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

The Evolution of Device-Assisted Enteroscopy: From Sonde Enteroscopy to Motorized Spiral Enteroscopy

The introduction of capsule endoscopy in 2001 opened the last "black box" of the gastrointestinal tract enabling complete visualization of the small bowel. Since then, numerous new developments in the field of deep enteroscopy have emerged expanding the diagnostic and therapeutic armamentarium against small bowel diseases. The ability to achieve total enteroscopy and visualize the entire small bowel remains the holy grail in enteroscopy. Our journey in the small bowel started historically with sonde type enteroscopy and ropeway enteroscopy. Currently, double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy are available in clinical practice. Recently, a novel motorized enteroscope has been described with the potential to shorten procedure time and allow for total enteroscopy in one session. In this review, we will present an overview of the currently available techniques, indications, diagnostic yield, and complications of device-assisted enteroscopy.

Novel rigidizing overtube for colonoscope stabilization and loop prevention (with video)

BACKGROUND AND AIMS

Loop formation can impede endoscope advancement, destabilize the tip, and cause pain. Strategies to mitigate looping include torque-based reduction maneuvers, variable stiffness shafts, and abdominal splinting. In some cases, these strategies are insufficient, and there is need for novel instruments. Loop formation is of particular concern in colonoscopy, but it can also impact performance of other endoscopic procedures such as enteroscopy and altered-anatomy ERCP. In this case series we demonstrate the utility of a novel rigidizing overtube (Pathfinder; Neptune Medical, Burlingame, Calif, USA) in colonoscopy and other endoscopic procedures where loop management is critical.

METHODS

We describe our initial experience with the Pathfinder overtube in 29 patients. The overtube is 85 cm long and can accommodate a pediatric colonoscope. In its native state, the overtube is extremely flexible. Once the overtube is advanced to the desired location, application of a vacuum to the device causes the device to become 15 times stiffer. The endoscope can then be advanced through the overtube without loop formation in the region that the overtube traverses.

RESULTS

The overtube was used in 29 patients to assist with difficult procedures. Patients were predominantly men (n = 18; 62.1%), with a median age of 66 years (interquartile range, 57-72). One patient received an upper endoscopy (3.4%), 24 received colonoscopy (82.8%), and 4 received enteroscopy (13.8%). The overtube was used in 12 procedures for incomplete colonoscopy (41.4%), 6 for depth (20.7%), and 11 for stability (37.9%). Colonoscopy was performed in the setting of screening (n = 3), surveillance given polyp history (n = 7), referrals for polyp removal (n = 10), workup of iron deficiency anemia (n = 2), and incomplete colonoscopy (n = 1). The lower endoscopy cases had a median cecal intubation time of 5 minutes (interquartile range, 4.25-7). Enteroscopy was performed in 4 patients: In one patient the distal 60 cm of the ileum was examined with a pediatric colonoscope to exclude ileitis, in another the overtube was used to stabilize a 6-mm endoscope to traverse a tight Crohn's ileocolonic stricture, in a third patient altered-anatomy ERCP was performed using an enteroscope through the overtube to reach a hepaticojejunostomy, and in the final patient upper enteroscopy was performed and the mid-jejunum was reached. We present 4 cases that demonstrate the use of the overtube. There were no adverse events.

CONCLUSIONS

Initial experience with a novel rigidizing overtube suggests that this tool can be useful in colonoscopy and other endoscopic procedures affected by looping.

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.

Device-assisted enteroscopy: An update on techniques, clinical indications and safety

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

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.

Update in enteroscopy: New devices and new indications

The present review provides an update of the currently available (proto-) types of device-assisted enteroscopy (DAE). In recent years, newly designed double- and single-balloon enteroscopes have emerged. They aim to improve insertion depth into the small bowel, and they also allow more efficient endoscopic interventions. Nowadays, almost all conventional endoscopic procedures are feasible using DAE, opening the door to new indications. Recently, more data have become available on pediatric DAE, DAE-assisted colonoscopy, and DAE in patients with altered anatomy, including DAE-assisted endoscopic retrograde cholangiopancreatography and direct cholangioscopy. Although new enteroscopes are being developed, few comparative studies are available in order to define which DAE suits best for each indication. It is the duty of the international endoscopy community to set up clinical research projects to provide answers to these open questions.

Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions

A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists.