success rates were 100% and 94.6%. Seven patients underwent bilateral stenting (partial stent-in-stent placement) for hilar MBO. The RBO rate was 13.5% (5/37) and the median TRBO was 212 (interquartile range [IQR], 154-296) days. No food impaction occurred in this study. Procedure related adverse events occurred in 5.4% (2/37) of cases. Reintervention was attempted in five patients and all succeeded (four patients underwent SEMS replacement, and one underwent plastic stent placement).

CONCLUSIONS

SEMS placement for unresectable MBO using a short SBE in patients with SAA is effective and safe in similar ways to that in patients with normal anatomy in terms of bilateral stenting, stent patency, and reintervention.

Probiotic lactobacilli as a promising strategy to ameliorate disorders associated with intestinal inflammation induced by a non-steroidal anti-inflammatory drug

Damage to the small intestine caused by non-steroidal anti-inflammatory drugs (NSAIDs) occurs more frequently than in the upper gastrointestinal tract, is more difficult to diagnose and no effective treatments exist. Hence, we investigated whether probiotics can control the onset of this severe condition in a murine model of intestinal inflammation induced by the NSAID, indomethacin. Probiotic supplementation to mice reduce the body weight loss, anemia, shortening of the small intestine, cell infiltration into the intestinal tissue and the loss of Paneth and Goblet cells associated with intestinal inflammation. Furthermore, a high antimicrobial activity in the intestinal fluids of mice fed with probiotics compared to animals on a conventional diet was elicited against several pathogens. Interestingly, probiotics dampened the oxidative stress and several local and systemic markers of an inflammatory process, as well as increased the secretion of IL-10 by regulatory T cells. Even more importantly, probiotics induced important changes in the large intestine microbiota characterized by an increase in anaerobes and lactobacilli, and a significant decrease in total enterobacteria. We conclude that oral probiotic supplementation in NSAID-induced inflammation increases intestinal antimicrobial activity and reinforces the intestinal epithelial barrier in order to avoid pathogens and commensal invasion and maintain intestinal homeostasis.

Endoscopic and percutaneous biliary interventions in patients with altered upper gastrointestinal anatomy-the Munich Multicenter Experience

BACKGROUND

In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era.

PATIENTS AND METHODS

Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed.

RESULTS

At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease.

CONCLUSION

In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.

P2Y12 Inhibitors Exacerbate Low-dose Aspirin-induced Small Bowel Injury in Dual Antiplatelet Therapy

Objective Antithrombotic drugs are being used increasingly frequently to prevent cardiovascular diseases. Few studies have evaluated small bowel mucosal injury induced by dual antiplatelet therapy (DAPT). The aim of the present study was to evaluate small bowel mucosal injury induced by DAPT compared with other antithrombotics using video capsule endoscopy (VCE). Methods The study included chronic users of antithrombotics who underwent VCE for obscure gastrointestinal bleeding between January 2007 and July 2018. We evaluated the instances of small bowel injury classified into erosions and ulcers. Results Overall, 183 patients (114 men and 69 women; mean age, 73.6 years old) were enrolled, and the study groups comprised 49 patients taking low-dose aspirin (LDA) only, 50 taking anticoagulants only, 37 being treated with DAPT, 33 on combined LDA and anticoagulants, and 14 taking P2Y12 inhibitors. Small bowel erosions and ulcers were most frequently observed in the DAPT group, with frequencies of 78.4% and 37.8%, respectively. Exacerbating factors of small bowel ulcers were DAPT [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.2-7.7] and age over 80 years old (OR 2.4, 95% CI 1.1-5.4). Conclusion P2Y12 inhibitors seem to exacerbate LDA-induced small bowel injury. Preventive strategies for small bowel injury induced by LDA, especially DAPT, are urgently required.

Significance of endoscopic deep small bowel evaluation using balloon-assisted enteroscopy for Crohn's disease in clinical remission

BACKGROUND

Small bowel lesions of Crohn's disease (CD) are known to be associated with a poor prognosis; however, endoscopic healing leads to favorable patients' outcome. The aim of this study was to clarify the clinical impact of assessing deep small bowel lesions (DSB) using balloon-assisted enteroscopy (BAE) on CD patients in clinical remission.

METHODS

From January 2012 to July 2018, a total of 100 CD patients in clinical remission were enrolled to undergo trans-anal enteroscopy using single-balloon enteroscope. Endoscopic evaluations at the terminal ileum (TI) were performed using a partial Simple Endoscopic Score for CD (pSES-CD). Endoscopic evaluations at the DSB used a modified partial SES-CD (mpSES-CD). We evaluated the factors associated with relapse, and the correlation of endoscopic score between the TI and DSB. For this study, relapse was defined as hospitalization within a year from enteroscopy.

RESULTS

30 patients (30.0%) relapsed within a year from enteroscopy. Multivariate logistic regression analysis revealed that the Harvey-Bradshaw Index (OR 1.77, 95% CI 1.18-2.65; p = 0.003) and an mpSES-CD at DSB (OR 3.10, 95% CI 1.86-5.15; p = 0.001) were independent predictors for relapse, whereas a SES-CD at the TI did not exhibit independence. There was a significant correlation trend between the relapse rate and greater than 5 points of an mpSES-CD at DSB; however, there was no correlation between the relapse rate and pSES-CD at the TI.

CONCLUSION

Even when Crohn's disease is in remission, it is important to evaluate DSB using BAE to assess endoscopic mucosal healing.

Combined Use of Computed Tomography Enterography/Enteroclysis and Capsule Endoscopy Improves the Accuracy of Diagnosis of Small Bowel Bleeding

Objective CT enterography/enteroclysis (CTE) is listed in the clinical practice guidelines as a method for diagnosing small bowel bleeding, as is capsule endoscopy (CE), but there are no real-world data yet available on CTE in Japan. This study aimed to investigate the diagnostic ability of CTE and long-term prognosis after CTE in Japan. Patients We conducted a retrospective cohort study of patients suspected of having small bowel bleeding who underwent both CTE and CE within 30 days between April 2008 and March 2019. The number of patients free from rebleeding for up to 24 months was thus determined. Results Seventy-one patients were extracted from the database. The 43 patients (60.6%) with a definite and suspicious source of bleeding in the small bowel were detected by CTE. When the 31 patients with a definite source of bleeding in the small bowel were analyzed, the sensitivity of CTE was 19/31 (61.3%) and that of CE was 24/31 (77.4%), thus indicating no significant difference (p=0.332). However, the sensitivity when CTE and CE were used in combination was 30/31 (96.8%), which was significantly higher than that of CE alone (p=0.0412). No rebleeding was observed in the CTE and CE negative group (p=0.0965). Conclusion The combined use of CTE and CE increased the detection rate of small bowel bleeding. Therefore, in patients with suspected tumor/polyp lesions, not only CE, but also CTE should be performed. This study provides the first real-world data on the diagnostic accuracy of CTE for small bowel bleeding in Japan.