Carbon dioxide versus room air insufflation during balloon-assisted enteroscopy: A systematic review with meta-analysis

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.

Efficacy and safety of water-exchange enteroscopy compared to carbon dioxide insufflation during enteroscopy

INTRODUCTION

carbon dioxide (CO2) insufflation during enteroscopy reduces procedure time and subsequent symptoms and increases the insertion depth compared with room air. In colonoscopy, the water-exchange (WE) technique is associated with less pain compared with CO2 insufflation. The WE technique is not well studied in enteroscopy. The aim of this study was to compare the efficacy and safety of enteroscopy with WE and CO2.

METHODS

a prospective, comparative and observational study was performed of double balloon enteroscopies (DBE) that were randomized in two groups. The first group used WE while the second group used CO2 insufflation. The data collected was evaluated via univariate analysis and multiple logistic regression (variables with p ≤ 0.10 according to the univariate analysis).

RESULTS

forty-six DBE were included; 23 in each arm. The median age of cases was 63.5 years and 37% were female. There were no statistical differences between the groups with regard to the access route, findings, therapy and complications. Four patients (20%) in the CO2 group had adverse events (abdominal distension and pain) and one in the WE group (nausea), which was not statistically significant. The median insertion depth was greater in the CO2 group; 260 cm vs 160 cm (p = 0.048). Multiple logistic regression showed a statistically significant difference in the insertion depth using CO2 insufflation (OR 1.009, 1.001-1.017; p = 0.034).

CONCLUSIONS

DBE with a CO2 insufflation technique and WE are safe with a greater insertion depth with CO2.

Bowel Preparation With Polyethylene Glycol 3350 or Fasting Only Before Peroral Single-balloon Enteroscopy: A Randomized European Multicenter Trial

BACKGROUND

Although bowel preparation before colonoscopy and capsule endoscopy is widely evaluated and usually follows established guidelines, a standard preparation regime for peroral small bowel enteroscopy is yet to be defined.The aim of the present study was to compare small bowel preparation with polyethylene glycol (PEG) and "fasting only" (FO) before peroral single-balloon enteroscopy (SBE).

STUDY

We compared small bowel preparation with PEG versus "FO" for peroral SBE in a randomized European multicenter trial. Patients' and procedural characteristics were documented and carefully analyzed. Primary endpoint was the oral intubation depth of the small bowel. A modified Boston preparation scale was used to assess bowel cleansing as a secondary endpoint.

RESULTS

In total, 43 patients were enrolled in this study (FO group: n=25; PEG group: n=18). In both groups, patients' characteristics were comparable. The indications for oral enteroscopy were equally distributed in both groups (P=0.894). The oral intubation depth was significantly higher in the PEG versus the FO group (261±87 vs. 203±66 cm; P=0.019; mean±SD), while the quality of bowel preparation was equally sufficient in both groups [complete visualization of the mucosa (Boston preparation scale) 83% versus 76% (P=1.000)].

CONCLUSIONS

Small bowel preparation with PEG for SBE yields significantly deeper intubation as compared with "FO" preparation. As patient comfort and safety was similar in both groups, PEG preparation might be favored, especially if deep intubation of the small bowel is desired. For patients requiring visualization of the proximal jejunum, a FO preparation seems to be sufficient.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

Clinical utility of double-balloon enteroscopy in children: A single-centre experience in South China

AIM

Double-balloon enteroscopy (DBE) is a useful tool for the evaluation and treatment of small bowel disease. Limited clinical data are available regarding the indications, clinical findings and safety associated with the use of DBE in children. The aim of this study is to investigate the utility and safety of DBE in children.

METHODS

A total of 72 DBE procedures were performed on 61 children at the Sixth Affiliated Hospital, Sun Yat-sen University, between 1 April 2013 and 31 December 2017. The clinical data were analysed retrospectively.

RESULTS

DBE was attempted 72 times in 61 children (45 boys and 16 girls) of an age range between 6 and 14 years (mean age: 11.9 years). The most common indication for DBE was occult gastrointestinal bleeding and abdominal pain. The positive rate of abnormal findings was 77.5% (55/72). Most children showed non-specific enteritis and Crohn's disease. Eight children underwent successful therapeutic enteroscopy. No serious complication was observed in any child in this case series.

CONCLUSION

DBE can be a useful diagnostic and therapeutic tool for small bowel disorders in children.

Carbon dioxide versus air insufflation enteroscopy: a systematic review and meta-analysis based on randomized controlled trials

OBJECTIVES

 To compare the insufflation of CO ₂ and ambient air in enteroscopy.

SEARCH SOURCES

 The investigators researched the electronic databases MedLine, Cochrane Library, Central, LILACS, BVS, Scopus and Cinahl. The grey search was conducted in the base of theses of the University of São Paulo, books of digestive endoscopy and references of selected articles and in previous systematic revisions.

STUDY ELIGIBILITY CRITERIA

 The evaluation of eligibility was performed independently, in a non-blind manner, by two reviewers, firstly by title and abstract, followed by complete text. Disagreements between the reviewers were resolved by consensus.

DATA COLLECTION AND ANALYSIS METHOD

 Through the spreadsheet of data extraction, where one author extracted the data and a second author checked the extraction. Disagreements were resolved by debate between the two reviewers. The quality analysis of the studies was performed using the Jadad score. The software RevMan 5 version 5.3 was used for the meta-analysis.

RESULTS

 Four randomized clinical trials were identified, totaling 473 patients submitted to enteroscopy and comparing insufflation of CO ₂ and ambient air. There was no statistical difference in the intubation depth between the two groups. When CO ₂ insufflation was reduced, there was a significant difference in pain levels 1 hour after the procedure (95 % IC, -2.49 [-4.72, -0.26], P : 0.03, I ² : 20%) and 3 hours after the procedure (95% IC, -3.05 [-5.92, -0.18], P : 0.04, I ² : 0 %). There was a usage of lower propofol dosage in the CO ₂ insufflation group, with significant difference (95 % IC, -67.68 [-115.53, -19.84], P : 0.006, I ² : 0 %). There was no significant difference between the groups in relation to the use of pethidine and to the oxygen saturation.

LIMITATIONS

 Restricted number of randomized clinical trials and nonuniformity of data were limitations to the analysis of the outcomes.

CONCLUSION

 The use of CO ₂ as insufflation gas in enteroscopy reduces the pain levels 1 hour and 3 hours after the procedure, in addition to the reduction of the sedation (propofol) dosage used.