The European experience with double-balloon enteroscopy: indications, methodology, safety, and clinical impact

Evaluation of symptomatic small bowel stricture in Crohn's disease by double-balloon endoscopy

PURPOSE

To assess the efficacy of double-balloon endoscopy (DBE) for the detection of small-bowel strictures in Crohn's disease (CD).

METHODS

This tertiary-referral hospital cohort study was conducted between January 2018 and May 2022. CD patients with symptoms of small-bowel stricture were enrolled sequentially. All of the patients were subjected to both computed tomography enterography (CTE) and DBE, and their symptoms of stricture were assessed using the Crohn's Disease Obstructive Score (CDOS). The diagnostic yield of DBE was compared to that of CTE, and the relationship between the DBE findings and CDOS was investigated. The factors influencing the DBE diagnosis were examined using Cox regression analysis.

RESULTS

This study included 165 CD patients. The CDOS scores were higher in 95 patients and lower in 70 patients. DBE detected 92.7% (153/165) and CTE detected 85.5% (141/165) of the strictures. The DBE diagnostic yields were 94.7% (90/95) in the high CDOS patients and 91.4% (64/70) in the low CDOS patients (P = 0.13). Patients with a history of abdominal surgery and abscess had a lower diagnosis rate in the multivariate analysis.

CONCLUSION

DBE has been demonstrated to be an efficient diagnostic method for detecting small bowel strictures in CD patients. Additionally, there was no difference in the diagnostic yields between patients with low and high obstructive scores.

Outcomes of Double Balloon-Enteroscopy in Elderly vs. Adult Patients: A Retrospective 16-Year Single-Centre Study

Background and Aim: Double-balloon enteroscopy (DBE) is a well-established procedure for direct visualisation of the entire small bowel mucosa, and, in contrast with other imaging techniques, allows to perform biopsies and therapeutic interventions. The aim of this study was to evaluate the indications, diagnostic yield, therapeutic yield, and complications of DBE in a cohort of consecutive patients according to patients’ age. Methods: We conducted a retrospective study of consecutive patients who underwent DBE in our endoscopy unit between January 2006 and December 2021. Results: A total of 387 consecutive patients who underwent 460 DBE procedures were included. Mean age of the patients was 63 years. The overall diagnostic yield was 67.6%; vascular lesions were the predominant endoscopic findings (31.5%), followed by polyps or neoplastic masses (17.6%). Older patients (≥65 years) showed statistically higher rates of clinically relevant findings than adult patients (18–65 years) (p = 0.001). Crohn’s disease and polyps or neoplastic masses were more frequent in the younger group (p = 0.009 and p = 0.066, respectively), while vascular lesions and non-specific inflammation were the most common findings in the older group (p < 0.001 and p < 0.001, respectively). The therapeutic intervention rate was 31.7%. Rates of endoscopic treatment were significantly higher in the older group (p < 0.001). Total complications occurred in five procedures (1.1%). Conclusion: In clinical practice, DBE is an efficient diagnostic and therapeutic tool with a high safety profile, particularly in the elderly population.

Performance of Balloon-Assisted Enteroscopy for Non-ERCP Indications in Patients with Surgically Altered Gastrointestinal Anatomy

BACKGROUND AND AIMS

Surgically altered gastrointestinal (GI) tract anatomy hinders deep enteroscopy. While enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered GI anatomy has been heavily investigated, the role of non-ERCP balloon-assisted enteroscopy (BAE) has yet to be fully elucidated.Please check and confirm the author names and initials are correct. Also, kindly confirm the details in the metadata are correct.I have checked all you asked and have no correction.  Thank you.

METHODS

A multicenter retrospective study of non-ERCP BAEs in patients with surgically altered GI tract anatomy at two tertiary academic hospitals was performed from January 2006 to December 2020. Altered GI tract anatomy was defined by surgical reconstruction affecting the length, angle, or overall trajectory of the endoscope during the intended approach. The main outcome measurements included technical success rate, diagnostic and therapeutic yields, and complication rate.Please check the edit made in the title of the article and correct if necessary.No more correction. Thank you.

RESULTS

A total of 68 patients with surgically altered GI tract anatomy underwent 56 antegrade and 24 retrograde non-ERCP BAE procedures. The technical success rate was 86.2% in both, including 83.9% via antegrade approach and 91.7% via retrograde approach. Antegrade approach in Roux-en-Y anatomy was associated with the lowest success rate of 77.8%, whereas retrograde approach in patients with colon resection resulted in the highest rate of 100%. The diagnostic and therapeutic yields of non-ERCP BAE were 79.4% and 82.9%, respectively. The diagnostic yields varied according to the procedural indications. The major complication was luminal perforation in one case (1.3%).

CONCLUSIONS

Non-ERCP BAE is effective and safe via both antegrade and retrograde approaches with a high technical success rate and diagnostic and therapeutic yields in patients with surgically altered GI tract anatomy.

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.

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.

Evaluation of the diagnostic and therapeutic utility of retrograde through-the-scope balloon enteroscopy and single-balloon enteroscopy

BACKGROUND

Retrograde single balloon enteroscopy (SBE) is a minimally invasive procedure which is less frequently performed compared with antegrade SBE. There are few studies on the retrograde through-the-scope enteroscopy (TTSE), a novel technique for evaluation of the small bowel.

AIM

To compare the clinical utility and safety of retrograde TTSE with retrograde SBE.

METHODS

Clinical data and complications of retrograde TTSE (2014-2018) and retrograde SBE (2011-2018) performed in a community hospital were reviewed and presented as mean ± SD or frequency (%) and compared using proper statistical tests. Technical success was defined as insertion of the enteroscope > 20 cm beyond ileocecal valve.

RESULTS

Data obtained from 54 retrograde SBE in 49 patients and 27 retrograde TTSE in 26 patients were studied. The most common indication for retrograde enteroscopy was iron deficiency anemia (41 patients) followed by gastrointestinal bleeding (37 patients), and chronic diarrhea (7 patients). The duration of retrograde SBE procedure (91.9 ± 34.2 min) was significantly longer compared with retrograde TTSE (70.5 ± 30.7 min) (P = 0.04). Technical success was comparable in TTSE [23/27 (85.2%)] and SBE [41/54 (75.9%) (P = 0.33)]. The mean depth of insertion beyond the ileocecal valve in retrograde SBE (92.5 ± 70.0 cm) tended to be longer compared with retrograde TTSE (64.6 ± 49.0 cm) (P = 0.08). No complication was observed in this study.

CONCLUSION

Both retrograde TTSE and retrograde SBE are feasible and safe. Retrograde TTSE takes a shorter time and has a comparable technical success with SBE. TTSE has a lower capacity of small bowel insertion.

Inspecting the total gastrointestinal tract by consecutive bidirectional double-balloon enteroscopy in patients with suspected small bowel bleeding

BACKGROUND/AIMS

This study aimed to investigate the feasibility, efficiency, and clinical significance of examining the total gastrointestinal (GI) tract by consecutive bidirectional double-balloon enteroscopy (DBE) within 1 day in patients with suspected small-bowel bleeding.

MATERIALS AND METHODS

From January 2016 to January 2018, the clinical and endoscopic data of 41 patients with suspected small-bowel bleeding undergoing DBE aimed at inspecting the total GI tract within 1 day.

RESULTS

A success rate of 87.8% (36/41) for examining the total GI tract with no adverse event was achieved by consecutive bidirectional DBE performed within 1 day. The total examination time was 140.61±36.41 (range, 82-270) minutes. Positive or negative findings of bleeding were detected in 51.2% (21/41) and 48.8% (20/41) patients, respectively. Single bleeding etiology with non-small-bowel lesions (NSBLs) or small-bowel lesions (SBLs) was detected in 12.2% (5/41) and 26.8% (11/41) of patients, respectively. Dual bleeding etiologies, including NSBLs and SBLs, were detected in 12.2% (5/41) of patients. A re-bleeding rate of positive or negative findings was different (4.8% vs. 40.0%; p<0.05).

CONCLUSION

Consecutive bidirectional DBE within 1 day can achieve complete vision of the total GI tract with a considerable success rate and high safety. This strategy may provide an option for detecting bleeding etiology throughout the GI tract. A negative finding with this method cannot absolutely exclude missed bleeding etiology and re-bleeding.

Quality indicators in enteroscopy. Enteroscopy procedure

Within the project "Quality Indicators in Gastrointestinal Endoscopy," under the leadership of the Sociedad Española de Patología Digestiva (SEPD), our goal is to propose the procedures and the structure, process, and outcome indicators required for the application and assessment of quality in enteroscopy. To this end a search was performed for quality indicators in enteroscopy. Quality of evidence was measured by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, and classified as high, moderate, low, and very low. A total of 10 process indicators (one preprocedure, eight procedure, one postprocedure) were identified for enteroscopy, with appropriate indication and choice of most efficient route being most significant.

Bacterial Endocarditis Following Deep Enteroscopy: Is Prophylaxis Warranted?

The development of bacterial endocarditis as a result of endoscopic interventions within the gastrointestinal tract is exceedingly rare. Antibiotic prophylaxis for endoscopic procedures is generally not warranted, except for certain high-risk patients. Double-balloon enteroscopy (DBE) is a common endoscopic procedure for evaluation of the small bowel. Bacterial endocarditis secondary to DBE has not been previously described. We describe the first case of enterococcal endocarditis attributed to DBE in a patient with a history of stage 1 primary biliary cholangitis.

Enteroscopy in the Elderly: Review of Procedural Aspects, Indications, Yield, and Safety

Background

As human longevity continues to increase, age-related diseases are more common, which leads to a higher use of gastroenterology services. Endoscopic procedures are generally considered to be of higher risk in the elderly with multiple comorbidities. However, some endoscopic techniques have already been proved to be well tolerated in the elderly.

Summary

<underline></underline>Enteroscopy enables the nonsurgical diagnosis and therapeutic management of a wide variety of small bowel diseases. Although it has been shown to be safe and effective, with high diagnostic yield and therapeutic success rate in the general population, its safety and efficacy in the elderly is largely unknown, and there are still some concerns about its use in these patients.

Key Messages

This review will focus on enteroscopy in elderly people, taking into account patient and procedure characteristics, indications, findings, yield, and complication rate.

Double-balloon enteroscopy: Experience with an innovative endoscopic technique at the Hospital Universitario de la Fundación Santa Fe de Bogotá

INTRODUCTION AND AIMS

Double-balloon enteroscopy is a recently introduced endoscopic method that enables complete visualization of the small bowel, as well as biopsy sampling and therapeutic interventions in that part of the intestine. The aim of the present study was to describe the experience acquired at our hospital to determine the characteristics of the patients that underwent the procedure.

MATERIALS AND METHODS

A descriptive, cross-sectional study was conducted on all patients above 18 years of age admitted to the Hospital Universitario de la Fundación Santa Fe de Bogotá for double-balloon enteroscopy, within the time frame of January 2013 to December 2017.

RESULTS

The study sample included 93 procedures in 73 patients. Mean patient age was 57.91 years, with a similar number of men and women. There were no severe complications. The most frequent indication for the enteroscopy was gastrointestinal bleeding (overt or occult), presenting in 49.46% of the patients, followed by chronic diarrhea (16.13%). Video capsule endoscopy was the previous study most frequently performed (53.76%). Anterograde double-balloon enteroscopy was carried out in 49 patients and 44 patients underwent the retrograde procedure. A total of 86.02% of the enteroscopies were diagnostic procedures and 13.98% were therapeutic. Normal enteroscopy was the most frequent finding (59.68%), followed by the presence of ulcers (15.05%).

CONCLUSIONS

Our results were similar to those reported worldwide, with respect to indications, insertion route, and insertion depth, and there were no severe complications.

Balloon enteroscopy versus spiral enteroscopy for small-bowel disorders: a systematic review and meta-analysis

BACKGROUND AND AIMS

Two novel enteroscopic procedures, balloon enteroscopy and spiral enteroscopy, have revolutionized the diagnostic and therapeutic approach to small-bowel disorders. These disorders that historically required surgical interventions are now investigated and managed nonsurgically. Only a few weakly powered studies have compared the outcomes of spiral enteroscopy and balloon enteroscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures.

METHODS

PubMed, Cochrane Library, Scopus, and clinicaltrials.gov databases were searched for all studies published up to January 12, 2017 comparing the efficacy and safety of balloon enteroscopy (single or double) and spiral enteroscopy. Primary outcomes of interest were diagnostic and therapeutic success rates. Other outcomes included procedure length, depth of maximal insertion (DMI), rate of complete enteroscopy, and adverse events. We calculated Odds ratios (ORs) for categorical variables and mean difference (MD) for continuous variables. The Mantel-Haenszel method was used to analyze the data. Fixed and random effect models were used for <50% heterogeneity and >50% heterogeneity, respectively.

RESULTS

Eight studies met the inclusion criteria for this meta-analysis. A total of 615 procedures were analyzed, which included 394 balloon enteroscopy and 221 spiral enteroscopy procedures. There were no significant differences in diagnostic and therapeutic success rates (OR, 1.27; 95% confidence interval [CI], .86-1.88; P = .22; and OR, 1.23; 95% CI, .82-1.84; P = .32, respectively) between the 2 procedures. Similarly, DMI was not significantly different between the 2 groups (MD, 26.29; 95% CI, 20.92-73.49; P = .28). However, the procedure time was significantly shorter for the spiral enteroscopy group compared with the balloon enteroscopy group (MD, 11.26; 95% CI, 2.72-19.79; P = .010). A subgroup analysis comparing double balloon enteroscopy with spiral enteroscopy yielded similar results.

CONCLUSIONS

Both procedures achieved similar diagnostic and therapeutic outcomes and with similar depth of insertion. Spiral enteroscopy has the benefit of shorter procedural time.

Detection Rate and Clinical Relevance of Ink Tattooing during Balloon-Assisted Enteroscopy

Background and Aims

Balloon-assisted enteroscopy (BAE) is a well-established tool in the diagnosis and therapy of small bowel diseases. Ink tattooing of the small bowel is used to mark pathologic lesions or the depth of small bowel insertion. The purpose of this study was to determine the safety, the detection rate, and the clinical relevance of ink tattooing during BAE.

Methods

We performed a retrospective analysis of all 81 patients who received an ink tattooing during BAE between 2010 and 2015.

Results

In all patients, ink tattooing was performed with no complications. 26 patients received a capsule endoscopy after BAE. The tattoo could be detected via capsule endoscopy in 19 of these 26 patients. The tattoo of the previous BAE could be detected via opposite BAE in 2 of 11 patients. In 9 patients, ink tattooing influenced the choice of approach for reenteroscopy. In 7 patients, the tattoo was used for intraoperative localization and in 3 patients for intraoperative localization as well as for reenteroscopy. The intraoperative detection rate of the tattoo was 100%.

Conclusion

Ink tattooing of the small intestine is a safe endoscopic procedure to mark the depth of scope insertion or a pathologic lesion during balloon-assisted enteroscopy.

Efficacy of double-balloon enteroscopy for small-bowel polypectomy: clinical and economic evaluation

BACKGROUND

We evaluated first the feasibility of endoscopic small-bowel polypectomy and second, the economic aspects, by comparing the cost of endoscopic and surgical polyp resection.

METHODS

A prospective, observational, multicenter study included 494 patients with positive capsule endoscopy (CE) before double-balloon enteroscopy (DBE). We selected only CE with at least one polyp. The retrospective economic evaluation compared patients treated by DBE or surgery for small-bowel polypectomy. Hospital readmission because of repeat polyp resection or complication-related interventions was noted. The 1-year cost was estimated from the viewpoint of the healthcare system and included procedures, hospital admissions and follow up.

RESULTS

CE indicated one or more polyps in 62 (12.5%) patients (32 males, 49 ± 5 years), all of whom underwent a successful DBE exploration. The DBE polyp diagnostic yield was 58%. There were no major complications. A total of 26 (42%) patients in the DBE group and 19 (39%) in the control group required hospital readmission. All readmissions in the DBE group were for repeat procedures to remove all polyps, and in the control group, for surgical complications. The total cost of the initial hospitalization (€4014 ± 2239 DBE versus €11,620 ± 7183 surgery, p < 0.0001) and the 1-year total cost (€8438 ± 9227 DBE versus €13,402 ± 7919 surgery, p < 0.0001) were lower in the DBE group.

CONCLUSIONS

Endoscopic polypectomy was efficient and safe. The total cost at 1 year was less for endoscopy than surgery. DBE should be proposed as the first-line treatment for small-bowel polyp resection.

Double-balloon enteroscopy: Indications, approaches, diagnostic and therapeutic yield, and safety. Early experience at a single center

INTRODUCTION AND AIMS

Double-balloon enteroscopy has been improving the visualization of the entire intestine for more than a decade. It is a complementary method in the study of intestinal diseases that enables biopsies to be taken and treatments to be administered. Our aim was to describe its main indications, insertion routes, diagnostic/therapeutic yield, and complications.

MATERIALS AND METHODS

All patients referred to our unit with suspected small bowel pathology were included. The insertion route (oral/anal) was determined through diagnostic suspicion. The variables measured were: insertion route, small bowel examination extent, endoscopic diagnosis/treatment, biopsy/histopathology report, complications, and surgical findings.

RESULTS

The study included 28 double-balloon enteroscopies performed on 23 patients, of which 10 were women and 13 were men (mean age of 52.95 years). The oral approach was the most widely used (n=21), the main indication was overt small bowel bleeding (n=16), and the general diagnostic yield was 65.21%. The therapeutic intervention rate was 39.1% and the procedure was effective in all the cases. The most widely used treatment was argon plasma therapy (n=7). The complication rate was 8.6%; one patient presented with low blood pressure due to active bleeding and another had deep mucosal laceration caused by the argon plasma.

CONCLUSIONS

Double-balloon enteroscopy is a safe and efficacious method for the study and management of small bowel diseases, with an elevated diagnostic and therapeutic yield.

Clinical outcome after enteroscopy for small bowel angioectasia bleeding: A Korean Associateion for the Study of Intestinal Disease (KASID) multiceter study

BACKGROUND AND AIMS

Angioectasias are the most common sources of bleeding in the small bowel. They can be treated using balloon-assisted enteroscopy (BAE). This study aimed to identify the rebleeding rate and associated factors after BAE in patients with small bowel angioectasia bleeding.

METHODS

We retrospectively analyzed the records of patients with bleeding due to small bowel vascular lesion in a multicenter enteroscopy database including 1108 BAEs. Finally, in rebleeding analysis, we analyzed 66 patients with angioectasia on the basis of the Yano-Yamamoto classification. Patients who had undergone endotherapy (ET) were divided into ET (n = 45) and non-ET (n = 21) groups. Rebleeding was defined as evidence of bleeding at least 30 days after BAE.

RESULTS

Fifty-three patients (80.4%) underwent only one-side enteroscopy. The most common ET was argon plasma coagulation (87.2%). During a mean follow-up duration of 24.5 months, ET and non-ET groups had rebleeding rates of 15.6% and 38.1% (P = 0.059), respectively. Median rebleeding time of ET and non-ET groups was 32.5 and 62 months, respectively. Liver cirrhosis (LC), low platelet count (< 10⁵ /μL), and transfusions were the rebleeding-associated factors in the univariate analysis. In the multivariate analysis, the presence of LC (HR 4.064, 95% CI 1.098-15.045; P = 0.036) was the only independent rebleeding-associated risk factor.

CONCLUSIONS

ET using BAE did not significantly affect the rebleeding rate in patients with small bowel angioectasia bleeding. An independent rebleeding risk factor was the presence of LC. Regardless of ET, careful long-term follow-up may be needed, especially in LC patients with small bowel angioectasia bleeding.

Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: A meta-analysis

BACKGROUND/AIMS

The aim of this study was to evaluate the effectiveness and safety of endoscopic retrograde cholangiopancreatography with double balloon enteroscope (DBE-ERCP) in patients with altered gastrointestinal anatomy in a meta-analysis.

MATERIALS AND METHODS

A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane library covering the period from January 2001 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using the I2 test.

RESULTS

Ten studies involving a total of 301 patients were included in the analysis. The pooled enteroscopy, diagnostic, and therapeutic success rates were 89.75% [95% confidence interval (CI): 79.65-94.30%], 79.92% (95% CI: 68.06-89.59%), and 63.55% (95% CI: 53.70-72.86%), respectively. DBE-ERCP-related complications occurred in 18 patients including perforation (5), pancreatitis (3), cholangitis (9), and bleeding (1). The incidence of DBE-ERCP-related complication was 6.27% (95% CI: 2.61-11.38%).

CONCLUSION

Diagnostic and therapeutic DBE-ERCPs are feasible in patients with altered gastrointestinal anatomy. DBE-ERCP may be considered when pancreaticobiliary diseases occur in patients undergoing Roux-en-Y reconstruction or pancreaticoduodenectomy.

Systematic review: Safety of balloon assisted enteroscopy in Crohn's disease

AIM

To determine the overall and comparative risk of procedure related perforation of balloon assisted enteroscopy (BAE) in Crohn's disease (CD).

METHODS

Systematic review (PROSPERO #CRD42015016381) of studies reporting on CD patients undergoing BAE. Seventy-three studies reporting on 1812 patients undergoing 2340 BAEs were included. Primary outcome of interest was the overall and comparative risk of procedure related perforation of diagnostic BAE in CD. Secondary outcomes of interest were risk of procedure related perforation of diagnostic double balloon enteroscopy (DBE), risk of procedure related perforation of therapeutic BAE, efficacy of stricture dilation, and clinical utility of endoscopically assessing small bowel disease activity.

RESULTS

Per procedure perforation rate of diagnostic BAE in CD was 0.15% (95%CI: 0.05-0.45), which was similar to diagnostic BAE for all indications (0.11%; IRR = 1.41, 95%CI: 0.28-4.50). Per procedure perforation rate of diagnostic DBE in CD was 0.12% (95%CI: 0.03-0.44), which was similar to diagnostic DBE for all indications (0.22%; IRR = 0.54, 95%CI: 0.06-0.24). Per procedure perforation rate of therapeutic BAE in CD was 1.74% (95%CI: 0.85-3.55). Eighty-six percent of therapeutic perforations were secondary to stricture dilation. Dilation was attempted in 207 patients and 30% required surgery during median follow-up of 18 months. When diagnostic BAE assessed small bowel disease activity, changes in medical therapy resulted in endoscopic improvement in 77% of patients.

CONCLUSION

Diagnostic BAE in CD has a similar rate of perforation as diagnostic BAE for all indications and can be safely performed in assessment of mucosal healing.

Double-balloon enteroscopy in small bowel diseases: Eight years single-center experience in China

The aim of the study was to evaluate the diagnostic and therapeutic value of double-balloon entoroscopy (DBE) in small bowel diseases (SBDs) in China.A retrospective review of 674 consecutive patients who underwent DBE between January 2007 and November 2015 was conducted. Patients were divided into 3 groups by age, young group (<45 years), middle-aged group (45-65 years), and elderly group (>65 years). Data were collected with regard to demographics, clinical, endoscopic findings, complications, diagnostic yield, and management.A total of 729 DBE procedures were performed successfully in our series. More than 20 types of SBDs were found with the detection rate of 70.9%(517/729). The majority of patients were Crohn's disease (33.4%,225/674), followed by tumor (18.8%,127/674) and angioectasia (7.9%, 53/674). Endoscopic treatment was performed in 60 patients in which hemostasis (17,28.3%) and polypectomy (15,25%) were the predominant form of intervention used. Adverse events occurred in 6 patients (0.96%,6/729) including perforation, hemorrhage, aspiration pneumonia. No acute pancreatitis or other major complications occurred. Adenocarcinoma, GIST, and lymphoma were the most common tumor detected, the majority of tumors located in the jejunum (56.7%), The detection rate of angioectasia was also higher in the jejunum (54.7%),77.8% of Crohn's disease was located in the ileum. The positive rate of DBE in small bowel tumor and Crohn's disease were significantly higher than that of angioectasia (P<0.05). In young cohort, Crohn's disease (48.1%) was the most commonly diseases followed by tumor (10.4%) and nonspecific enteritis (7.1%). Yet in the elderly group, the majority of patients were tumor (27.6%); angioectasia (21.3%) was also detected frequently. The positive rate of capsule endoscopy was 75.44 %(202/268) which was a little high than DBE (67.9%, 182/268) (P > 0.05). The obscure gastrointestinal bleeding (OGIB) was the most common indication, and the diagnostic yield was 71.8%.DBE is a useful diagnostic and therapeutic tool with high clinical practice value for the investigation of SBDs. With growing experience of endoscopist, we believe that DBE must be kept in mind as the first-line modality for suspected SBDs.

Double balloon enteroscopy: A 7-year experience at a tertiary care Centre

BACKGROUND

Double Balloon Enteroscopy (DBE) provides the opportunity not only to investigate but also apply endoscopic therapeutic interventions for small intestinal disturbances. The aim of this study is to assess the indications, diagnosis, therapeutic interventions, complications and safety in clinical practise of DBE procedures that have been performed in our clinic.

MATERIAL-METHODS

The data of patients who had undergone DBE procedure in our clinic between October 2007 and December 2014 were retrospectively investigated. All features including indications, findings, histopathological results, applied interventions and complications due to procedure were noted.

RESULTS

A total of 297 patients, 160 (53,9%) male and 137 (46,1%) female were enrolled in the study. Total number of procedures for these 297 patients were 372 [256 (68,8%) oral and 116 (31,2%) anal]. Mean age of the patients was 46,9 (14-94) years. The most common indications were; obscure gastrointestinal (GI) bleeding (28,3%), iron deficiency anaemia (17,5% ) and abnormal findings in a prior imaging study (13,8%), respectively. The rate of new diagnosis with DBE was 11.8%, where the rate for confirmation of a possible diagnosis was 16.2%, rate of endoscopic treatment with definite diagnosis was 11%, rate for ruling out possible diagnosis or showing normal findings was 34.7% and rate for insufficient or unsuccessful procedures was 26.3%. Ulcers, inflammation and erosions (13%), polyposis syndromes (9.8%) and vascular pathologies (7.4%) were the most common endoscopic findings.

CONCLUSION

Our study shows that DBE has high efficacy for diagnosis and ability to perform treatment of small intestinal disturbances with safety.

Performance characteristics of retrograde single-balloon endoscopy: A single center experience

AIM: To evaluate the technical success, diagnostic yield (DY) and therapeutic potential of retrograde single balloon enteroscopy (rSBE).

METHODS: A retrospective review of 136 rSBE procedures performed at a tertiary academic referral center from January 2006 and September 2013 was completed. Patient characteristics including age, gender and inpatient status were collected. The indication for the procedure was categorized into one of three groups: Obscure gastrointestinal bleeding (GIB), evaluation for Crohn’s disease and abnormal imaging. Procedural characteristics including insertion depth (ID), procedure time, concordance with pre-procedural imaging and complications were also recorded. Lastly, DY, defined as the percentage of cases producing either a definitive diagnosis or findings that could explain clinical symptoms and therapeutic yield (TY), defined as the percentage of cases in which a definitive intervention was performed, were determined. Mucosal tattooing and biopsy alone were not included in the TY.

RESULTS: A total of 136 rSBE procedures were identified. Mean patient age was 57.5 (± 16.2) years, 67 (49.2%) were male, and 110 (80.9%) procedures were performed on an outpatient basis. Indications for rSBE included GIB in 55 (40.4%), evaluation of inflammatory bowel disease (IBD) in 29 (21.3%), and imaging suggestive of pathology other than GIB or IBD in 43 (31.6%). Nine (6.6%) rSBEs were performed for other indications. Mean ID was 68.3 (± 39.3) cm proximal to the ileocecal valve and mean time to completion was 41.7 (± 15.5) min. Overall, 73 (53.7%) cases were diagnostic and 25 (18.4%) cases were therapeutic in which interventions (argon plasma coagulation, stricture dilatation, polypectomy, etc.) were performed. Pre-procedural imaging was performed in 88 (64.7%) patients. Endoscopic concordance of positive imaging findings was seen in 31 (35.2%) cases. Follow up data was available in 93 (68.4%) patients; 2 (2.2%) reported post-procedural abdominal pain within 30 d following rSBE. There were no other reported complications.

CONCLUSION: rSBE exhibits an acceptable diagnostic and TY, rendering it a safe and effective procedure for the evaluation and treatment of small bowel diseases.

Meckel's diverticulum in an adult: an obscure presentation of gastrointestinal bleeding

A 17-year-old boy, with a background of haemophilia A, presented to hospital with an episode of brisk and painless per rectal (PR) bleeding. Initial investigation with gastroscopy and colonoscopy revealed no source of bleeding. Examination of the small bowel including MRI, CT angiogram and capsule endoscopy revealed no abnormalities. Double balloon enteroscopy (DBE) from an antegrade position was attempted, with no abnormalities noted. The symptoms persisted and DBE was attempted again from a retrograde approach and a diverticulum was subsequently noted. Laparoscopic surgery was performed identifying a diverticulum as the source of bleeding, 110 cm from the ileocaecal valve, which is more proximal than is normally seen. Histological examination revealed a Meckel's diverticulum. The case described here, although more unusual in adults, demonstrates that complete visualisation of the small bowel remains challenging and that newer modalities of enteroscopy including DBE can help aid in the diagnosis of obscure gastrointestinal bleeding.

Overtube-assisted enteroscopy and capsule endoscopy for the diagnosis of small-bowel polyps and tumors: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Several studies have evaluated the utility of double-balloon enteroscopy (DBE) and capsule endoscopy (CE) for patients with small-bowel disease showing inconsistent results. The aim of this study was to determine the sensitivity and specificity of overtube-assisted enteroscopy (OAE) as well as the diagnostic concordance between OAE and CE for small-bowel polyps and tumors.

PATIENTS AND METHODS

We conducted a systematic review and meta-analysis of studies in which the results of OAE were compared with the results of CE for the evaluation of small-bowel polyps and tumors. When data for surgically resected lesions were available, the histopathological results of OAE and surgical specimens were compared. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the diagnosis of small-bowel polyps and tumors were analyzed. Secondarily, the rates of diagnostic concordance and discordance between OAE and CE were calculated.

RESULTS

There were 15 full-length studies with a total of 821 patients that met the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were as follows: 0.89 (95 % confidence interval [CI] 0.84 - 0.93), with heterogeneity χ(2) = 41.23 (P = 0.0002) and inconsistency (I (2)) = 66.0 %; 0.97 (95 %CI 0.95 - 0.98), with heterogeneity χ(2) = 45.27 (P = 0.07) and inconsistency (I (2)) = 69.1 %; 16.61 (95 %CI 3.74 - 73.82), with heterogeneity Cochrane's Q = 225.19 (P < 0.01) and inconsistency (I (2)) = 93.8 %; and 0.14 (95 %CI 0.05 - 0.35), with heterogeneity Cochrane's Q = 81.01 (P < .01) and inconsistency (I (2)) = 82.7 %, respectively. A summary receiver operating characteristic curve (SROC) curve was constructed, and the area under the curve (AUC) was 0.97.

CONCLUSION

OAE is an accurate test for the detection of small-bowel polyps and tumors. OAE and CE have a high diagnostic concordance rate for small-bowel polyps and tumors. This study was registered in the PROSPERO international database (www.crd.york.ac.uk/prospero/) with the study number CRD42015016000.

Enteroscopy

Noninvasive imaging with CT and magnetic resonance enterography or direct visualization with wireless capsule endoscopy can provide valuable diagnostic information and direct therapy. Enteroscopy technology and techniques have evolved significantly and allow diagnosis and therapy deep within the small bowel, previously attainable only with intraoperative enteroscopy. Push enteroscopy, readily available in most endoscopy units, plays an important role in the evaluation and management of lesions located up to the proximal jejunum. Currently available device-assisted enteroscopy systems, DBE, SBE, and spiral enteroscopy each have their technical nuances, clinical advantages, and limitations. Newer, on-demand enteroscopy systems appear promising, but further studies are needed. Despite slight differences in parameters such as procedural times, depths of insertion, and rates of complete enteroscopy, the overall clinical outcomes with all overtube-assisted systems appear to be similar. Endoscopists should therefore master the enteroscopy technology based on institutional availability and their level of technical expertise.

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

Evaluation and outcomes of patients with obscure gastrointestinal bleeding

Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding or presence of iron deficiency anaemia after evaluation with a negative bidirectional endoscopy. OGIB accounts for 5% of gastrointestinal bleeding and presents a diagnostic challenge. Current modalities available for the investigation of OGIB include capsule endoscopy, balloon assisted enteroscopy, spiral enteroscopy and computed tomography enterography. These modalities overcome the limitations of previous techniques. Following a negative bidirectional endoscopy, capsule endoscopy and double balloon enteroscopy remain the cornerstone of investigation in OGIB given their high diagnostic yield. Long-term outcome data in patients with OGIB is limited, but is most promising for capsule endoscopy. This article reviews the current literature and provides an overview of the clinical evaluation of patients with OGIB, available diagnostic and therapeutic modalities and long-term clinical outcomes.

Diagnosis of gastrointestinal bleeding: A practical guide for clinicians

Gastrointestinal bleeding is a common problem encountered in the emergency department and in the primary care setting. Acute or overt gastrointestinal bleeding is visible in the form of hematemesis, melena or hematochezia. Chronic or occult gastrointestinal bleeding is not apparent to the patient and usually presents as positive fecal occult blood or iron deficiency anemia. Obscure gastrointestinal bleeding is recurrent bleeding when the source remains unidentified after upper endoscopy and colonoscopic evaluation and is usually from the small intestine. Accurate clinical diagnosis is crucial and guides definitive investigations and interventions. This review summarizes the overall diagnostic approach to gastrointestinal bleeding and provides a practical guide for clinicians.

Magnetic resonance enterography in refractory iron deficiency anemia: A pictorial overview

AIM: To highlight magnetic resonance enterography (MRE) for diagnosis of patients with refractory iron deficiency anemia and normal endoscopy results.

METHODS: Fifty-three patients diagnosed with iron deficiency anemia refractory to treatment and normal gastroscopy and colonoscopy results were admitted to this prospective study between June 2013 and December 2013. All patients underwent a standardized MRE examination with a 1.5 Tesla magnetic resonance imaging system using two six-channel phased-array abdominal coils. Adequate bowel distention and fast imaging sequences were utilized to achieve diagnostic accuracy. All segments of the small bowel, duodenum, jejunum, and ileum were examined in detail. All cases were examined independently by two radiologists with > 5 years of experience in abdominal magnetic resonance imaging. A consensus reading was performed for each patient following image examination. Both radiologists were blinded to patient history, laboratory findings, and endoscopy results.

RESULTS: Twenty (37.7%) male and 33 (62.3%) female patients were included in the study. The mean age of the patients was 52.2 ± 13.6 years (range: 19-81 years, median 51.0). The age difference between the male and female patient groups was not statistically significant (54.8 ± 16.3 years vs 50.7 ± 11.7 years). MRE results were normal for 49 patients (92.5%). Four patients had abnormal MRE results. One patient with antral thickening was diagnosed with antral gastritis in the second-look gastroscopy. One patient had focal wall thickening in the 3^rd and 4^th portions of the duodenum. The affected areas were biopsied in a subsequent duodenoscopy, and adenocarcinoma was diagnosed. One patient had a fistula and focal contrast enhancement in the distal ileal segments, consistent with Crohn’s disease. One patient had focal wall thickening with luminal narrowing in the mid-jejunum that was later biopsied during a double-balloon enteroscopy, and lymphoma was diagnosed.

CONCLUSION: MRE is a non-invasive and effective alternative for evaluating possible malignancies of the small intestines and can serve as a guide for a second-look endoscopy.

Factors associated with reduced insertion depth at double balloon enteroscopy: a retrospective, multivariate analysis

BACKGROUND

Deep small bowel insertion during double balloon enteroscopy can be difficult to achieve.

AIMS

To determine the factors influencing depth of insertion during double balloon enteroscopy.

METHODS

History of abdomino-pelvic surgery, route of insertion, type of enteroscope, age, sedation or general anaesthesia used and gender were considered as potential influencing factors; procedures were categorised accordingly and maximal depth of insertion calculated.

RESULTS

At multivariate analysis, maximal depth of insertion was significantly associated with history of abdominal-pelvic surgery (P<0.001), rectal approach (P=0.011), gender (P=0.02) and use of the therapeutic enteroscope (P=0.047). Mean maximal depth of insertion was 266±12cm, 255±9cm (P=0.50), 197±10cm (P<0.0001), 160±12cm (P<0.01) and 103±33cm (P<0.15) when 0, 1, 2, 3 and 4 influencing factors were present, respectively.

CONCLUSION

Maximal depth of insertion was significantly influenced by history of abdomino-pelvic surgery, insertion route, gender and type of enteroscope used.

Double-balloon endoscopy for diagnosis of small intestinal disorders: A systematic review of data over the first decade of use

AIM: To systematically analyze data on diagnostic rate, observation scope, and complications of double-balloon endoscopy (DBE) for small bowel diseases, and to further evaluate its clinical value and security.

METHODS: A total of 1036 patients (585 men and 451 women) with suspected or known small-bowel diseases underwent 1202 DBE procedures (oral 589, anal 613, both approaches 184) under anesthesia with propofol at our institution over the past decade.

RESULTS: The success rate of DBE was 99.2% (1193/1202), and the positive diagnostic yield was 84.5% (875/1036). The main diagnosis was polyps and tumors (391/1202; 32.5%), erosions and ulcerations (246/1202; 20.4%), and angiodysplasia (52/1202; 4.32%). The mean duration of the procedure was 78 min ± 43 min (30-180 min). On average, 231 cm ± 74 cm of the small bowel was visualized by using the oral route and 176 cm ± 69 cm by using the anal route (P < 0.05). Most common lesions detected in patients with OGIB (obscure gastrointestinal bleeding) were ulcers and erosions (57/218; 26.1%), vascular diseases (33/218; 15.1%), and tumors and polyps (28/218; 12.8%). Among 63 small bowel tumor cases, 45 were malignant (45/63; 71%) and 18 were benign (18/63; 29%). Histopathology was consistent with the endoscopic diagnosis in 87.5% (63/72) of patients with small bowel tumors. Severe complications were observed in 11/1202 (0.915%) of cases. A minority of patients complained of mild sore throat, anal pain or abdominal distension after the DBE procdure.

CONCLUSION: Our retrospective analysis shows that DBE is a safe and effective method to diagnose small bowel disorders by visualization and tissue sampling to assist in diagnosis of etiology.

Single-balloon enteroscopy: a single-center experience of 48 procedures

The aim of this study was to report the analysis of a single-center experience with single-balloon enteroscopy (SBE). A retrospective analysis of patients with small-bowel disorder who underwent SBE procedure from February 2011 to February 2013 was carried out. A total of 40 patients underwent 48 SBE procedures. Antegrade and retrograde approaches were used in 68.8 % and 31.2 % of subjects, respectively. The main indications were obscure gastrointestinal bleeding (n = 28), chronic diarrhea (n = 6), and chronic abdominal pain (n = 6). Average (SD) insertion length by antegrade approach was 150.6 (31.4) cm (range 90-210 cm) beyond the duodenojejunal flexure and by retrograde approach was 106.6 (29.4) cm (range 40-140 cm) proximal to the ileocecal junction. Average procedure time for antegrade approach was 46.3 (9.0) min (range 25-60 min) and for retrograde approach was 61.3 (12.8) min (range 45-90 min). Panendoscopy was not possible in any of the eight patients in whom antegrade and retrograde approaches were performed. Overall diagnostic yield was 55 % and therapeutic procedures were done in 20 % of patients. There were no significant complications. SBE is a safe and effective method to diagnose patients with small-bowel disease and provides a useful tool for intervention.

The role of double-balloon enteroscopy following capsule endoscopy in diagnosis of obscure Small intestinal diseases

Objective: The aim of this study was to evaluate the detection rate accuracy of Double-balloon Enteroscopy (DBE) after Capsule Endoscopy (CE) in patients with suspected small bowel diseases.

Methodology: From January 2009 to March 2012, sixty-two patients with obscure small bowel diseases who underwent CE followed by DBE were included in this study. Introduction of the endoscope by DBE was either orally or anally according to CE.

Results: Sixty-two patients are reported. The overall detection rate of small bowel diseases using CE was 70.9% (44/62). Sixty-eight DBE procedures following capsule endoscopy were carried out, There was no significant difference (χ²=0.6739, P>0.05) of Positive findings between CE and CE +DBE. Furthermore, the detection rate of small bowel diseases in patients with obscure small intestinal bleeding using CE +DBE (90.9%, 30/33) was superior to that of CE (78.8%, 26/33); χ²=1.8857, P>0.05.

Conclusions: Capsule Endoscopy (CE) can cover the whole GI tract and provide the selection of the route of Double-balloon enteroscopy (DBE). DBE can also serve as a good complementary approach after an initial imaging using CE. It can verify the findings of CE and provide therapeutic intervention. Using of CE followed by DBE is effective in the diagnosis and management of patients with obscure small bowel diseases.

Double- vs. single-balloon enteroscopy: single center experience with emphasis on procedural performance

PURPOSE

This study aims to compare double- (DBE) and single-balloon enteroscopy (SBE) in small bowel disorders with respect to procedural performance and clinical impact.

METHODS

This retrospective analysis at a tertial referral center included 1,052 DBEs and 515 SBEs performed in 904 patients over 7 years. Procedural and patients' characteristics were precisely analyzed.

RESULTS

Significantly more patients with anemia and gastrointestinal bleeding were investigated by DBE (P < 0.01). Oral insertion depth and length of investigated small bowel in the combined approach were significantly higher in the DBE compared to the SBE group (245 ± 65.3 vs. 218 ± 62.6 and 355 ± 101.9 vs. 319 ± 91.2, respectively; P < 0.001, each). By analyzing only recent years of enteroscopy (2008-2011), no difference in small bowel visualization could be observed. The anal insertion depths and complete enteroscopy rates (CER) were comparable. Procedure times were significantly shorter within the SBE procedure (oral: 50 vs. 40 min; anal: 55 vs. 46 min, P < 0.001) and the usage of sedation was significantly less (propofol: P < 0.001; pethidine: P < 0.05). Diagnostic yield was significantly higher in the SBE, compared to the DBE group (61.7 vs. 48.2 %; P < 0.001). The rate of severe adverse events was close to zero.

CONCLUSION

Both enteroscopy techniques are safe diagnostic tools and proved to be indispensable in the daily gastroenterological practice. The lower insertion depths, but higher diagnostic yield, of SBE may reflect the more focused selection of patients scheduled for small bowel diagnostics in recent years.

Comparison of double balloon enteroscopy in adults and children

AIM: To compare results of double balloon enteroscopy (DBE) procedures in pediatric and adult patients.

METHODS: The medical files of patients who underwent DBE at Gazi University School of Medicine, Ankara, Turkey between 2009 and 2011 were examined retrospectively. Adult and pediatric patients were compared according to DBE indications, procedure duration, final diagnosis, and complications. DBE procedures were performed in an operating room under general anesthesia by two endoscopists. An oral or anal approach was preferred according to estimated lesion sites. Overnight fasting of at least 6 h prior to the start of the procedure was adequate for preprocedural preparation of oral DBE procedures. Bowel cleansing was performed by oral administration of sennosides A and B solution, 2 mL/kg, and anal saline laxative enema. The patients were followed up for 2 h after the procedure in terms of possible complications.

RESULTS: DBE was performed in 35 patients (5 pediatric and 30 adult). DBE procedures were performed for abdominal pain, chronic diarrhea, bleeding, chronic vomiting, anemia, and postoperative evaluation of anastomosis. Final diagnosis was diffuse gastric angiodysplasia (n = 1); diffuse jejunal angiodysplasia (n = 1); ulceration in the bulbus (n = 1); celiac disease (n = 1); low differentiated metastatic carcinoma (n = 1); Peutz-Jeghers syndrome (n = 1); adenomatous polyp (n = 1) and stricture formation in anastomosis line (n = 1). During postprocedural follow-up, abdominal pain and elevated amylase levels were noted in three patients and one patient developed abdominal perforation.

CONCLUSION: With the help of technological improvements, we may use enteroscopy as a safe modality more frequently in younger and smaller children.

Is a repeat double balloon endoscopy in the same direction useful in patients with recurrent obscure gastrointestinal bleeding?

GOALS

To evaluate the usefulness of repeat double balloon endoscopy (DBE) in obscure gastrointestinal bleeding (OGIB).

BACKGROUND

OGIB recurs in 11% to 42% of patients after DBE. Little is known about the outcome of repeat DBE in recurrent OGIB after DBE.

STUDY

We reviewed clinical course of patients who underwent repeat DBE for recurrent OGIB in the same direction as in previous DBE. Diagnostic yield and therapeutic intervention of repeat DBE were analyzed.

RESULTS

Thirty-five repeat DBEs were performed in 32 patients (M:F=15:17; age range, 36 to 85 y). The first DBE identified a probable bleeding source in 21 (65.6%) patients. Angiodysplasia was the most common and was found in 16 patients. The second DBEs were performed after a median of 30 weeks (range, 1 to 204 wk). Oral approach only was performed in 28 patients and anal approach only in 4. Probable bleeding sources were detected in 17 (53.1%) patients. Sixteen (94.1%) cases were angiodysplasia, of which 14 patients had angiodysplasia also at the first DBE. All detected bleeding sources were managed with endoscopic interventions such as argon plasma coagulation. Seventeen of 21 patients with positive first DBE showed bleeding source at the repeat DBE, whereas none of the 11 patients with negative first DBE did (81.0% vs. 0%; P<0.001). Three patients underwent the third DBE. Angiodysplasias were detected in 2 patients (66.7%).

CONCLUSIONS

Repeat DBE in the same direction may detect bleeding sources in 53% of recurrent OGIB patients. The probability of bleeding source detection in repeat DBE is higher in patients with a prior positive DBE.

Multicenter comparison of double-balloon enteroscopy and spiral enteroscopy

BACKGROUND AND AIM

Spiral enteroscopy is a novel technique for small bowel exploration. The aim of this study is to compare double-balloon and spiral enteroscopy in patients with suspected small bowel lesions.

METHODS

Patients with suspected small bowel lesion diagnosed by capsule endoscopy were prospectively included between September 2009 and December 2010 in five tertiary-care academic medical centers.

RESULTS

After capsule endoscopy, 191 double-balloon enteroscopy and 50 spiral enteroscopies were performed. Indications were obscure gastrointestinal bleeding in 194 (80%) of cases. Lesions detected by capsule endoscopy were mainly angioectasia. Double-balloon and spiral enteroscopy resulted in finding one or more lesions in 70% and 75% of cases, respectively. The mean diagnosis procedure time and the average small bowel explored length during double-balloon and spiral enteroscopy were, respectively, 60 min (45-80) and 55 min (45-80) (P=0.74), and 200 cm (150-300) and 220 cm (200-300) (P=0.13). Treatment during double-balloon and spiral enteroscopy was possible in 66% and 70% of cases, respectively. There was no significant major procedure-related complication.

CONCLUSION

Spiral enteroscopy appears as safe as double-balloon enteroscopy for small bowel exploration with a similar diagnostic and therapeutic yield. Comparison between the two procedures in terms of duration and length of small bowel explored is slightly in favor of spiral enteroscopy but not significantly.

Small bowel polypectomy by double balloon enteroscopy: Correlation with prior capsule endoscopy

AIM: To investigate the feasibility of small bowel polypectomy using double balloon enteroscopy and to evaluate the correlation with capsule endoscopy (CE).

METHODS: This is a retrospective review of a single tertiary hospital. Twenty-five patients treated by enteroscopy for small bowel polyps diagnosed by CE or other imaging techniques were included. The correlation between CE and enteroscopy (correlation coefficient of Kendall for the number of polyps, intra-class coefficient for the size and coefficient of correlation kappa for the location) was evaluated.

RESULTS: There were 31 polypectomies and 12 endoscopic mucosal resections with limited morbidity and no mortality. Histological analysis revealed 27 hamartomas, 6 adenomas and 3 lipomas. Strong agreement between CE and optical enteroscopy was observed for both location (Kappa value: 0.90) and polyp size (Kappa value: 0.76), but only moderate agreement was found for the number of polyps (Kendall value: 0.47).

CONCLUSION: Double balloon enteroscopy is safe for performing polypectomy. Previous CE is useful in selecting the endoscopic approach and to predicting the difficulty of the procedure.

A novel diagnostic and treatment strategy for small intestinal lesions in children: hybrid treatment using transumbilical minimal incision surgery combined with double-balloon enteroscopy

INTRODUCTION

Double-balloon enteroscopy (DBE) is a useful and feasible modality for evaluating small intestinal lesions, even in children.

METHODS

DBE makes it possible to perform biopsy, diagnosis, polypectomy and endoscopic therapies including hemostasis, tattooing and clipping of the small intestinal lesions. However, endoscopic procedures in the small intestines of children are more difficult than in adults, because the intestinal wall is thin and the lumen is narrow. A novel hybrid treatment was developed using DBE for small bowel lesions combined with transumbilical minimal incision surgery.

CONCLUSION

This hybrid treatment is safe, effective, provides excellent cosmetic results and can be used as an alternative for traditional open laparotomy or endoscopic surgery.

Changes in efficiency and resource utilization after increasing experience with double balloon enteroscopy

AIM: To investigate changes in efficiency and resource utilization as a single endoscopist’s experience increased with each subsequent 100 double balloon enteroscopy (DBE) procedures.

METHODS: We reviewed consecutive DBE procedures performed by a single endoscopist at our center over 4 years. DBE was employed when the clinician deemed the procedure was needed for disease management. The approach (oral, anal or both) was chosen based on suspected location of the target lesion. All DBE was performed in a standard endoscopy room with a portable fluoroscopy unit. Fluoroscopy was used to aid in shortening the small intestine and reducing bowel loops. For oral DBE, measurements were taken from the incisors. For anal DBE, measurements were taken from the anal verge. Enteroscopy continued until the target lesion was reached, until the entire small intestine was examined, or until no further progress was deemed possible. The length of small intestine examined (cm), procedure duration (min), and fluoroscopy time (s) were analyzed for sequential groups of 100 DBE. Sub-groups of diagnostic and therapeutic procedures were analyzed using multivariable linear regression.

RESULTS: 802 consecutive DBE procedures were analyzed. For oral DBE, median [interquartile range (IQR)] length of small bowel examined was 230.8 cm (range: 210-248 cm) and for anal DBE was 143.5 cm (range: 100-180 cm). No significant increase in length examined was noted for either the oral or anal approach with advancing position in series. In terms of duration of procedure, the median (IQR) for oral DBE was 86 min (range: 71-105 min) and for anal DBE was 81.3 min (range: 67-105 min). When comparing by the position in series, there was a significant (P value < 0.001) decrease in procedure duration for both upper and lower procedures with increasing experience. Median (IQR) time of exposure to fluoroscopy for oral DBE was 190 s (114-275) compared to anal DBE which was 196.4 s (312-128). This represented a significant (P value < 0.001) decrease in the amount of fluoroscopy used with increasing position in series. For both oral and anal DBE, fluoroscopy time was reduced by greater than 50% over the course of 802 total procedures performed. Sub-group analysis was conducted on therapeutic and diagnostic groups. Out of 802 procedures, a total of 434 were considered therapeutic. Argon plasma coagulation was by far the most common therapeutic intervention performed. There was no evidence of a difference in length examined or fluoroscopy exposure among oral DBE for diagnostic and therapeutic procedures, P = 0.91 and P = 0.32 respectively. The median (IQR) for length was 235 cm (range: 178-280 cm) for diagnostic vs 230 cm (range: 180-275 cm) for therapeutic procedures; additionally, fluoroscopy time median (IQR) was 180 s (range: 110-295 s) and 162 s (range: 102-263 s) for no intervention and intervention. However, there was a significant difference in procedure duration among oral DBE (P < 0.001). The median (IQR) was 80 min (range: 60-97 min) and 94 min (range: 77-110 min) for diagnostic and therapeutic interventions respectively.

CONCLUSION: For a single endoscopist, increased DBE experience with number of performed procedures is associated with increased efficiency and decreased resource utilization.

Patient burden and patient preference: comparing magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy

BACKGROUND AND AIM

We aimed to prospectively determine patient burden and patient preference for magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy in patients with suspected or known Crohn's disease (CD) or occult gastrointestinal bleeding (OGIB).

METHODS

 Consecutive consenting patients with CD or OGIB underwent magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy. Capsule endoscopy was only performed if magnetic resonance enteroclysis showed no high-grade small bowel stenosis. Patient preference and burden was evaluated by means of standardized questionnaires at five moments in time.

RESULTS

From January 2007 until March 2009, 76 patients were included (M/F 31/45; mean age 46.9 years; range 20.0-78.4 years): 38 patients with OGIB and 38 with suspected or known CD. Seventeen patients did not undergo capsule endoscopy because of high-grade stenosis. Ninety-five percent (344/363) of the questionnaires were suitable for evaluation. Capsule endoscopy was significantly favored over magnetic resonance enteroclysis and balloon-assisted enteroscopy with respect to bowel preparation, swallowing of the capsule (compared to insertion of the tube/scope), burden of the entire examination, duration and accordance with the pre-study information. Capsule endoscopy and magnetic resonance enteroclysis were significantly preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, and magnetic resonance enteroclysis was significantly preferred over balloon-assisted enteroscopy for bowel preparation, painfulness and burden of the entire examination. Balloon-assisted enteroscopy was significantly favored over magnetic resonance enteroclysis for insertion of the scope and procedure duration. Pre- and post-study the order of preference was capsule endoscopy, magnetic resonance enteroclysis and balloon-assisted enteroscopy.

CONCLUSION

Capsule endoscopy was preferred to magnetic resonance enteroclysis and balloon-assisted enteroscopy; it also had the lowest burden. Magnetic resonance enteroclysis was preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, bowel preparation, painfulness and burden of the entire examination, and balloon-assisted enteroscopy over magnetic resonance enteroclysis for scope insertion and study duration.

Endoscopic techniques for small bowel imaging

Advances in small bowel enteroscopy have led to an increase in the endoscopic evaluation and management of small bowel disorders. The entire small bowel can now be visualized in a noninvasive manner by capsule endoscopy, while therapeutic management can be performed with deep enteroscopy techniques, including balloon-assisted and spiral enteroscopy. Each of these enteroscopy tools has its unique advantages and disadvantages, which need to be taken into consideration during selection of the appropriate tool. Capsule endoscopy and deep enteroscopy are often used as complementary tests in the evaluation of small bowel disorders.

Single-balloon enteroscopy for small bowel diseases: results from an initial experience at a single Chinese center

OBJECTIVE

This study aimed to evaluate the performance, diagnostic yield, and safety of single-balloon enteroscopy (SBE) at a Chinese tertiary-care center.

METHODS

A total of 67 patients with suspected small bowel diseases who underwent SBE via the oral and/or anal routes from January 2009 to August 2011 were retrospectively analyzed. Data were extracted from electronic clinical and endoscopy records. The indications, SBE procedure time, diagnostic yield and complications were summarized and evaluated.

RESULTS

A total of 42 SBE procedures through the oral route and 38 via the anal route were performed in these 67 patients. Patients were referred mainly for obscure gastrointestinal bleeding (OGIB) (40.3%) and abdominal pain (29.8%). The mean procedure duration was 68.1 min from the oral cavity and 77.5 min from the anus. The estimated depth of insertion was 247.6 ± 80.3 cm from the oral cavity and 131.1 ± 68.7 cm from the anus. The overall significant diagnostic yield was 68.7%. In patients with OGIB and unexplained chronic abdominal pain, the diagnostic yield was 74.1% and 50.0%, respectively. There were no significant complications.

CONCLUSION

SBE appears to be a safe and effective method for the diagnosis and treatment of deep small bowel disease.

SINGLE-01: a randomized, controlled trial comparing the efficacy and depth of insertion of single- and double-balloon enteroscopy by using a novel method to determine insertion depth

BACKGROUND

Single-balloon enteroscopy (SBE) was introduced as an alternative to double-balloon enteroscopy (DBE) for the investigation and management of small-bowel conditions. To date, there is only 1 randomized, controlled trial comparing SBE and DBE in a Western population.

OBJECTIVE

To compare the 2 instruments in a Western population to assess for differences in clinical outcomes and insertion depth (ID). A novel method to determine ID by counting folds on withdrawal was used.

DESIGN

Multicenter, randomized, controlled trial.

SETTING

University hospitals in Melbourne and Sydney, Australia.

PATIENTS

Patients with suspected or proven small-bowel disease.

INTERVENTIONS

SBE and DBE.

MAIN OUTCOME MEASUREMENT

The primary endpoint was diagnostic yield (DY). Secondary endpoints were therapeutic yield (TY), procedure times, and ID. An intention-to-treat analysis was performed.

RESULTS

A total of 116 patients were screened, and 107 patients were enrolled between July 2008 and June 2010, in whom 119 procedures were undertaken (53 SBEs and 66 DBEs). DY was 57% for SBE and 53% for DBE (P = .697). TY was 32% for SBE and 26% for DBE (P = .490). The median enteroscopy times were identical for SBE and DBE at 60 minutes. The mean ID by the fold-counting method for antegrade procedures was 201.1 folds for SBE and 258.6 folds for DBE (P = .046). After multiple comparisons adjustment, this difference did not reach statistical significance. Mean IDs by using the visual estimation method for SBE and DBE were, respectively, 72.1 cm and 75.2 cm (P = .835) for retrograde procedures and 203.8 cm and 234.1 cm (P = .176) for antegrade procedures.

LIMITATIONS

Unable to reach target sample size, mostly single-center recruitment, novel method to determine ID, which requires further validation.

CONCLUSIONS

SBE has DY, TY, and procedure times similar to those of DBE. There were no statistically significant differences in ID between SBE and DBE. By using the fold-counting method for antegrade procedures, the estimated IDs for SBE and DBE were 201.1 folds versus 258.6 folds (P = .046; P = not significant after adjustment for multiple comparisons). (

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12609000917235.).