Intermittent melena and refractory anemia due to jejunal cavernous lymphangioma: A case report

BACKGROUND

Lymphangiomas in the gastrointestinal tract are extremely rare in adults. As a benign lesion, small intestine lymphangiomas often remain asymptomatic and pose challenges for definitive diagnosis. However, lymphangiomas can give rise to complications such as abdominal pain, bleeding, volvulus, and intussusception. Here, we report a case of jejunal cavernous lymphangioma that presented with intermittent melena and refractory anemia in a male adult.

CASE SUMMARY

A 66-year-old man presented with intermittent melena, fatigue and refractory anemia nine months prior. Esophagogastroduodenoscopy and colonoscopy were performed many times and revealed no apparent bleeding. Conservative management, including transfusion, hemostasis, gastric acid secretion inhibition and symptomatic treatment, was performed, but the lesions tended to recur shortly after surgery. Ultimately, the patient underwent capsule endoscopy, which revealed a more than 10 cm lesion accompanied by active bleeding. After single-balloon enteroscopy and biopsy, a diagnosis of jejunal cavernous lymphangioma was confirmed, and the patient underwent surgical resection. No complications or recurrences were observed postoperatively.

CONCLUSION

Jejunal cavernous lymphangioma should be considered a cause of obscure gastrointestinal bleeding. Capsule endoscopy and single-balloon enteroscopy can facilitate diagnosis. Surgical resection is an effective management method.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a technical review

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

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.

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.

Factors affecting complete stone extraction in the initial procedure in short type single-balloon enteroscopy-assisted endoscopic retrograde cholangiography for patients with Roux-en-Y gastrectomy

OBJECTIVES

This study aimed to evaluate the efficacy and safety of stone extraction in patients who underwent Roux-en-Y gastrectomy using short-type single-balloon enteroscopy (SBE) and to clarify the factors affecting complete stone extraction in the initial procedure.

METHODS

The data of patients with Roux-en-Y gastrectomy who underwent endoscopic stone extraction using short SBE between September 2011 and January 2022 was analyzed.

RESULTS

Overall, 85 patients were scheduled to undergo stone extraction. 77 patients were intended stone extraction after successful biliary cannulation. The complete stone extraction success in the initial procedure, overall complete stone extraction success including repeated procedures, and adverse event rates were 68.2% (95% confidence interval [CI], 57.2%-77.9%), 87.1% (95% CI, 78.0%-93.4%), and 8.2% (95% CI, 3.4%-16.2%), respectively. Multiple logistic regression analysis indicated that bile duct diameter affected the success of complete stone extraction after successful biliary cannulation in the initial procedure (odds ratio 0.53, 95% CI, 0.30-0.94, p = .03).

CONCLUSIONS

Stone extraction in patients with Roux-en-Y gastrectomy using short SBE was effective. Patients with a large diameter bile duct required several sessions for complete stone extraction, suggesting that more dedicated devices are warranted for patients with surgically altered anatomy.

Mechanistic loop resolution strategy for short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y reconstruction after gastrectomy (with video)

BACKGROUND

Endoscopic access to the targeted site is a major challenge for the endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Roux-en-Y (R-Y) reconstruction after total or subtotal gastrectomy. We aimed to evaluate the feasibility, reproducibility, and safety of mechanistic loop resolution strategies using a short-type single-balloon enteroscopy (short SBE) system.

METHODS

Between February 2020 and March 2022, consecutive patients with a previous R-Y gastrectomy requiring ERCP were prospectively enrolled. Different mechanistic loop resolution strategies for two-dimensional loops, three-dimensionally rotated loops, and loops making a cane or S-shape were applied during the SBE approach.

RESULTS

Forty-three short SBE-ERCP procedures were performed on 37 patients, with an approach success rate of 100.0% (43/43). The mean time to reach the jejunojejunal anastomosis and target site were 8.0 (6.0-11.0) minutes and 26.0 (16.0-36.0) minutes, respectively. The major challenges for the approach were the cane or S-shaped loop in the jejunojejunal anastomosis or Treitz ligament. The retroflex positioning of a SBE in front of the papilla was achieved in 86.0% (37/43), and the cannulation success rate in patients with an intact papilla was 90.9% (30/33). The initial, overall therapeutic successes, median total procedure time, and adverse event rate were 87.8%, 92.7%, 77.0 (IQR 56-100.5) minutes, and 11.6%, respectively.

CONCLUSIONS

Short SBE-ERCP using standardized mechanistic loop resolution strategies is effective and reproducible in patients with R-Y reconstruction after gastrectomy.

TRIAL REGISTRATION

ClinicalTrial.gov (NCT04847167).

Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma in the Ileum with Successful Preoperative Endoscopic Evaluation

A 80-year-old man with the history of operations for gastric cancer and adhesive ileus developed abdominal pain. Positron emission computed tomography (CT) showed prominent wall thickening in the ileum with a maximal standardized uptake value of 12.1. Prior CT to diagnose adhesive ileus just taken only 4 months before did not show any masses in the abdomen. Single-balloon enteroscopy via colon showed a protruding mass at approximately 40–50 cm proximal point from the ileum end. Pathological examination of the biopsied specimen showed diffuse infiltration of medium- to large-sized atypical lymphocytes. Immunohistochemistry analysis showed that the atypical cells were positive for CD3 and CD56 and negative for CD8 and CD20. MIB-1 labeling index was extremely high as 80%. Under the diagnosis of intestinal T-cell lymphoma, the patient underwent tumorectomy, leading to the diagnosis of monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) after the negativity confirmation of Epstein-Barr virus-encoded mRNAs. The patient recovered with manageable complication and is going to receive chemotherapy. This is the first case of MEITL with extremely rapid progression in the distal ileum to be observed and diagnosed with single-balloon enteroscopy.

Efficacy of Novel Ultrathin Single-Balloon Enteroscopy for Crohn's Disease: A Propensity Score-Matched Study

Background/Aims

The evaluation of small bowel lesions of Crohn's disease (CD) using balloon-assisted enteroscopy (BAE) is crucial because mucosal healing is associated with a good prognosis. However, BAE procedures are invasive, requiring sedation or analgesia to reduce the patient's pain. This study evaluated the clinical usefulness of a novel ultrathin single-balloon enteroscopy (SBE) procedure for CD.

Methods

This single-center retrospective study included 102 CD patients who underwent trans-anal SBE between January 2012 and May 2018. Of these patients, 82 underwent enteroscopy using conventional SBE, while 20 underwent ultrathin SBE. Patients were analyzed using propensity score matching, with 20 patients per group. The median duration of the examination, terminal ileum intubation rate, median cecum intubation time, median insertion depth, adverse events, and sedated dose in each group were compared.

Results

Before propensity score matching, the conventional SBE group had a larger number of surgical history patients than the ultrathin SBE group (p=0.05). After matching, the two groups did not significantly differ clinically. There were no significant differences in the mean duration of the examination, cecum intubation time, or terminal ileal intubation rate between ultrathin SBE and conventional SBE. The mean insertion depth of ultrathin SBE tended to be deeper than that of conventional SBE (p=0.09). The use of ultrathin SBE also reduced the sedative dose during needed for enteroscopy compared with conventional SBE (p=0.005).

Conclusions

Novel ultrathin SBE may be less painful for CD patients than conventional SBE.

Relationship between the gut microbiota and bile acid composition in the ileal mucosa of Crohn's disease

Background/Aims

Crosstalk between the gut microbiota and bile acid plays an important role in the pathogenesis of gastrointestinal disorders. We investigated the relationship between microbial structure and bile acid metabolism in the ileal mucosa of Crohn's disease (CD).

Methods

Twelve non-CD controls and 38 CD patients in clinical remission were enrolled. Samples were collected from the distal ileum under balloon-assisted enteroscopy. Bile acid composition was analyzed by liquid chromatography-mass spectrometry. The gut microbiota was analyzed by 16S rRNA gene sequencing.

Results

The Shannon evenness index was significantly lower in endoscopically active lesions than in non-CD controls. β-Diversity, evaluated by the UniFrac metric, revealed a significant difference between the active lesions and non-CD controls (P=0.039). The relative abundance of Escherichia was significantly higher and that of Faecalibacterium and Roseburia was significantly lower in CD samples than in non-CD controls. The increased abundance of Escherichia was more prominent in active lesions than in inactive lesions. The proportion of conjugated bile acids was significantly higher in CD patients than in non-CD controls, but there was no difference in the proportion of primary or secondary bile acids. The genera Escherichia and Lactobacillus were positively correlated with the proportion of conjugated bile acids. On the other hand, Roseburia, Intestinibacter, and Faecalibacterium were negatively correlated with the proportion of conjugated bile acids.

Conclusions

Mucosa-associated dysbiosis and the alteration of bile acid composition were identified in the ileum of CD patients. These may play a role in the pathophysiology of ileal lesions in CD patients.

Endoscopic treatment of blue rubber bleb nevus syndrome in a 4-year-old girl with long-term follow-up: A case report

BACKGROUND

Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular disease, difficult to diagnose and choose a treatment method, especially in young children. There are several limiting factors to the use of enteroscopy for diagnostics and treatment in pediatric patients, in general. The literature on BRBNS cases is limited and presents various therapeutic approaches.

CASE SUMMARY

We present here a case of BRBNS involving a 4-year-old female, whose intestinal venous lesions were successfully treated by endoscopic sclerotherapy and aethoxysklerol foam. Skin lesions, typical for BRBNS, appeared on the 8^th d of the child’s life and their number increased over the next several months. The child also experienced episodes of critical decrease in hemoglobin level (by as much as 52 g/L) for several years, requiring iron supplementation and several blood transfusions. Video capsule endoscopy revealed numerous vascular formations in the small bowel. The combined findings of gastrointestinal venous formations and skin lesions prompted BRBNS diagnosis. Single-balloon enteroscopy was used to perform sclerotherapy, with aethoxysklerol foam. A positive effect was observed within 19 mo of follow-up. We continue to monitor the patient’s hemoglobin level, every 2 wk, and it has remained satisfactory (> 120 g/L).

CONCLUSION

Endoscopic sclerotherapy can be effective in the clinical management of gastrointestinal manifestations of BRBNS in young children.

Technical and Clinical Aspects of Diagnostic Single-Balloon Enteroscopy in the First Decade of Use: A Systematic Review and Meta-Analysis

Background/Aims

Single-balloon enteroscopy (SBE) has been widely used in diagnosing small bowel disease. We conducted this study to systematically appraise its technical and clinical performance.

Methods

Studies on SBE published by September 2018 were systematically searched. Technical and clinical performance data were collected and analyzed with descriptive or meta-analysis methods.

Results

In total, 54 articles incorporating 4,592 patients (6,036 procedures) were included. Regarding technical parameters, the pooled insertion depths (IDs) for anterograde and retrograde SBE were 209.2 cm and 98.1 cm, respectively. The pooled retrograde ID in Asian countries was significantly greater than that in Western countries (129.0 cm vs 81.1 cm, p<0.001). The pooled anterograde and retrograde procedure times were 57.6 minutes and 65.1 minutes, respectively. The total enteroscopy rate was 21.9%, with no significant difference between Asian and Western countries. Clinically, the pooled diagnostic yield of SBE was 62.3%. Obscure gastrointestinal bleeding (OGIB) was the most common indication (50.0%), with a diagnostic yield of 59.5%. Vascular lesions were the most common findings in Western OGIB patients (76.9%) but not in Asian ones (31.0%). The rates of severe and mild adverse events were 0.5% and 2.5%, respectively.

Conclusions

SBE is technically efficient and is clinically effective and safe, but total enteroscopy is relatively difficult to achieve with this technique. Etiologies of OGIB in Asian countries differ from those in Western countries.

Single-balloon enteroscopy in management of small-bowel disorders

BACKGROUND

Device-assisted enteroscopy including single-balloon enteroscopy (SBE) allows direct visualization of the small bowel and has good safety and efficacy in experienced hands. Our study is aimed to share our single-centre experience of SBE in diagnosing and treating small-bowel disorders.

METHODS

We reviewed the prospectively collected data (from December 2016 to December 2019) of 180 consecutive anterograde and/or retrograde procedures. Analysis of baseline characteristics, endoscopic findings, and diagnostic and therapeutic rates was done.

RESULTS

SBE was done in 158 patients with a median age of 55 years (range, 13-94 years) for suspected small-bowel lesions. Dual enteroscopy (anterograde plus retrograde) was done in 22 patients (13.92%). The indication for the procedure was obscure gastrointestinal bleeding in 129 (71.66%), chronic unexplained abdominal pain in 20 (11.11%), suspected small-bowel abnormality in the form of narrowing and/or mass on imaging in 10 (5.5%), chronic diarrhea in 9 (5%), unexplained iron deficiency anemia in 9 (5%), and retained capsule in 2 (1.11%). The most common finding was ulcer, which was noted in 45 (25%) patients followed by stricture in 8 (4.44%) and both ulcers and strictures in 6 (3.33%) patients. SBE was normal in 61 (33.88%) patients. SBE gave a diagnosis in 66.11% while in 28.43% cases, therapeutic intervention was done. Minor complications like bleeding were noted in 3 patients and mild acute pancreatitis in 2 patients. Jejunal perforation requiring surgical intervention was noted in 1 patient.

CONCLUSION

SBE is a safe and effective procedure in diagnosing and treating small-bowel diseases.

Single-balloon and spiral enteroscopy may have similar diagnostic and therapeutic yields to double-balloon enteroscopy: Results from a meta-analysis of randomized controlled trials and prospective studies

BACKGROUND

Double-balloon, single-balloon, and spiral enteroscopy (DBE, SBE, and SE) have revolutionized the management of intestinal diseases. However, evidence about efficacies of these methods is lacking. We aimed to conduct a meta-analysis comparing the clinical outcomes among DBE, SBE, and SE.

METHODS

We searched randomized controlled trials and prospective studies in MEDLINE, PubMed, EMBASE, Cochrane Library, and Chinese CQVIP database. Studies referencing the comparison of at least two of these three methods were included. Primary outcome was diagnostic yield. Other outcomes were therapeutic yield, total enteroscopy, examination time, time to maximum insertion, and depth of maximal insertion (DMI).

RESULTS

Eleven studies including 727 patients were identified: DBE vs SE (n = 6), DBE vs SBE (n = 4), and SBE vs SE (n = 1). The diagnostic and therapeutic yields did not differ significantly when comparing DBE with SE [odds ratio (OR) = 1.19, 95% confidence interval (CI): 0.68-2.08; OR = 1.17, 95%CI: 0.61-2.23] and DBE with SBE (OR = 0.85, 95%CI: 0.55-1.33; OR = 1.71, 95%CI: 0.64 - 4.60). Total enteroscopy, examination time, time to maximum insertion, and DMI were similar between SBE and DBE. DBE was superior to SE with regard to DMI [mean difference (MD) = 36.76, 95%CI: 5.09-68.43], with longer time to maximum insertion (MD = 15.14, 95%CI: 12-18.27) and examination time (MD = 12.98, 95%CI: 9.57-16.38).

CONCLUSION

DBE and SBE have similar clinical outcomes. Compared with DBE, SE seems to have similar diagnostic and therapeutic yields, but shorter procedural time in cost of less depth of insertion. SE needs further evaluation vs SBE. DBE is recommended for complete enteroscopy.

[Rapunzel Syndrome Removed with Enteroscopy in a Child]

A trichobezoar is a type of bezoar that is composed of hair. In most cases, it is confined to the stomach, but in rare cases, it may extend to the small intestine. This condition is referred to as Rapunzel syndrome. The therapeutic method for bezoar removal depends on its type, location, and size. Generally, the treatment for Rapunzel syndrome involves surgical laparotomy. Endoscopic removal has also been effective in some cases. On the other hand, complications, such as respiratory difficulty and esophageal impaction may be encountered during endoscopic removal. Until now, the successful endoscopic removal of trichobezoars has been limited to the stomach or duodenum. This paper reports the case of a 4-year-old female patient with Rapunzel syndrome whose trichobezoar reached the proximal jejunum. The trichobezoar was removed without complications using an electrosurgical knife and snare through a single-balloon enteroscopy. The trichobezoar can be removed successfully using enteroscopy under general anesthesia without abdominal laparotomy in young children. Therefore, this method of removal can be considered preferentially for children with Rapunzel syndrome.

Use of a Transparent Cap Increases the Diagnostic Yield in Antegrade Single-Balloon Enteroscopy for Obscure GI Bleed

BACKGROUND AND AIMS

Single-balloon enteroscopy (SBE) is utilized in the evaluation of obscure gastrointestinal bleeding, but 40-50% of these patients experience continued GI blood loss, in part due to missed lesions. The utilization of a transparent cap attached to the end of the endoscope can improve mucosal visualization in other endoscopic applications, but has not yet been evaluated in SBE. The aim of this study was to evaluate the impact of a cap on the diagnostic yield of SBE.

METHODS

Consecutive adult patients scheduled for anterograde SBE for the evaluation of obscure GI bleeding were screened for inclusion from 2014 to 2017. Patients were randomized to SBE with or without a transparent cap. The primary outcome was the proportion of enteroscopies in which a P2 lesion (high potential for bleeding) was identified.

RESULTS

A total of 90 patients (65.7 ± 12.7 years old, 47.7% female) were analyzed. There were significantly more P2 arteriovenous malformations identified in the cap group (14.8% vs. 0%, p = 0.02). Additionally, the use of a cap was associated with a significantly greater depth of small bowel insertion (191.9 cm vs. 156.2 cm, p = 0.01). There was one perforation in the group without a cap, successfully treated with clip placement, and no adverse events in the cap group.

CONCLUSIONS

The use of a transparent cap during SBE performed for the evaluation of obscure gastrointestinal bleeding may be an important, safe augmentation to standard SBE techniques.

Indolent T cell lymphoproliferative disorder with villous atrophy in small intestine diagnosed by single-balloon enteroscopy

Chronic diarrhea is one of the major symptoms in gastroenterology. However, this may be caused by pathologic conditions for which the diagnosis is critical. Villous atrophy, as an endoscopic lesion, accompanied by chronic diarrhea can occasionally be observed in the patients with inflammatory diseases of the gastrointestinal (GI) tract. Herein, we present a case with persistent diarrhea accompanied by intestinal wall thickening without any other significant endoscopic features other than villous atrophy in the jejunum and the ileum, where we diagnosed as an indolent T cell lymphoproliferative disorder (T-LPD) of the GI tract, defined in the 2016–2017 revised World Health Organization classification, via single-balloon enteroscopy (SBE). Interestingly, we found the same lymphocyte infiltration from the distal third portion of the duodenum, where gastroscopy could not reach, via SBE, even though no endoscopic findings were observed such as villous atrophy. Since infiltrating cells in the intestinal tissues were CCR4⁺, mogamulizumab was administered with resulting durable symptomatic remission for more than 2 years. Patients with persistent diarrhea may have serious small intestinal disorder including not only chronic inflammatory diseases but also lymphoid neoplasmic conditions including T-LPD of GI tract.

Novel Magnified Single-Balloon Enteroscopy Enables Observation of Jejunal White Spots Associated with Lymphangiectasia

A 59-year-old woman was diagnosed with primary intestinal lymphangiectasia (PIL), with characteristic findings on capsule enteroscopy and confirmation by histopathological examination of biopsy specimens. We viewed the abnormal jejunal mucosa using a newly developed magnifying single-balloon enteroscope (SIF-Y0007). Conventional observation showed leakage of chyle. However, using this new scope, we could see scattered white villi, representing dilated lymphatic vessels within the intestinal villi protruding from the dilated submucosal lymphoid vessels (D2-40 positive) within an edematous jejunal lesion. This report is the first to describe the white villi in a patient with PIL observed clearly using a newly developed magnifying enteroscope. Technological advancements and the accumulation of reported pathological data would further improve our understanding of the pathophysiological aspects of this disease entity, even in the jejunum.

A Deeper Look at the Small Bowel: Training Pathways in Video Capsule Endoscopy and Device-Assisted Enteroscopy

BACKGROUND

Although there are guidelines for video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), little is known about fellowship training in these technologies.

AIMS

The aims were to better characterize current small bowel endoscopy training in 3-year GI fellowship programs and 4th-year advanced endoscopy programs in the U.S.

METHODS

We developed an online multiple-choice survey to assess current GI fellowship program training in small bowel endoscopy. The survey was distributed via email to GI fellowship program directors in the U.S.

RESULTS

Of the 168 program directors contacted, 59 responded (response rate = 35.1%). There was no statistically significant difference in the availability of VCE or DAE between respondents and non-respondents. VCE training was universally available in 3-year training programs, with 84.8% (50/59) requiring it for fellows. The majority of 3-year GI fellows graduated with independence in VCE: 83.1% (49/59) of programs reported "most" or "all" graduates were able to read independently. DAE techniques were available in 86.4% of training programs (51/59). Training in DAE was more limited and shared between 3-year and 4th-year programs: 12.1% (7/58) of 3-year programs required training in DAE and 22.9% (8/35) of 4th-year programs required training in DAE .

CONCLUSIONS

Training in VCE is widely available in U.S. GI fellowship programs, although programs have different ways of incorporating this training into the curriculum and of measuring competency. While DAE technology was available in the majority of programs, training was less frequently available, and training is shared between 3-year fellowship programs and 4th-year advanced endoscopy programs .

Comparison of the Efficacy and Safety of Single- versus Double-Balloon Enteroscopy Performed by Endoscopist Experts in Single-Balloon Enteroscopy: A Single-Center Experience and Meta-Analysis

Background/Aims

Studies concerning the efficacy and safety of single-balloon enteroscopy (SBE) compared with that of double-balloon enteroscopy (DBE) often appear to be conflicting. However, previous studies were performed by endoscopists who were less experienced in SBE compared with DBE.

Methods

We performed a retrospective analysis of SBE and DBE data performed by a single enteroscopist, with expertise in SBE, using a prospective balloon-assisted enteroscopy registry from 2013 to 2015. Furthermore, we performed a comprehensive literature search and meta-analysis of available studies, including the current study, to clarify the efficacy and safety of SBE versus DBE.

Results

A total of 65 procedures in 44 patients with SBE and 74 procedures in 69 patients with DBE were analyzed. There were no significant differences in diagnostic yield (61.1% vs 77.3%, respectively, p=0.397), therapeutic yield (39.1% vs 31.8%, respectively, p=0.548), and complication rate (4.4% vs 2.3%, p=1.000). In the meta-analysis, which included four randomized controlled trials and three observational studies, there were no significant differences in the pooled relative risk and odds ratio for diagnostic and therapeutic yield and complications of SBE compared with those of DBE.

Conclusions

The performance of SBE appears to be similar to that of DBE in terms of diagnostic and therapeutic yield and complications.

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.

Training in Endoscopy: Enteroscopy

The balloon-assisted enteroscope has been regarded as the standard device for direct visualization of deep small bowels and allows for the diagnosis and treatment of small bowel disease. At the beginning, its application was focused on the diagnosis of obscure gastrointestinal bleeding, inflammatory bowel disease, and small bowel tumor. However, the indications are being expanded to various therapeutic procedures, not only confined to bleeding control. With the expansion of the indications, the need to perform enteroscopy effectively and safely is increasing. Recent studies have been focused on the diagnostic yield, therapeutic yield, and long-term outcomes of the device. However, with the increasing number of procedures, procedural guidelines and quality indicators are also needed.

A Case of Primary Small Bowel Melanoma Diagnosed by Single-Balloon Enteroscopy

Although metastasis from cutaneous malignant melanoma to the small intestine is not uncommon, primary small bowel melanoma (SBM) is extremely rare. This case report describes a rare case of primary SBM, diagnosed by single-balloon enteroscopy. A 74-year-old man presented with recurrent melena. Upper endoscopy and colonoscopy were unremarkable. Abdominal computed tomography (CT) revealed an ileal mass with ileo-ileal intussusception. Subsequent single-balloon enteroscopy identified an ileal tumor, which was histologically diagnosed as melanoma. Extensive clinical examination did not reveal any primary cutaneous lesions. To the best of our knowledge, this is the first case of primary SBM in South Korea.

Exploring the Small Bowel: Update on Deep Enteroscopy

Deep enteroscopy allows for the diagnosis and treatment of small bowel disorders that historically required operative intervention. There are a variety of endoscopic platforms using balloons and rotational overtubes to facilitate small bowel intubation and even allow for total enteroscopy. Obscure gastrointestinal bleeding is the most common indication for deep enteroscopy. By visualizing segments of the small bowel not possible through standard EGD or push enteroscopy, deep enteroscopy has an established high rate of identification and treatment of bleeding sources. In addition to obscure bleeding, other common indications include diagnosis and staging of Crohn's disease, evaluation of findings on capsule endoscopy and investigation of possible small bowel tumors. Large endoscopy databases have shown deep enteroscopy to be not only effective but safe. Recent research has focused on comparing the diagnostic rates, efficacy, and total enteroscopy rates of the different endoscopic platforms.

Single-Balloon Enteroscopy

Single-balloon enteroscopy is among 3 device-assisted enteroscopy systems on the market. Compared with double-balloon enteroscopy, no significant difference in diagnostic yield was found. Additionally, no significant difference was found in oral and anal insertion depth, adverse events, or procedure times. Some studies observed lower complete enteroscopy rates, which have evidently no diagnostic impact. With a learning curve of around 30 procedures, the single-balloon endoscope is a safe endoscopic tool, which seems equally suitable for diagnostic and therapeutic interventions. Carbon dioxide should be used for single-balloon endoscopy procedures, especially in patients with a history of surgical abdominal interventions.

Capsule endoscopy and single-balloon enteroscopy in small bowel diseases: Competing or complementary?

AIM

To evaluate diagnostic yields of capsule endoscopy (CE) and/or single-balloon enteroscopy (SBE) in patients with suspected small bowel diseases.

METHODS

We retrospectively analyzed 700 patients with suspected small bowel diseases from September 2010 to March 2016. CE, SBE, or SBE with prior CE was performed in 401, 353, and 47 patients, respectively. Data from clinical and endoscopy records were collected for analysis. Indications, procedure times, diagnostic yields, and complications were summarized and evaluated.

RESULTS

The overall diagnostic yield for the CE group was 57.6%. The diagnostic yield of CE in patients with obscure gastrointestinal bleeding (OGIB) was significantly greater than that in patients with no bleeding (70.5% vs 43.8%, P < 0.01). The overall diagnostic yield of SBE was 69.7%. There was no difference in the diagnostic yield of SBE between patients with OGIB and those with no bleeding (72.5% vs 68.9%, P = 0.534). Forty-seven patients underwent CE prior to SBE. Among them, the diagnostic yield of SBE with positive findings on prior CE was 93.3%. In addition, SBE detected two cases with superficial ulcer and erosive lesions in the small bowel, which were missed by CE. However, one case with lymphoma and two with Crohn’s disease were not confirmed by SBE. The rate of capsule retention was 2.0%. There were no significant complications during or after SBE examinations.

CONCLUSION

SBE is a safe and effective technique for diagnosing small bowel diseases. SBE with prior CE seemed to improve the diagnostic yield of small bowel diseases.

Capsule Studies Performed in a Tertiary Care Center Versus Community Referrals Prior to Single-Balloon Enteroscopy: Does It Matter?

BACKGROUND AND AIMS

Within the community, patients with positive capsule endoscopy (CE) are often referred to centers performing balloon-assisted enteroscopy. There is limited data evaluating the concordance and diagnostic/therapeutic yield of CE performed in the community versus CE conducted at institutions experienced with enteroscopy. The primary aim of this retrospective study was to evaluate the concordance between CE and SBE after CE was performed either in the community or at our tertiary care center.

METHODS

A total of 141 patients were analyzed after selecting patients undergoing evaluation of obscure GI bleeding from January 2010 to May 2014. Forty-seven CE were performed inside and the remaining 94 CE were performed at outside institutions prior to single-balloon enteroscopy at our institution. Agreement beyond chance was evaluated using kappa coefficient. A p value <5% was considered significant.

RESULTS

The most frequent findings on CE were vascular lesions in 39 patients (41.5%) within the referral group and 23 within inside patients (48.9%), followed by active bleeding/clots in 23 patients (24.5%) and in 14 patients (29.8%) respectively. There was a fair degree of concordance in the referral group for vascular lesions 0.23 (0.03-0.42) compared to a good degree in the inside group 0.65 (0.44-0.87). Fair agreement was found looking at ulcers within the referral group 0.29 (0.06-0.65) compared to a moderate agreement in the inside group 0.55 (0.17-0.94).

CONCLUSIONS

Degree of concordance for vascular lesions and ulcers was significantly higher for patients undergoing CE at our institution compared to those referred from the community. Patients referred to tertiary care centers for balloon-assisted enteroscopy may benefit from advanced endoscopists re-reading the capsule findings or even potentially repeating CE in hemodynamically stable patients if the study is not available.

Current status of single-balloon enteroscopy: Insertability and clinical applications

The single-balloon enteroscopy (SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy (DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. However, many methods have been proposed to improve the depth of insertion with the SBE system, involving several techniques and endoscopic accessories. SBE is used for investigating not only small bowel diseases, but also diseases of the pancreatobiliary and colonic structures. SBE is a necessary advancement for many endoscopic procedures and applications in modern clinical practice. In our review, we summarized the current literature concerning the insertability of SBE and described the technical aspects of improving the rate of deep insertion in SBE procedures. In addition, the recent applications of SBE to diseases besides those of the small bowel are described.

Complications of enteroscopy: how to avoid them and manage them when they arise

Deep small bowel enteroscopy is a safe procedure that has revolutionized the strategy for diagnosis and treatment of small bowel diseases. However, enteroscopy-associated adverse events are more common compared with standard endoscopy. Prevention, early detection, and effective intervention are crucial in reducing the adverse event severity and improving outcomes. In this article, how to safely perform enteroscopy, avoid adverse events, detect adverse events early, and accomplish effective treatments are discussed. This knowledge can serve as a continuing quality improvement process to reduce the risk of future adverse events and improve the overall quality of endoscopy.

Emergency single-balloon enteroscopy in overt obscure gastrointestinal bleeding: Efficacy and safety

We aimed to evaluate the impact of emergency single-balloon enteroscopy (SBE) on the diagnosis and treatment for active overt obscure gastrointestinal bleeding (OGIB).

METHODS

SBE procedures for OGIB were retrospectively reviewed and sub-divided according to the bleeding types: active-overt and inactive-overt bleeding. The patient's history, laboratory results, endoscopic findings and therapeutic interventions were registered. Emergency SBE was defined as an endoscopy that was performed for active-overt OGIB, within 24 hours of clinical presentation.

RESULTS

Between January 2010 and February 2013, 53 SBEs were performed in 43 patients with overt OGIB. Seventeen emergency SBEs were performed in 15 patients with active overt-OGIB procedures (group A), which diagnosed the bleeding source in 14: angiodysplasia (n = 5), ulcers/erosions (n = 3), bleeding tumors (gastrointestinal stromal tumor (GIST), n = 3; neuroendocrine tumor, n = 1), and erosioned polyps (n = 2). Endoscopic treatment was performed in nine patients, with one or multiple hemostatic therapies: argon plasma coagulation (n = 5), epinephrine submucosal injection (n = 5), hemostatic clips (n = 3), and polypectomy (n = 2). Twenty-eight patients with inactive bleeding (group B) were submitted to 36 elective SBEs, which successfully diagnosed 18 cases. The diagnostic yield in group A (93.3%) was significantly higher than in group B (64.3%)-Fisher's exact test, p = 0.038.

CONCLUSION

This study revealed an important role of emergency SBE in the diagnosis of bleeding etiology in active overt OGIB.

Deep enteroscopy: which technique will survive?

The advent of deep enteroscopy (DE) has dramatically changed diagnostic and therapeutic approaches to small bowel diseases. Unlike capsule endoscopy, which is unable to obtain biopsies or treat a disease, DE techniques have diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was introduced in 2001, and single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) were subsequently developed for small bowel investigation. In published reports comparing these different enteroscopy techniques, most comparative parameters (depth of insertion, complications, learning curve, diagnostic yield, and therapeutic yield) were comparable among DBE, SBE, and SE. However, the procedure duration appears to be shorter for SE than for DBE and SBE. The rate of complete enteroscopy is clearly superior for DBE, compared with SE and SBE. Because these results do not indicate an increase in diagnostic or therapeutic yield, the clinical impact of complete enteroscopy remains controversial. According to previous studies, the three DE methods seem to be equally effective and safe in the clinical setting. Although larger randomized controlled trials are needed to evaluate the procedural characteristics and clinical impact, the selection of an enteroscopic technique should be based on availability and the endoscopist's experience.

Ileal gallstone obstruction: Single-balloon enteroscopic removal

Gallstone-induced ileus is a rare complication of cholelithiasis. Since localization of gallstones impacted in the small bowel, especially in the ileum, prevents access by conventional endoscopy in most cases, the mainstay of treatment remains surgical. Recent invention of double- and single-balloon enteroscopy has added much to the ability of imaging the small bowel and enables endoscopically directed therapy. Herein, for the first time, we report a successful endoscopic calculus removal via peroral single-balloon enteroscopy in an 81-year-old woman suffering from gallstone ileus of the ileum.