Therapeutic double-balloon enteroscopy: a binational, three-center experience

The evolving role of device-assisted enteroscopy: The state of the art as of August 2023

Device-assisted enteroscopy (DAE), balloon-assisted enteroscopy (BAE) in particular, has become a routine endoscopic procedure which has revolutionized our approach to small-bowel disease. Evidence demonstrating the efficacy and safety of BAE spans over 22-years of experience, making it an established pillar of minimally invasive care. The robust evidence for BAE's safety and efficacy has now been incorporated into international clinical guidelines, technical reviews, benchmarking performance measures and curricula. The more recently introduced motorized spiral enteroscopy (MSE) which had replaced the previous manual version, abruptly ended its 7-year stint in clinical practice, when it was withdrawn and recalled from the market by its manufacturing company in July 2023, due to several associated serious adverse events (including fatalities). This article, written by the original developer of double-balloon enteroscopy (DBE) and other recognized international experts and pioneers in this field, focuses mainly on the technical aspects, evolving indications, and equipment-related technological advances. Despite the very recent withdrawal of MSE from clinical practice, for completeness, this technology and its technique is still briefly covered here, albeit importantly, along with a short description of reported, associated, serious adverse events which have contributed to its withdrawal/recall from the market and clinical practice.

Role of Interventional Inflammatory Bowel Disease (IBD) in the Management of Complex IBD: Initial Prospective Experience from a Tertiary Center in India

Background/Aims With the growing multidisciplinary model of practice in the management of complex inflammatory bowel disease (IBD) and rising incidence of IBD, interventional IBD (IIBD) promises to play a key role. We aimed to evaluate current the role of IIBD in India and its short-term outcomes.

Methods IBD patients undergoing IIBD procedures for stricture, bleeding, colitis-associated neoplasia, therapeutic small bowel endoscopy including retained capsule retrieval and postsurgical complications were enrolled prospectively between September 2021 and May 2022. Demographic and disease details, indications, initial and redo procedure details, technical/clinical success, and complications were recorded.

Results IIBD procedures were performed in total 54 patients (61% males, median age: 37.5 years, range: 21–74 years, Crohn's disease [CD]: 42, ulcerative colitis [UC]: 12 between September 2021 and April 2022). Endoscopic balloon dilation (EBD) was performed in 44 patients (56 strictures, 9% anastomotic, 9% pouch) who underwent total 83 EBD procedures in 63 sessions. Short-term clinical efficacy after maximal dilation, technical success (i.e., scope passage after EBD), and complications (all mild) were noted in 95.4, 81.8, and 9.1%, respectively. Recurrent symptoms were seen in 27.3% on short-term follow-up (1–8 months, median: 5 months) for which redilation, surgery, and endoscopic stricturotomy were done in 22.7, 2.3, and 2.3% respectively. During small bowel EBD, motorized spiral enteroscopy-guided retained capsule endoscope retrieval was done in four patients. Ulcerative colitis-associated neoplasia (UCAN) was resected endoscopically in six patients (endoscopic submucosal dissection (ESD)—1, endoscopic mucosal resection (EMR)—5). High-grade dysplasia was resected in two patients (1 ESD for recurrent UCAN, 1 EMR had residual neoplasia on follow-up treated with underwater EMR). R0 resection was achieved in 83.3%. Endoscopic hemostasis was done with hemoclipping and sclerotherapy for UC-related bleeding in two, whereas a case of CD with proximal ileal bleeding was controlled with antegrade single-balloon enteroscopy-assisted hemoclipping.

Conclusions IIBD is a promising modality in resource-limited settings like India acting as a bridge between medical therapy and surgery. Surgery can be avoided in a significant proportion with good short-term outcomes. Long-term outcomes need to be evaluated.

Predictors for outcomes and readmission rates following double balloon enteroscopy: a tertiary care experience

AIM

 The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting positive diagnostic yield, therapeutic yield, and readmission.

METHODS

 We conducted a retrospective cohort study of patients (n = 420) who underwent DBE at a tertiary care center between 2012 and 2016 at a tertiary referral center. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and t-test analyses were used to compare patient characteristics. Logistic regression was used to predict outcomes of interest.

RESULTS

 Of patients included in the study, 59 % were male with a mean age of 61.49 (SD = 15.15) Altered anatomy was noted in 14 %, while 5 % and 13 % of patients had end stage renal disease (ESRD) and current use of anticoagulation, respectively. The most common indication for DBE was obscure gastrointestinal bleed (OGIB) (33 %). Forty-nine patients had obscure and overt gastrointestinal bleeding (GIB) and 22 % had occult GIB with iron deficiency. The cohort's rate of positive diagnostic yield was 73 % and 35 % for therapeutic yield. The 30-day and 6-month readmission rates were both 11 %. A higher proportion of those readmitted were male (75 % vs 57 %, P  = 0.027) and had longer procedural time (38.68 vs 46.57, P  = 0.011). Likewise, occult GIB with iron deficiency anemia and iron deficiency alone (OR = 2.45, CI: 1.233 - 4.859, P  = 0.011), inpatient status (OR 2.42, CI 1.344 - 4.346, P  = 0.003), and longer procedural time (OR = 1.02, CI: 1.004 - 1.029, P  = 0.008) were associated positively with readmission.

CONCLUSION

 DBE procedures have relevant efficacy for both diagnostic and therapeutic yield while evaluating small bowel disease. Readmission rates are low and more in those with GI bleed and iron deficiency with longer index procedural times.

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.

New method of direct percutaneous endoscopic jejunostomy tube placement using balloon-assisted enteroscopy with fluoroscopy

BACKGROUND AND AIM

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method to provide nutrition to patients with a variety of gastrointestinal (GI) problems. The present study describes a new method of DPEJ using balloon-assisted-enteroscopy.

METHODS

This observational, retrospective, single-arm case study conducted at a tertiary care hospital during a 15-month period included 25 patients (12 females, 13 males, mean age 54 years, age range 31-79 years) with necrotizing pancreatitis, n = 7; complex upper GI surgery, n = 6; complex fistula, n = 6; impossibility to place a gastrostomy tube, n = 5; and bowel obstruction, n = 1. The new DPEJ technique focused on three key components: (i) use of balloon-assisted overtube; (ii) use of fluoroscopy; (iii) leaving the overtube in place during the entire procedure (and also for DPEJ removal).

RESULTS

Technical success was 96%. Mean time of the procedure was 30.5 min (range 24 to 45 min). Clinical success was 100% (24/24); all DPEJ could be used for their intended purpose.

CONCLUSIONS

This new method of inserting a DPEJ using balloon enteroscopy and fluoroscopy was safe and successful. Future comparative studies are now warranted.

Deep enteroscopy - indications, diagnostic yield and complications

Since its introduction in 2001 capsule endoscopy opened up the small bowel for diagnostic approaches followed by double balloon enteroscopy which enabled the endoscopic community to perform therapeutic interventions in the whole small intestine. In this review the scientific developments related to indications, diagnostic yield and complications of the last years between the competing devices double ballon enteroscopy, single balloon enteroscopy and spiral enteroscopy are illustrated.

Management and endoscopic techniques for digestive foreign body and food bolus impaction

Ingested foreign bodies, food bolus impaction, migration or retention of medical devices are frequent, in children as well as in adults. Most of these foreign bodies will naturally pass through the gastro-intestinal tract. Complications are rare but sometimes severe (oesophageal perforations are the most frequent and most feared). We aimed to review the literature on therapeutic management of digestive foreign bodies and food bolus impaction, with special focus on endoscopic indications, material, timing and techniques for removal. The role of the gastroenterologist is to recognise specific situations and to plan endoscopic removal in a timely manner with the most adequate conditions and extraction tools. Risk factors and underlying pathology, for example eosinophilic esophagitis, must be investigated and if necessary treated.

Changes over time in indications, diagnostic yield, and clinical effects of double-balloon enteroscopy

BACKGROUND & AIMS

We performed a retrospective study to investigate changes between different time periods in the indications, diagnostic yield, and clinical impact of double-balloon enteroscopy (DBE).

METHODS

We analyzed records from the database at Soonchunhyang University College of Medicine from all patients undergoing DBE between September 2004 and May 2011 (181 DBEs, 133 patients). We compared DBE-related factors between the first stage (September 2004-August 2006; 117 DBEs, 79 patients) and second stage (September 2006-May 2011; 64 DBEs, 54 patients) of the study period.

RESULTS

The number of DBEs performed decreased between stages. Obscure gastrointestinal bleeding was the most common indication for DBE during each stage (65.8% vs 50%; P = .06). Abnormalities in other modalities as the second indication increased significantly in the second stage compared with the first (11.4% vs 29.6%; P = .008). Between stages, use of computed tomography increased (53.8% vs 81.5%; P = .001), along with capsule endoscopy (29.1% vs 44.4%; P = .06). Mucosal lesions were the most common finding in each stage (56% and 53.1%; P = .686). The diagnostic yield of DBE was 89.3% in the first stage and 93.9% in the second (P = .384). In the first stage, DBE identified 86.4% of cases that had negative results from other modalities; in the second, it identified all cases (P = .3). Therapeutic plans were determined in 89.7% of patients only on the basis of results from DBE.

CONCLUSIONS

Between the time periods of 2004-2006 and 2006-2011, the clinical indications for DBEs and outcomes did not change. However, the selectivity of the number of patients decreased between stages.