Single-balloon-assisted colonoscopy in patients with previously failed colonoscopy

A randomized prospective study comparing single-balloon-assisted colonoscopy and cap-assisted colonoscopy in patients with previous incomplete conventional colonoscopy

INTRODUCTION

Cecal intubation may be unsuccessful by conventional colonoscopy in some patients. Single-balloon-assisted colonoscopy (SBC) and cap-assisted colonoscopy (CAC) were studied to solve this problem. There was no head-to-head comparison between them.

METHODS

We conducted a randomized study from 2018 to 2021 to compare cecal intubation rate of SBC and CAC in patients with previous incomplete conventional colonoscopy. We recruited patients with incomplete conventional colonoscopy in two hospitals in Hong Kong. Patients were randomized into SBC group and CAC group in 1:1 ratio. In the case of failure in cecal intubation by allocated method, alternative modality would be performed as rescue.

RESULTS

Forty-four patients were recruited. Cecal intubation rate was superior in SBC group (22/22, 100%) than CAC group (16/22, 72.7%) (P = 0.02). No difference in cecal intubation time, polyp detection rate, and diagnostic gain in area not examined previously. SBC induced less discomfort (modified Gloucester comfort score 2.14 vs 2.63, P = 0.03) with use of comparable amount of midazolam and fentanyl as CAC. For patients failed cecal intubation by CAC, all (n = 6) were rescued successfully by SBC. Body weight, body mass index (BMI), and waist circumference were greater in rescue subgroup. More patients were obese (BMI ≥ 25 kg/m) in rescue subgroup (67% vs 19%). None in rescue subgroup had history of successful cecal intubation by conventional colonoscopy (0% vs 56%, P = 0.046). However, we failed to demonstrate significant association in multivariate analysis owing to small sample size. No adverse event was noted.

CONCLUSION

SBC is superior to CAC in cecal intubation in patients with previous incomplete conventional colonoscopy.

Prospective evaluation of the motorized spiral enteroscope for previous incomplete colonoscopy

Background and study aims  A significant percentage of colonoscopies remain incomplete because of failure to intubate the cecum. The motorized spiral enteroscope (MSE) technique, originally developed for deep small bowel enteroscopy, may be an effective alternative technique in cases of incomplete examination of abnormally long colons (dolichocolon). We prospectively evaluated the success rate of cecal intubation, safety and the therapeutic consequences of using MSE after incomplete conventional colonoscopy. Patients and methods  A total of 36 consecutive patients with an indication for diagnostic and/or therapeutic colonoscopy were prospectively enrolled in this multicenter trial. All patients had undergone at least one incomplete colonoscopy attributed to abnormally long colons. Patients with incomplete colonoscopy due to stenosis were excluded. Results  Twenty-two men and 14 women (median age 66 years, range 35-82) were enrolled. Median procedure time was 30 minutes (range 16-50). Cecal intubation rate was 100 % and median cecal intubation time was 10 minutes (range 4-30). Abnormalities, mostly neoplastic lesions, were detected in 23 of 36 patients, corresponding to a diagnostic yield of 64 %. All these findings were in the right side of the colon and had not been described by the antecedent incomplete coloscopy. No adverse events occurred. Conclusions  In case of a difficult and long colon, MSE is safe and effective for diagnostic and therapeutic colonoscopy. It may provide an attractive solution to accomplish completeness of previous incomplete colonoscopies in these patients.

Balloon-Assisted Colonoscopy after Incomplete Conventional Colonoscopy-Experience from Two European Centres with A Comprehensive Review of the Literature

Background: Conventional colonoscopy (CC) allows access for colonic investigation and intervention; in the small group in whom CC is unsuccessful alternative imaging is often sufficient. There remains a subset, however, requiring full colonic visualisation or intervention. Balloon-assisted colonoscopy (BAC) gives a further option when access is difficult. Aims: This study aims to present the experience with BAC of two European tertiary referral centres. Methods: Procedures were carried out under local protocol over 15-years (2006–2020). Markers of procedural quality such as caecal intubation, complications and comfort were retrospectively compiled and analysed. Published evidence was summarised for comparison. Results: 122 procedures were undertaken, with polyps the most frequent indication and 90.2% having at least one previously incomplete CC. Features associated with difficult colonoscopy were common, including intraabdominal surgery (32.0%). 92.6% reached the caecum; completion was higher (96.3%) in those failing CC due to discomfort and lower in those failing due to anatomical difficulties (90.7%) or previous surgery (84.6%). Mean time to the caecum was 20.9 minutes and mean midazolam and fentanyl doses were 2.6 mg and 49.9 µg with low discomfort scores. Conclusion(s): Balloon-assisted colonoscopy is successful in >90% of patients, is well-tolerated, and is safe.

Performance of radiographic imaging after incomplete colonoscopy for nonmalignant causes in clinical practice

BACKGROUND AND AIMS

CT colonography (CTC) or barium enema are commonly ordered to complete colorectal imaging after an incomplete colonoscopy. We evaluated the sensitivity of radiographic studies performed for this purpose in clinical practice outside clinical trials.

METHODS

Adult patients referred to an expert endoscopist for incomplete colonoscopy because of a redundant colon or a difficult sigmoid and who underwent previous radiographic imaging between July 2001 and July 2019 were identified. None of the patients had a malignant obstruction as the cause of incomplete colonoscopy. Data on polyp size, location, and pathology were obtained from colonoscopy and radiology reports. Polyps identified on imaging and colonoscopy were matched based on polyp size and location.

RESULTS

Among 769 patients referred for incomplete colonoscopy, we identified 65 with a radiographic examination performed within 36 months of colonoscopy at our center. Per-patient sensitivity for CTC was suboptimal (70%) and was very low for barium enema (26.7%). Per-polyp sensitivity for both CTC and barium enema was poor (23.8% and 7.6%). Quality of the examination did not seem to affect procedure sensitivity.

CONCLUSIONS

Radiographic imaging after incomplete colonoscopy for reasons other than malignant obstruction had poor sensitivity for polyps. Patients with incomplete colonoscopies should be considered for repeat colonoscopy by an expert.

Use of enteroscope without the overtube in incomplete colonoscopies

Objectives: Colonoscopy is the gold standard diagnostic method for colorectal cancer (CRC) screening. Despite the progress in the endoscopy technology field, a small percentage of colonoscopies is still incomplete. The reasons for that are mostly associated with anatomic features, such as fixed, angulated, long and loopy colon, intra-abdominal adherences and female gender. To overcome such difficulties, the usefulness of scopes different from conventional adult colonoscope (CF), such as paediatric colonoscope (PCF), gastroscope (GIF), single and double balloon enteroscope (SBE and DBE, respectively), has been shown in literature. Our retrospective study aims to evaluate the caecal intubation rate using a SBE without the overtube in patients who previously underwent an incomplete procedure with a different scope.Methods: Patients with a previous incomplete colonoscopy with CF, PCF or GIF were retrospectively enrolled through the analysis of a dedicated database. The enteroscope used was the Olympus Enteropro Single Balloon SiF-Q180 with no overtube. Complete colonoscopy was defined as successful caecal intubation.Results: SBE was used to scope 47 adult patients, mostly female, and it led to a complete procedure in 91% of them. The most frequent reason for an incomplete procedure even with the use of SBE was a fixed and angulated colon.Conclusions: Colonoscopy performed with SBE was safe and no adverse events during and/or after the procedure occurred. Our results suggest that SBE with no overtube is a useful and valid alternative to other type of scopes in difficult cases, especially those related to fixed/angulated colon and in female gender.

Pediatric Endoscopy and High-risk Patients: A Clinical Report From the NASPGHAN Endoscopy Committee

Pediatric gastrointestinal endoscopy has been established as safe and effective for diagnosis and management of many pediatric gastrointestinal diseases. Nevertheless, certain patient and procedure factors should be recognized that increase the risk of intra- and/or postprocedural adverse events (AEs). AEs associated with endoscopic procedures can broadly be categorized as involving sedation-related physiological changes, bleeding, perforation, and infection. Factors which may increase patient risk for such AEs include but are not limited to, cardiopulmonary diseases, anatomical airway or craniofacial abnormalities, compromised intestinal luminal wall integrity, coagulopathies, and compromised immune systems. Examples of high-risk patients include patients with congenital heart disease, craniofacial abnormalities, connective tissues diseases, inflammatory bowel disease, and children undergoing treatment for cancer. This clinical report is intended to help guide clinicians stratify patient risks and employ clinical practices that may minimize AEs during and after endoscopy. These include use of CO2 insufflation, endoscopic techniques for maneuvers such as biopsies, and endoscope loop-reduction to mitigate the risk of such complications such as bleeding and intestinal perforation. Endoscopic infection risk and guidance regarding periprocedural antibiotics are also discussed.

Single Balloon-assisted Colonoscopy for Placement of Colonic Manometry Catheters: Initial Experience in Children

OBJECTIVES

Colonic manometry is used frequently in children with long standing and difficult to manage constipation to aid in management decisions. Accurate analysis requires placement of the colonic manometry catheter in the colon without looping. This is technically difficult due to the long-standing nature of the constipation in most patients leading to sigmoid and other colonic redundancy. Single balloon colonoscopy has been successfully used in adult in cases of difficult colonoscopy. We report the first series of single balloon-assisted colonoscopy for performing difficult colonoscopy in children and placing colonic manometry catheters.

METHODS

Retrospective chart review was performed to identify patients undergoing the procedure. All patients had prior preparation with nasogastric golytely.

RESULTS

Using the single balloon technique, 36 patients underwent placement of the colonic manometry catheter (ages ranging from 3 to 16 years, weights 12 to 95 kg). Catheter placement was successful in all cases with procedure times of 20 to 105 minutes. No major complications were noted.

CONCLUSIONS

This is the first reported series of using single balloon-assisted colonoscopy to perform difficult colonoscopy in children and place colonic manometry catheters. It may have other therapeutic implications in children such as removal of polyps or placement of similar catheters.

High Efficacy of Repeating Colonoscopy by an Advanced Endoscopist after an Incomplete Colonoscopy

Background and Aims

This study aims to evaluate the role of an advanced endoscopist to study the entire colon after an incomplete colonoscopy.

Methods

All patients with an elective incomplete colonoscopy performed under deep sedation in our department between January 2010 and October 2016 were included. Patients with a colonic stenosis, an inadequate bowel preparation, or a colonoscopy performed without deep sedation were excluded. Included patients were followed up to evaluate if and what type of subsequent examinations (colonoscopy by an advanced endoscopist, single-balloon enteroscopy [SBE], and/or CT colonography) was performed to complete the study of the entire colon. Lesions found during these subsequent examinations were also recorded.

Results

Ninety-three patients had an incomplete colonoscopy, with no diagnosis of colorectal cancer (CRC) and a high-risk polyp rate of 5.4% (n = 5). Seventy-seven patients with incomplete colonoscopies underwent subsequent examinations, namely CT colonography in 45.5% (n = 35), colonoscopy by an advanced endoscopist in 53.2% (n = 41), and SBE in 13% (n = 10). In the 49 patients who performed either colonoscopy (n = 39) or SBE (n = 10) by an advanced endoscopist, the cecal intubation rate was 100%, and high-risk polyps were found in 26.5% (n = 13) and CRC in 4.1%. CT colonography revealed findings consistent with polyps and CRC in 22.9% (n = 8) and 2.9% (n = 1) of the cases, respectively. Colonoscopy was further repeated in 6 patients with suspected polyps in CT colonography, confirming the initial diagnosis in 5 patients.

Conclusions

Colonoscopy by an advanced endoscopist achieved cecal intubation in all patients, representing a good choice after an incomplete colonoscopy.

Alternatives to Incomplete Colonoscopy

A thorough and complete colonoscopy is critically important in preventing colorectal cancer. Factors associated with difficult and incomplete colonoscopy include a poor bowel preparation, severe diverticulosis, redundant colon, looping, adhesions, young and female patients, patient discomfort, and the expertise of the endoscopist. For difficult colonoscopy, focusing on bowel preparation techniques, appropriate sedation and adjunct techniques such as water immersion, abdominal pressure techniques, and patient positioning can overcome many of these challenges. Occasionally, these fail and other alternatives to incomplete colonoscopy have to be considered. If patients have low risk of polyps, then noninvasive imaging options such as computed tomography (CT) or magnetic resonance (MR) colonography can be considered. Novel applications such as Colon Capsule™ and Check-Cap are also emerging. In patients in whom a clinically significant lesion is noted on a noninvasive imaging test or if they are at a higher risk of having polyps, balloon-assisted colonoscopy can be performed with either a single- or double-balloon enteroscope or colonoscope. The application of these techniques enables complete colonoscopic examination in the vast majority of patients.

Clinical usefulness of a single-use splinting tube for poor endoscope operability in deep colonic endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

Poor endoscope operability remains a significant challenge during colorectal endoscopic submucosal dissection (ESD). We retrospectively evaluated the experience and clinical usefulness of a new single-use splinting tube in deep colonic ESD in the setting of poor scope operability.

PATIENTS AND METHODS

Among 691 patients with colorectal tumors treated with ESD at Hiroshima University Hospital between November 2009 and July 2015, we analyzed 20 consecutive patients who underwent deep colonic ESD using a single-use splinting tube because of poor scope operability. Poor operability was defined as paradoxical movement of the endoscope, poor control with adhesions, and lesion motion with heartbeat or breathing. Technical and clinical success rates and adverse events were assessed.

RESULTS

Paradoxical movement and poor control with adhesions were improved in all cases using the single-use splinting tube. The en bloc resection rate was 95 % (19/20) and histological en bloc resection rate was 100 % (20/20). There were no complications related to use of the splinting tube.

CONCLUSIONS

Use of a single-use splinting tube helped to overcome poor scope operability in deep colonic ESD.

Regional center for complex colonoscopy: yield of neoplasia in patients with prior incomplete colonoscopy

BACKGROUND AND AIMS

Incomplete colonoscopy increases the risk of incident proximal colon cancer postcolonoscopy. Incomplete colonoscopy is often followed by barium enema or CT colonography. We sought to describe the yield of completion colonoscopy in a regional center for complex colonoscopy.

METHODS

This is a retrospective cohort study of 520 consecutive patients referred to a single colonoscopist over a 14-year period for completion colonoscopy after a previous incomplete examination.

RESULTS

Colonoscopy was completed to the cecum in 506 of 520 patients (97.3%). A total of 913 conventional adenomas was removed in 277 patients (adenoma detection rate 53.3%). There were 184 adenomas ≥ 1 cm in size or with advanced pathology. There were 525 serrated-class lesions removed in 175 patients, including 54 sessile serrated polyps in 26 patients and 41 hyperplastic polyps greater than 1 cm in 26 patients. Nine colorectal cancers were found. We estimated that approximately 57% of the conventional adenomas, 58% of the sessile serrated polyps, 27% of the hyperplastic polyps, and all 9 cancers detected by the completion colonoscopy were beyond the extent of the previous examination.

CONCLUSIONS

The yield of completion colonoscopy in a cohort of patients with previous failed cecal intubation was substantial. Regional centers for complex colonoscopy can provide high rates of cecal intubation in cases of incomplete colonoscopy and high yields of lesions in these cases. The regional center for complex colonoscopy is an important medical service.

Advances in balloon endoscopes

In September 2003, a double-balloon endoscope (DBE) composed of balloons attached to a scope and an overtube was released in Japan prior to becoming available in other parts of the world. The DBE was developed by Dr. Yamamoto (1), and 5 different types of scopes with different uses have already been marketed. In April 2007, a single-balloon small intestinal endoscope was released with a balloon attached only to the overtube as a subsequent model. This article presents a detailed account of the development of these scopes up to the present time.

The role of single-balloon colonoscopy for patients with previous incomplete standard colonoscopy: Is it worth doing it?

BACKGROUND

The rate of cecal intubation is a well-recognized quality measure of successful colonoscopy. Infrequently, the standard colonoscopy techniques fail to achieve complete examination. The role of single-balloon overtube-assisted colonoscopy (SBC) in these situations has only been sparsely studied. This prospective single-center study aimed to investigate the technical success (rate of cecal intubation) and the diagnostic gain of SBC.

METHODS

The study recruited consecutive patients with previous incomplete standard colonoscopy who were admitted for SBC at our tertiary center in Eastern Switzerland between February 2008 and October 2014. The primary outcome was defined as successful cecal intubation. Data on patient characteristics, indication, technical details of procedure, and outcome were collected prospectively. The Olympus enteroscope SIF-Q180 was used.

RESULTS

The study included 100 consecutive patients (median age 70 years; range 38-87 years; 54 % female) who were examined using a single-balloon overtube-assisted technique. The cecal intubation rate was 98 % (98/100). The median time of total procedure was 54 min (range 15-119 min); the median time to reach the cecal pole was 27.5 min (range 4-92 min). Passage of the sigmoid colon was not possible in two cases with a fixed, angulated sigmoid colon. The diagnostic gain was 21 % regarding adenomatous polyps in the right colon. The complication rate was 2 % (2/100, minor) without need for surgery.

CONCLUSIONS

This prospective patient cohort study shows that single-balloon colonoscopy is a safe and effective procedure to achieve a complete endoscopic examination in patients with a previous failed standard colonoscopy. A significant diagnostic and therapeutic gain in the right colon justifies additional procedure time.

Efficacy and safety of endoscopic interventions using the short double-balloon endoscope in patients after incomplete colonoscopy

BACKGROUND AND AIM

We have previously reported excellent cecal intubation rates using a short double-balloon endoscope in patients with a history of incomplete colonoscopy. However, data on the endoscopic treatment of colorectal tumors using a double-balloon endoscope are limited. The aim of the present study was to evaluate the efficacy and safety of endoscopic intervention of colorectal tumors using a short double-balloon endoscope.

METHODS

We analyzed data from a multicenter, prospective study on 110 patients (62 men, median age 66.5 years) who underwent total colonoscopy after incomplete colonoscopy to assess the characteristics of colorectal tumors, endoscopic interventions, and complications.

RESULTS

In all, 113 colorectal tumors were detected in 55 patients; 109 of the tumors were adenomas (24 advanced adenomas) and two each were intramucosal and advanced cancers. Locations of the lesions were eight in the cecum, 30 in the ascending colon, 18 in the transverse colon, 12 in the descending colon, 34 in the sigmoid colon, five in the rectosigmoid and six in the rectum. Average tumor diameter was 6.8 ± 6.3 mm. Fifty-nine polypectomies, 22 endoscopic mucosal resections, four hot biopsies, and six cold biopsies were done. All endoscopic interventions were successfully completed and no complications were noted. Two advanced cancers were located in the ascending colon and only a double-balloon endoscope could reach them to take a biopsy sample.

CONCLUSION

Double-balloon endoscopy is effective and safe for endoscopic intervention of colorectal tumors, irrespective of the location, in patients after incomplete colonoscopy.

Double-balloon endoscopy: an effective rescue procedure after incomplete conventional colonoscopy

OBJECTIVE

A significant percentage of colonoscopies remain incomplete because of a failure to intubate the caecum. By double-balloon endoscopy (DBE), originally developed for deep enteroscopy, an otherwise incomplete examination of the colon might be completed. We evaluated the success rate of caecal intubation, the reasons for its failure and the therapeutic consequences of using DBE after incomplete conventional colonoscopy.

METHODS

We report our single-centre experience of using DBE to complete an otherwise incomplete colonoscopy. A total of 114 consecutive patients, 45 male and 69 female, with a mean age of 64.8 years, who had undergone 116 procedures, were evaluated retrospectively by a review of their medical records.

RESULTS

The main causes for failed caecal intubation using a conventional colonoscope were loop formation in 70 patients (61.4%) and an adhesive angulated sigmoid in 33 (28.9%). Caecal intubation by DBE was successful in 101 patients (88.6%). The rate of failure was not associated with the cause of failure of the previous colonoscopy. In 55 patients (48.2%) a relevant new diagnosis was made in the previously inaccessible part of the colon: carcinoma (n=4; 3.5%), one or more adenomas (n=48; 42.1%) and caecal flat hyperplastic polyps (n=4; 3.5%). Endoscopic polypectomy was performed in 51 patients (44.7%); two complications occurred, both being mild postpolypectomy bleedings. In seven patients (6.1%) a subsequent surgical resection was performed.

CONCLUSION

Colonoscopy by DBE was useful in most patients in whom conventional colonoscopy was incomplete, irrespective of the cause of the failure. In nearly half the patients, a relevant new diagnosis was made with therapeutic consequences.

Colonoscopy with magnetic control system to navigate the forepart of colonoscope shortens the cecal intubation time

BACKGROUND

Colonoscopy is considered the most effective method for diagnosing colorectal diseases, but its application is sometimes limited due to invasiveness, patient intolerance, and the need for sedation.

OBJECTIVE

The aim of this study was to improve the problem of loop formation and shorten the cecal intubation time of colonoscopy by using a magnetic control system (MCS).

METHODS

Two experienced gastroenterologists, three trainees, and a novice repeated colonoscopy without or with MCS on three colonoscopy training model simulator cases. These cases were divided into introductory (case 2) and challenging levels (cases 4 and 5). The cecal intubation times were recorded.

RESULTS

For all cases, the average cecal intubation times for the experienced gastroenterologists with MCS were significantly shorter than without MCS (case 2: 52.45 vs. 27.65 s, p < 0.001; case 4: 166.7 vs. 120.55 s, p < 0.01; case 5: 130.35 vs. 100.2 s, p < 0.05). Those of the trainees also revealed significantly shorter times with MCS (case 2: 67.27 vs. 51 s, p < 0.01; case 4: 253.27 vs. 170.97 s, p < 0.001; case 5: 144.1 vs. 85.57 s, p < 0.001).

CONCLUSION

Conducting colonoscopy with MCS is safe and smooth, and shortens the cecal intubation time by navigating the forepart of the colonoscope. In addition, all diagnostic and therapeutic benefits of conventional colonoscopy are retained.

Utility of single and double balloon endoscopy in patients with difficult colonoscopy: A randomized controlled trial

AIM: To compare the utility of single-balloon colonoscopy (SBC) or double-balloon colonoscopy (DBC) for difficult colonoscopies.

METHODS: Between August 2008 and June 2010, patients in whom total colonoscopy failed within 30 min of insertion were assigned randomly to undergo either SBC or DBC. No sedatives were used. After the endoscopy, all patients were asked to evaluate pain during the procedure on a 10-point analog scale (1 = no pain; 10 = worst imaginable pain) with a questionnaire. The study outcomes were the cecal intubation rate and time, endoscopic findings, complications, and pain score.

RESULTS: The SBC and DBC groups included 11 and 10 patients, respectively. All but one SBC patient achieved total colonoscopy successfully. The cecal intubation times were 18 min (range: 10-85 min) and 12.8 min (range: 9.5-42 min) in the SBC and DBC groups, respectively (P = 0.17). No difference was observed in the prevalence of colon polyps between the SBC and DBC groups (45% vs 30%, P = 0.66). SBC showed advanced colon cancer in the ascending colon, which was inaccessible using conventional colonoscopy. The respective pain scores were 5 (1-10) [median (range)] and 5 (1-6) in the SBC and DBC groups (P = 0.64). No complications were noted in any patient.

CONCLUSION: The utility of single- and double-balloon endoscopy for colonoscopy seems comparable in patients with incomplete colonoscopy using a conventional colonoscope.

Renewed attention for overtube-assisted colonoscopy to prevent incomplete endoscopic examination of the colon

BACKGROUND

Colonoscopy is the standard examination to detect mucosal pathology in the colon. However, failure to complete colonoscopy may reach more than 10% in population-based endoscopy practices. The reasons for incomplete conventional colonoscopy are diverse and result in missed diagnosis of colonic polyps and carcinoma.

OBJECTIVE

Recent endoscopic developments have shown that the use of specialized overtubes may help to reach the cecum in the case of a difficult colonoscopy, even with less discomfort. Several types of overtubes are currently available, whereas other types are being developed and clinically evaluated. The current review highlights the development of overtubes for colonoscopy and the available clinical data on overtube-assisted colonoscopy in the case of incomplete conventional colonoscopy.

DATA SOURCES

Data were derived from a PubMed search through November 2012.

STUDY SELECTION

Available clinical literature data on recent developments in overtube-assisted colonoscopy were studied.

INTERVENTION

A descriptive comparison was made of currently available endoscopy systems used for overtube-assisted colonoscopy.

MAIN OUTCOME MEASURES

The primary outcomes measured were the feasibility and safety of different endoscopy systems to perform overtube-assisted colonoscopy.

RESULTS

Several overtube-assisted colonoscopy systems have recently been developed to complete colonoscopy in the case of difficult conventional colonoscopy. Literature data show excellent feasibility to reach the cecum with very low complication rates and good patient tolerance for the different overtube systems.

LIMITATIONS

The majority of available studies are uncontrolled case series describing 7 to 110 patients undergoing overtube-assisted colonoscopy with only 1 direct comparison between 2 overtube systems.

CONCLUSIONS

Overtube-assisted colonoscopy has been shown to be useful in performing colonoscopy by increasing the cecal intubation rate and patient tolerance and by decreasing the need for sedation. There is no standardized superior overtube system at this moment.

Clinical usefulness of single-balloon endoscopy in patients with previously incomplete colonoscopy

AIM: To evaluate the clinical usefulness of single-balloon endoscopy (SBE) in patients in whom a colonoscope was technically difficult to insert previously.

METHODS: The study group comprised 15 patients (8 men and 7 women) who underwent SBE for colonoscopy (30 sessions). The number of SBE sessions was 1 in 7 patients, 2 in 5 patients, 3 in 1 patient, 4 in 1 patient, and 6 in 1 patient. In all patients, total colonoscopy was previously unsuccessful. The reasons for difficulty in scope passage were an elongated colon in 6 patients, severe intestinal adhesions after open surgery in 4, an elongated colon and severe intestinal adhesions in 2, a left inguinal hernia in 2, and multiple diverticulosis of the sigmoid colon in 1. Three endoscopists were responsible for SBE. The technique for inserting SBE in the colon was basically similar to that in the small intestine. The effectiveness of SBE was assessed on the basis of the success rate of total colonoscopy and the presence or absence of complications. We also evaluated the diagnostic and treatment outcomes of colonoscopic examinations with SBE.

RESULTS: Total colonoscopy was successfully accomplished in all sessions. The mean insertion time to the cecum was 22.9 ± 8.9 min (range 9 to 40). Abnormalities were found during 21 sessions of SBE. The most common abnormality was colorectal polyps (20 sessions), followed by radiation colitis (3 sessions) and diverticular disease of the colon (3 sessions). Colorectal polyps were resected endoscopically in 15 sessions. A total of 42 polyps were resected endoscopically, using snare polypectomy in 32 lesions, hot biopsy in 7 lesions, and endoscopic mucosal resection in 3 lesions. Fifty-six colorectal polyps were newly diagnosed on colonoscopic examination with SBE. Histopathologically, these lesions included 2 intramucosal cancers, 42 tubular adenomas, and 2 tubulovillous adenomas. The mean examination time was 48.2 ± 20.0 min (range 25 to 90). Colonoscopic examination or endoscopic treatment with SBE was not associated with any serious complications.

CONCLUSION: SBE is a useful and safe procedure in patients in whom a colonoscope is technically difficult to insert.

Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications

Enteroscopy, defined as direct visualization of the small bowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past several years. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies one of which is non-invasive, the video capsule, and a type of invasive technique, the device-assisted enteroscopy. In particular, the device-assisted enteroscopy consists then of three different types of instruments all able to allow, in skilled hands, to display partially or throughout its extension (if necessary) the small intestine. Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocarcinoma or gastrointestinal stromal tumors. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

Water immersion simplifies cecal intubation in patients with redundant colons and previous incomplete colonoscopies

BACKGROUND

Interest in effective ways to complete colon examinations in patients who had previously undergone failed colonoscopies has increased recently.

OBJECTIVE

To determine whether water immersion decreased the need for ancillary equipment to achieve cecal intubation in patients who had previously undergone incomplete colonoscopies.

DESIGN

Retrospective cohort study.

SETTING

Tertiary academic center.

PATIENTS

A total of 345 consecutive patients referred to a tertiary center for the indication of a previous incomplete colonoscopy.

INTERVENTIONS

Colonoscopy with or without water immersion insertion.

MAIN OUTCOME MEASUREMENTS

Cecal intubation rates, type of equipment, and maneuvers used.

RESULTS

Cecal intubation was achieved in 332 of 345 patients (96.2%) and was similar in those with and without water immersion (170/178, 95.5% vs 162/167, 97%, P = .58). An external straightening device was used in 6 of 178 cases with water immersion (3.4%) compared with 25 of 168 cases with air insufflation (15%) (P < .0001). Among patients with a redundant colon as the sole cause of previously incomplete examinations, water immersion required an external straightener in 7% compared with 37% with air insufflation during insertion (P < .0001), and position change was required in 5% of those with water immersion compared with 22% with air insufflation (P = .01).

LIMITATIONS

Retrospective review; single-center, single-endoscopist study.

CONCLUSION

Water immersion decreases the need for external straightening devices and position change maneuvers in patients with redundant colons and previously incomplete colonoscopies.

Comparison of single- versus double-balloon assisted-colonoscopy for colon examination after previous incomplete standard colonoscopy

BACKGROUND

Colonoscopy fails to achieve cecal intubation in 5-10 % of cases. Many of these cases can be completed using balloon-assisted colonoscopy, either with the single-balloon colonoscopy (SBC) or the double-balloon colonoscopy (DBC) techniques.

AIM

To compare the completion rates of SBC and DBC in patients with previous incomplete conventional colonoscopy.

METHODS

Between August 2009 and July 2011 either SBC or DBC was performed in 53 patients in whom previous conventional colonoscopy did not achieve cecal intubation. The medical records of these 53 patients were reviewed retrospectively for details regarding (1) indication for the initial colonoscopy, (2) patient characteristics, (3) data from the initial colonoscopy, and (4) details on both SBC and DBC.

RESULTS

SBC was successful in intubating the cecum in 100 % (26/26) of patients and DBC was successful in 93 % (25/27) of patients. The median (range) time to reach the cecum was 17 (9-43) min in the SBC group and 20 (7-58) min in the DBC group (P = 0.37). The presence of polyps was an entirely new finding in 35 % (9/26) of patients in the SBC group and 30 % (8/27) of patients in DBC group. Therapeutics were performed in 73 % (19/26) of patients in SBC group and 67 % (18/27) of patients in DBC group.

CONCLUSION

For patients with incomplete conventional colonoscopy, SBC and DBC offer high cecal intubation rates as well as detection of additional polyps and therapeutic capability. Either SBC or DBC can be considered after incomplete conventional colonoscopy.

Small bowel enteroscopy

Over the past decade, the advent of capsule endoscopy and balloon-assisted enteroscopy has revolutionized the approach to small intestinal diseases. The small bowel is no longer out of reach, and has fallen within the diagnostic and therapeutic realm of the gastrointestinal endoscopist. Double-balloon enteroscopy was the first type of balloon-assisted endoscopy and is the method for which there are the most data. Single-balloon enteroscopy has since been introduced as an alternative balloon-assisted method, followed more recently by the development of spiral overtube-assisted enteroscopy. The purpose of the present article is to review these methods of small bowel enteroscopy and to discuss the latest developments. While the investigation of small bowel diseases cannot be addressed without considering the central role of capsule endoscopy, a detailed assessment is beyond the scope of the present article, and capsule endoscopy will only be discussed as it pertains to enteroscopy.

Colon capsule endoscopy: Advantages, limitations and expectations. Which novelties?

Since the first reports almost ten years ago, wireless capsule endoscopy has gained new fields of application. Colon capsule endoscopy represents a new diagnostic technology for colonic exploration. Clinical trials have shown that colon capsule endoscopy is feasible, accurate and safe in patients suffering from colonic diseases and might be a valid alternative to conventional colonoscopy in selected cases such as patients refusing conventional colonoscopy or with contraindications to colonoscopy or when colonoscopy is incomplete. Despite the enthusiasm surrounding this new technique, few clinical and randomized controlled trials are to be found in the current literature, leading to heterogeneous or controversial results. Upcoming studies are needed to prove the substantial utility of colon capsule endoscopy for colon cancer screening, especially in a low prevalence of disease population, and for other indications such as inflammatory bowel disease. Possible perspectives are critically analysed and reported in this paper.

A multicenter, prospective trial of total colonoscopy using a short double-balloon endoscope in patients with previous incomplete colonoscopy

BACKGROUND

There is no specific insertion method for patients who previously underwent an incomplete colonoscopy. No multicenter prospective study using a double-balloon endoscope (DBE) for total colonoscopy was previously performed.

OBJECTIVE

To demonstrate the effectiveness and safety of using short DBEs in patients who previously underwent incomplete colonoscopies.

DESIGN

A multicenter, prospective trial.

SETTING

Four tertiary care academic centers and 6 community hospitals.

PATIENTS

Patients with a history of incomplete colonoscopy, ages 20 to 79 years, were included. Exclusion criteria were colonoscopy performed by endoscopists with experience in fewer than 1000 cases, history of colectomy, poor bowel preparation, inflammatory bowel disease, active bowel obstruction, and active bleeding.

INTERVENTION

Total colonoscopies using short DBEs were attempted in all patients.

MAIN OUTCOME MEASUREMENTS

Primary endpoint was the cecal intubation rate. Secondary endpoints were time to cecal intubation, complications, and tolerability.

RESULTS

A total of 110 patients (62 males, median age 66.5 years) were included. Fifty-four patients had a history of abdominal surgery. The cecal intubation rate was 100% (110/110). Median intubation time was 12 minutes (range 4-47 minutes). Mild mucosal tears without symptoms occurred in 1 patient. For 64.5% of patients, intravenous sedatives and/or analgesics were used during examinations. Based on questionnaires, 50.9% had no pain, 31.8% slight pain, and 17.3% tolerable pain. Moreover, 96.4% of patients answered that their examination was more comfortable than their previous colonoscopy.

LIMITATION

Uncontrolled trial.

CONCLUSION

The use of a short DBE is an effective and safe method for total colonoscopy in patients who previously underwent incomplete colonoscopies. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN3464.).

Utility of single balloon enteroscopy (SBE) for difficult cases of total colonoscopy

Balloon enteroscopy (BE) was originally developed for observation of the deep small intestine, and has recently been utilized for difficult cases of total colonoscopy due to reasons such as adhesions and elongation. In this report, we present our experience with single balloon enteroscopy (SBE) to facilitate successful colonoscopy when standard techniques failed. In two cases, early colon cancers were detected in the cecum by SBE and were removed endoscopically or surgically. A third case is discussed in which SBE was attempted but was ultimately not successful. In that case, total colonoscopy was not performed because of looping in the sigmoid and transverse colon. A fourth case in which SBE was performed in order to remove colonic gas in a patient with megacolon. In that case, total colonoscopy could not be completed because the SBE balloon could not "grab" the dilated colon and therefore could not advance. SBE is a useful adjunct to standard colonoscopy in challenging cases, but has limitations and does not always ensure success.

Push enteroscopy has a 96% cecal intubation rate in colonoscopies that failed because of redundant colons

BACKGROUND

Performing a complete colonoscopy to the cecum is important for ruling out malignancy and other lesions, but failure rates are significant with a standard colonoscope. A previous study using a push enteroscope for failed colonoscopies had a completion rate of 68.7%.

OBJECTIVE

To improve the cecal intubation rate by using a newer version of a push enteroscope.

DESIGN

Retrospective study at first, then a prospective study.

SETTING

Single-center veterans health care system.

PATIENTS

A total of 47 patients in whom the cecum was not reached with a regular adult colonoscope between January 2007 and December 2010 were included. Those with poor bowel preparation were excluded.

INTERVENTIONS

Repeat colonoscopy using a new version of a push enteroscope.

MAIN OUTCOME MEASUREMENTS

The rate of cecal intubation and additional pathological findings.

RESULTS

The cecum or terminal ileum was reached in 45 patients (96%). Additional significant pathological findings in the previously unexamined colon were seen in 18 patients (38%).

LIMITATIONS

Small sample size, lack of comparison with other endoscopes.

CONCLUSIONS

Colonoscopy with a push enteroscope could be advanced to either the terminal ileum or cecum in 96% of patients, which is one of the highest known completion rates in patients in whom colonoscopy failed. Clinical management changed in all patients with additional findings.

Enteroscope without overtube for cecal intubation after an incomplete colonoscopy

BACKGROUND

Cecal intubation is one of the targets of colon endoscopic evaluation, however even under experienced hands 5-10% of colonoscopies are incomplete.

AIMS

The aim of the study is to evaluate the usefulness of single balloon enteroscope (SBE) without employing overtube-balloon equipment in patients with incomplete colonoscopy.

METHODS

Between January 2009 and July 2010, patients with an incomplete standard colonscopy were prospectively enrolled to perform a colonoscopy with a single balloon enteroscope. Examinations were performed by the same expert operator during the same session.

RESULTS

Enteroscopy was performed on 79 patients, cecal intubation were obtained in 93.6% of the cases (74/79). It provided a new diagnosis in 43% of cases (34/79). Procedure was safe and well tolerated. Overall the additional use of single balloon enteroscope allowed to obtain the cecal intubation in up to 99.2% cases (898/905).

CONCLUSIONS

The use of the enteroscope without overtube-balloon equipment may be an effective method to increase the cecal intubation rate after failure of a standard colonoscopy.

Literature review and recommendations for clinical application of Colon Capsule Endoscopy

Colon Capsule Endoscopy represents a new diagnostic technology for colonic exploration. Despite the great enthusiasm around this new technique, only few studies are available in the literature, and reported results are still controversial and non-homogeneous. Current preparation protocols have led to discordant results. In January 2010, the first Italian Meeting on Colon Capsule Endoscopy was held. Aim of this Meeting was to critically evaluate the available results obtained by Colon Capsule Endoscopy in clinical studies, in order to identify the proper test indications, to propose a shared preparation protocol and Colon Capsule Endoscopy procedure. Studies published in literature were extensively reviewed and analysed during the Meeting. The available evidence served to propose recommendations for preparation protocols, proper test indications and Colon Capsule Endoscopy procedure. Possible perspectives were also critically analysed and are reported in this paper.

Single-balloon colonoscopy versus repeat standard colonoscopy for previous incomplete colonoscopy: a randomized, controlled trial

BACKGROUND

Optical colonoscopy is the only examination allowing complete visualization of the colon with simultaneous polyp removal. In a minority of patients, a complete examination is unsuccessful. It is unknown whether single-balloon, overtube-assisted colonoscopy (SBC) is superior to simply repeating a standard colonoscopy (SC) on an alternate day.

OBJECTIVE

To compare the success rates of SC and SBC in patients with previous incomplete examinations.

DESIGN

Randomized, controlled trial.

SETTING

Tertiary care academic center.

PATIENTS

Thirty subjects with previous incomplete colonoscopy.

INTERVENTIONS

Repeat colonoscopy either by SC or SBC. If cecal intubation was unsuccessful, subjects were crossed over to the alternate group.

RESULTS

Thirty subjects (73.3% female, mean age 59.2 years) with previous incomplete colonoscopy were randomized (SBC, 14 subjects; SC, 16 subjects). Cecal intubation was significantly more successful with SBC (92.9%) than with SC (50%) (P = .016). For all SC failures, cecal intubation was successful after crossover to the SBC group (100%). Cecal intubation time was similar in both groups. Proximal colon adenomas were detected in 38.1% of subjects. There were no procedure-related complications.

LIMITATIONS

Singe endoscopist performing all procedures; inability to ensure all incomplete colonoscopies were included in the study.

CONCLUSIONS

For patients with a previous incomplete colonoscopy, balloon colonoscopy performed by using the single-balloon enteroscope with an overtube was superior to a repeat attempt with a standard colonoscope. For patients with a previous incomplete examination, consideration should be given to a repeat attempt with balloon colonoscopy if available. (

CLINICAL TRIAL REGISTRATION NUMBER

STU00008540.).