Total enteroscopy with a nonsurgical steerable double-balloon method

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.

Does it matter how long the small bowel is?

The small bowell (SB) is a very long organ hardly accessible to conventional endoscopy. The revolution entailed by its complete diagnostic exploration with capsule endoscopy (CE) has led to a change in traditional surgical management and its related gold standard - intraoperative enteroscopy. CE is currently the first-line diagnostic strategy for the SB. An emergent technique in its wake has played a key role in the management of patients with SB conditions: to wit, device-assisted enteroscopy (DAE). Thus were developed first double-balloon enteroscopy (DBE), then single-balloon enteroscopy, and most recently motorized spiral enteroscopy.

Small bowel polyp resection using device-assisted enteroscopy in Peutz-Jeghers Syndrome: Results of a specialised tertiary care centre

INTRODUCTION

Enteroscopy resection of small bowel polyps in Peutz-Jeghers syndrome has only been described in small case series. Herein, we aimed to assess the efficacy of enteroscopy resection of small bowel polyps within a specialised tertiary care centre and the impact on intraoperative enteroscopy.

METHODS

This was an observational single-centre study. All adult Peutz-Jeghers syndrome patients followed in the Predisposition Digestive Ile-de-France network who underwent an endoscopic resection of at least one small bowel polyp ≥ 1 cm by enteroscopy between 2002-2015 were included. Small bowel polyps were detected under a dedicated screening programme by previous capsule endoscopy and/or magnetic resonance enterography, performed every 2-3 years. Complete treatment was defined as the absence of polyps ≥ 1 cm after conventional endoscopic resection. Intraoperative enteroscopy or surgical resection were indicated in incomplete treatments. The overall complete treatment rate including conventional enteroscopy and intraoperative enteroscopy was also considered.

RESULTS

Endoscopic resection of 216 small bowel polyps (median: 8.6 per patient, size: 6-60 mm) was performed by 50 enteroscopies in 25 patients (mean age: 36 years, range: 18-71, 56% male) with small bowel polyp ≥ 1 cm. Twenty-three patients (92%) underwent 42 screening capsule endoscopies and 14 (57%) had 23 magnetic resonance enterographies during a median follow-up of 60 months. Complete treatment was achieved in 76%. Intraoperative enteroscopy and surgical resection were performed in four (16%) and two (8%) patients. Intraoperative enteroscopy improved by 16% the complete treatment rate and the overall rate was 92%. The complication rate was 6%.

CONCLUSION

This long-term study confirmed the efficacy and safety of endoscopic resection of small bowel polyps in Peutz-Jeghers syndrome. Intraoperative enteroscopy can be a complementary approach in selected cases.

Diagnostic efficacy of double-balloon enteroscopy in patients with suspected isolated small bowel Crohn's disease

BACKGROUND

Owing to the development of double-balloon enteroscopy (DBE) and video capsule endoscopy (VCE) in recent years, direct visualization of the entire small intestinal mucosa has become possible. Because of the nonspecific symptoms and the anatomic location of the small bowel, diagnosis of isolated small bowel Crohn's disease (CD) remains a challenge. The aim of this research was to explore the value of DBE for isolated small bowel CD in situations where routine tests cannot confirm the diagnosis.

METHODS

This study included patients with suspected isolated small bowel CD who were hospitalized in Shengjing Hospital from April 2014 to June 2018. We included patients presenting with chronic diarrhea, abdominal pain, abdominal mass, perianal lesions, and systemic symptoms including weight loss, fever, and anemia after excluding infection factors. Patients with purely colonic CD were excluded from this cohort. Patients with suspected isolated small bowel CD underwent DBE.

RESULTS

In 16/18 patients, pathological findings were detected by DBE. In 12 of the cases, small bowel CD was confirmed. The remaining four patients were diagnosed with small bowel inflammation, duodenal carcinoma, ileum inflammation and small bowel ulcers. However, the diagnosis of CD was confirmed in 14/18 (78%) patients by taking into account the clinical presentation, endoscopic and histological results as well as the experimental treatment. DBE assisted in the diagnosis in 86% (12/14) of the patients.

CONCLUSIONS

In the diagnosis of small bowel CD, DBE is a helpful tool. Before assessment with DBE, clinical features, colonoscopy, and CT were used to initially assess the intestine. According to the lesions indicated by CT, we chose the most appropriate endoscope insertion route, and combined the endoscopic characteristics and pathological results of DBE to confirm the diagnosis.

Emergent Double Balloon Enteroscopy in Overt Suspected Small Bowel Bleeding: Diagnosis and Therapy

BACKGROUND Double balloon enteroscopy (DBE) is a diagnosis and therapy method for suspected small bowel bleeding (SSBB). The data for emergent DBE is limited in overt SSBB cases. The aim of this study was to investigate the role of diagnosis and therapy of emergent DBE in patients with overt SSBB. MATERIAL AND METHODS The clinical and endoscopic data for patients with overt SSBB undergoing DBE in a single center from January 2010 to December 2017 were collected and analyzed. Emergent DBE was defined as DBE performed less than 3 days of last bleeding onset. RESULTS A total of 265 DBEs in 265 patients with overt SSBB were enrolled (mean age, 44.7±17.3 years; 66.8% males). The patients were divided into 3 groups according to the timing of DBE: less than 3 days (n=32), more than 3 days and less than 7 days (n=146), and more than 7 days (n=87) (first group was the emergent group, the latter 2 groups were the non-emergent groups). The diagnosis yield for the emergent group was significantly higher than the non-emergent groups (84.4% versus 65.1% or 59.8%, respectively, P<0.05), but was not different between the 2 non-emergent groups (P>0.05). The top 3 diagnoses were angioectasias (19.6%), diverticulum (16.2%), and tumor (12.1%). For therapy yield, there was a remarkable reducing trend in the emergent group (<3 days), and the 2 non-emergent groups (3 to 7 days group and >7 days group: 78.1%, 58.2% and 39.1%, respectively, P<0.05. The top 3 endoscopic treatments were hemostatic clips (21.9%), argon plasma coagulation (15.8%), and epinephrine injection (14.0%). CONCLUSIONS The emergent DBE had the highest yields for diagnosis and therapy. The study finding showed a pivotal role of emergent DBE in overt SSBB.

Single incision laparoscopic assisted double balloon enteroscopy: a novel technique to manage small bowel pathology

BACKGROUND AND AIMS

Double balloon enteroscopy (DBE) has revolutionised the diagnosis and treatment of small bowel (SB) conditions. However, deep SB insertion can be challenging in patients with a history of abdominal surgery and a two-step procedure is required when findings are not amenable to endoscopic therapy. This case series reports the development of laparoscopically assisted DBE (LA-DBE) using single incision laparoscopic surgery (SILS).

METHODS

Retrospective review of LA-DBE procedures performed in a single tertiary centre over 6 years.

RESULTS

Seventeen patients (median age: 40 years, male 41%) underwent 17 LA-DBE procedures. The approach was oral in 13 and rectal in 4. Laparoscopic approach was standard (multi-port) in the first four cases, SILS was then used in all subsequent patients (13/17). Indications for LA-DBE were previously failed standard DBE (n = 16) and need for a combined procedure (n = 1). Indications for DBE were Peutz-Jeghers syndrome (PJS) (n = 10), suspected submucosal/polypoid lesion at small bowel imaging (n = 5) and obscure gastrointestinal bleeding (OGIB) with vascular abnormalities seen at capsule endoscopy (n = 2). In 1/17 the suggested pathology on imaging was not identified. Therapy was applied in 15/17 (88%) cases. Diagnoses were PJS polyps (n = 8), neuroendocrine tumour (NET) (n = 2), PJS and NET (n = 1), transmural arteriovenous malformation (n = 1), angioectesia (n = 1), inflammatory polyp (n = 1), leiomyoma (n = 1) and Meckel's diverticulum (n = 1). The median (range) procedure time was 147 (84-210) mins. Median (range) length of stay post-procedure was 2 (1-19) days. Three patients developed complications. The 30-day mortality rate was 0%.

CONCLUSIONS

LA-DBE is a safe, effective and minimally invasive procedure that can be applied for the management of selected patients with small bowel pathology. A SILS approach allows all therapeutic modalities to be available, including conversion to intraoperative enteroscopy (IOE), laparoscopic small bowel resection and laparotomy.

Computer tomography in the diagnosis of small bowel diseases

Introduction. The relevance of the study is caused by the difficulties in diagnosing diseases of the small bowel (SB). Due to the prevalence and widespread introduction of X-ray computed tomography (CT) into clinical practice, its capabilities in the diagnosis of small bowel diseases are of great interest and potential. Objective. to reveal the possibilities of computed tomography using intravenous bolus contrast enhancement in identifying the symptom of wall thickening of the small bowel and its prognostic significance in various nosologies. Methods. Analysis of the data from MSCT studies performed according to the Protocol for the study of abdominal organs using intravenous bolus contrast enhancement and oral water intake in adult patients from 18 to 87 years of age with small bowel diseases. Results. The article shows the possibilities of multispiral computed tomography performed according to the standard Protocol in detecting thickening of the SB wall. The range of diseases was determined for which thickening of the SB wall was one of the main radiological symptoms of the lesion. The prognostic significance of this radiological symptom is presented. The features of thickening of the intestinal wall in various diseases and other distinctive features that can be used in the differential diagnosis are described. Conclusion. Thickening of the wall is a common sign of SB damage, which is convincingly detected in CT studies with bolus contrast enhancement. In our study, the common causes of thickening of the SB wall in primary disease were: Crohn's disease (37%), lymphoma (20%) and anastomosis (13%). However, we determined thickening of the SB wall as a result of primary tumors (adenocarcinoma, sarcoma) in 7% and as a result of a secondary tumor lesion in 18.6% of cases. The considered diseases were different in the degree of thickening of the intestinal wall (from 6 to 70 mm), its spreading (focal thickening 48%; segmental 52%), number of affected areas (from 1 to 3) of their localization (proximal-middle or distal section), form of the transition area from the affected part of the intestine to the unchanged one (sharply defined or smooth), the presence or absence of symptoms of intestinal obstruction, and the features of contrast enhancement (severity and type).

Double balloon enteroscopy improves ERCP success in patients with modified small bowel anatomy

OBJECTIVE

The aim of this study was to evaluate the effect of double-balloon enteroscopy (DBE) on the success of endoscopic retrograde cholangiopancreatography (ERCP) procedures in patients with surgically modified gastrointestinal (GI) tract anatomy.

METHODS

The medical records of patients who underwent ERCP in the Gastroenterology Department of Kocaeli University School of Medicine hospital between December 2008 and September 2014 were examined. From the patient group that was scheduled to undergo DBE-ERCP, the details of cases in which ERCP via standard duodenoscope or DBE-ERCP was performed during the same session because standard ERCP failed were included. Procedure parameters, outcomes, and complications related to the procedure in both groups were analyzed. Patients who underwent the DBE-ERCP procedure directly, those who underwent push enteroscopy, or gastroscopy to evaluate the GI tract anatomy before the day of ERCP, and who underwent DBE-ERCP on a day other than the initial ERCP session were excluded. Afferent loop intubation, access to the major papilla, selective cannulation, therapeutic success rates, and the effect of DBE on overall procedure success were evaluated.

RESULTS

Fifty-one patients with a history of BII gastrojejunostomy and 11 patients with hepaticojejunostomy (with or without Roux-en-Y) were included in the study. In all patients, the ERCP procedure was initiated with a standard duodenoscope. If intubation of the afferent loop was unsuccessful in reaching the major papilla or enterobiliary anastomosis, DBE was used. In 30 (48.4%) of the 62 patients whose GI tract was anatomically altered, the duodenoscope was successfully advanced to the ampulla and 27 (43.5%) were cannulated successfully. Thirty-one patients underwent DBE-ERCP. DBE reached the ampulla or enterobiliary anastomosis in 30 patients (96.8%) and selective choledocus cannulation was achieved in all patients but 3 (90%), including 1 patient with a hepaticojejunostomy. The overall ERCP success rate increased from 43.5% (27/62) to 87.1% (54/62). Two perforations (1 during standard duodenoscopy and 1 with DBE-ERCP) were observed.

CONCLUSION

The overall success rate of ERCP increased with use of the DBE technique in patients with small bowel anatomic variations that were the result of previous surgery.

Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Analysis of the ‘Endoworm’ prototype’s ability to grip the bowel in in vitro and ex vivo models

Access to the small bowel by means of an enteroscope is difficult, even using current devices such as single-balloon or double-balloon enteroscopes. Exploration time and patient discomfort are the main drawbacks. The prototype ‘Endoworm’ analysed in this paper is based on a pneumatic translation system that, gripping the bowel, enables the endoscope to move forward while the bowel slides back over its most proximal part. The grip capacity is related to the pressure inside the balloon, which depends on the insufflate volume of air. Different materials were used as in vitro and ex vivo models: rigid polymethyl methacrylate, flexible silicone, polyester urethane and ex vivo pig small bowel. On measuring the pressure–volume relationship, we found that it depended on the elastic properties of the lumen and that the frictional force depended on the air pressure inside the balloons and the lumen’s elastic properties. In the presence of a lubricant, the grip on the simulated intestinal lumens was drastically reduced, as was the influence of the lumen’s properties. This paper focuses on the Endoworm’s ability to grip the bowel, which is crucial to achieving effective endoscope forward advance and bowel folding.

New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review

Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.

Endoscopic submucosal dissection: an update on tools and accessories

Endoscopic submucosal dissection (ESD) is a minimally invasive therapeutic procedure to remove larger polyps or early non-metastatic lesions. It has long been used in Asia, but is now fast growing in popularity in the West. There are multiple challenges faced by ESD practitioners. While the practice of ESD in gastric lesions is relatively well established, the oesophagus with its narrow lumen and challenging workspace, and the colon with its tortuous course and folds are more challenging frontiers. The nature of performing a procedure endoscopically means that conventional methods offer no mechanism for providing counter-traction while performing dissection, impeding visibility and increasing the rate of complications. There are a multitude of tools available to those performing ESD for the different stages of the procedure. This article reviews the accessories currently used in regular ESD practice including the knives used to cut and dissect lesions, the cap and hood devices used to improve visibility and safety, injection fluids to lift the submucosal plane, haemostatic devices, generators, and finally, emerging traction apparatus. There is some evidence behind the use of these tools, however, ESD remains the domain of a small number of practitioners and the practice relies heavily on expert experience. Evolution of the ESD toolbox will make the procedure more accessible to more endoscopists, which in turn will drive the development of a more substantial evidence base to evaluate efficacy and safety of the multitude of tools.

Diaphragm disease associated with nonsteroidal anti-inflammatory drugs mimicking intestinal tumor: A case report

INTRODUCTION

Diaphragm disease is rare and caused by intestinal obstruction due to nonsteroidal anti-inflammatory drugs (NSAIDs). Given the availability of video capsule endoscopy (VCE) and balloon enteroscopy (BE) this disease will be diagnosed more often.

PRESENTATION OF CASE

A 73-year-old man was presented to our hospital for persistent nausea and vomiting. Abdominal ultrasound and computed tomography revealed small-bowel thickening, stricture in the terminal ileum, and dilation of the proximal small intestine. Differential diagnosis included ileal lymphoma and multiple ileal adenocarcinomas, and a diagnostic laparoscopy was performed. Twenty-centimeter of ileum was resected by primary ileo-ileal anastomosis. On pathological examination, fibrosis of the submucosa was identified, and erosions and numerous inflammatory cells reaching the submucosa were also identified from the specimen.

DISCUSSION

The preoperative diagnosis of diaphragm disease is sometimes challenging due to its uncharacteristic symptoms; moreover, radiological findings are usually indefinite and distinctive. Currently, the main treatment for diaphragm disease is surgery.

CONCLUSION

We have documented a case of intestinal obstruction by NSAIDs. However, it is desirable to determine the course of treatment based on small bowel endoscopic dilatation cases in the future.

Management of obscure gastrointestinal bleeding: Comparison of guidelines between Japan and other countries

Small-bowel bleeding accounts for the majority of obscure gastrointestinal bleeding, but it is caused by various types of small bowel disease, upper gastrointestinal disease, and colorectal disease. For the diagnosis, history taking and physical examination are required, leading to a determination of what diseases are involved. Next, cross-sectional imaging, such as computed tomography, should be carried out, followed by the latest enteroscopy such as small bowel capsule endoscopy and deep enteroscopy according to the severity of hemorrhage and patient condition. After a comprehensive diagnosis, medical, enteroscopic, or surgical treatment should be selected. This article reviews recent advances in the endoscopic diagnosis of obscure gastrointestinal bleeding and compares perspectives of the management of obscure gastrointestinal bleeding in Japan with that in other countries.

Automatic detection of small bowel tumors in wireless capsule endoscopy images using ensemble learning

PURPOSE

Wireless Capsule Endoscopy (WCE) is a minimally invasive diagnosis tool for lesion detection in the gastrointestinal tract, reaching places where conventional endoscopy is unable to. However, the significant amount of acquired data leads to difficulties in the diagnosis by the physicians; which can be eased with computer assistance. This paper addresses a method for the automatic detection of tumors in WCE by using a two-step based procedure: region of interest selection and classification.

METHODS

The first step aims to separate abnormal from normal tissue by using automatic segmentation based on a Gaussian Mixture Model (GMM). A modified version of the Anderson method for convergence acceleration of the expectation-maximization (EM) algorithm is proposed. The proposed features for both segmentation and classification are based on the CIELab color space, as a way of bypassing lightness variations, where the L component is discarded. Tissue variability among subjects, light inhomogeneities and even intensity differences among different devices can be overcome by using simultaneously features from both regions. In the second step, an ensemble system with partition of the training data with a new training scheme is proposed. At this stage, the gating network is trained after the experts have been trained decoupling the joint maximization of both modules. The partition module is also used at the test step, leading the incoming data to the most likely expert allowing incremental adaptation by preserving data diversity.

RESULTS

This algorithm outperforms others based on texture features selected from Wavelets and Curvelets transforms, classified by a regular support vector machine (SVM) in more than 5%.

CONCLUSIONS

This work shows that simpler features can outperform more elaborate ones if appropriately designed. In the current case, luminance was discarded to cope with saturated tissue, facilitating the color perception. Ensemble systems remain an open research field. In the current case, changes in both topology and training strategy have led to significant performance improvements. A system with this level of performance can be used in current clinical practice.

Analysis of the factors involved in procedural failure: Endoscopic retrograde cholangiopancreatography using a short-type single-balloon enteroscope for patients with surgically altered gastrointestinal anatomy

AIM

To analyze factors involved in procedural failure and to discuss responses to procedural failure by using the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) carried out using a short-type single-balloon enteroscope (short SBE) in patients with surgically altered gastrointestinal anatomy.

METHODS

The study sample included patients who underwent ERCP-related procedures using a short SBE between September 2011 and September 2018 at our hospital. Outcomes, including procedural success rate, were studied retrospectively to analyze the factors involved in procedural failure.

RESULTS

Analysis included 191 procedures carried out in 121 patients. Procedural success rate was 85.9% with an adverse event rate of 8.4%. Causes of procedural failure included malignant biliary obstruction (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.19-7.25, P = 0.02), first ERCP attempt (OR: 5.32, 95% CI: 1.30-36.30, P = 0.02), and Roux-en-Y reconstruction (OR: 0.08, 95% CI: 0.004-0.39, P < 0.001). With regard to the response to failure, in cases of malignant biliary obstruction, reattempted short SBE-assisted ERCP was difficult because of invasion of the small intestine or papilla. A large number of these cases required alternative treatment (10 of 15 cases, 66.7%) using percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided biliary drainage (EUS-BD).

CONCLUSION

Endoscopic retrograde cholangiopancreatography using a short SBE is safe and effective, with malignant biliary obstruction being a specific cause of failure. Technical proficiency with different modalities, such as PTBD and EUS-BD, is necessary to respond to failure in these cases.

Endoscopic ultrasonography and small-bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small-bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device-assisted enteroscopy have quickly become the reference standard for the diagnosis of small-bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up-to-date overview of the latest advances in endoscopic ultrasonography and small-bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.

Impact of Urgent Double-Balloon Enteroscopy on the Short-Term and Long-Term Outcomes in Overt Small Bowel Bleeding

BACKGROUND

Double-balloon enteroscopy (DBE) is a safe and useful procedure for managing small bowel bleeding. However, there are limited studies regarding the preferable timing of DBE and its impact on long-term outcomes.

AIM

We aimed to evaluate the association between the timing of DBE and the long-term outcomes of patients suspected of having overt small bowel bleeding who underwent DBE.

METHODS

We retrospectively reviewed a prospectively collected database of patients who underwent DBE procedures between May 2004 and April 2016. The electronic medical records were reviewed, and interviews were conducted via mail and telephone.

RESULTS

One-hundred sixty-five patients could be followed up. The bleeding source was detected during the initial DBE (DBE-positive group) for 102 patients. Sixty-three patients had no definite lesion during the initial DBE (DBE-negative group). Urgent DBE (DBE within 24 h after the last bleeding episode) was performed more often for the DBE-positive group (50/102; 49.0%) than for the DBE-negative group (10/63; 16.1%) (p < 0.0001). Nine patients in the DBE-positive group underwent curative surgery after diagnosis. Among the remaining DBE-positive patients, 38 of 93 (40.9%) had recurrent bleeding during 2675 days of follow-up. Twenty-one of 63 patients (33.3%) in the DBE-negative group had recurrent bleeding during 2490 days of follow-up. There was no significant difference between the two groups in terms of intervals without rebleeding (p = 0.17).

CONCLUSION

Urgent DBE at the initial bleeding episode was useful for detecting lesions. However, the rebleeding rate was not dependent on the initial DBE results.

Cryptogenic Multifocal Ulcerating Stenosing Enteropathy(CMUSE) and/or Chronic Non-specific Multiple Ulcers of the Small Intestine(CNSU) and Non-granulomatous Ulcerating Jejunoileitis (NGUJI)

PURPOSE OF REVIEW

The purpose is to make aware of the existence of the rare and exclusive small intestine (SI) diseases, namely cryptogenic multifocal ulcerating stenosing enteropathy (CMUSE) or chronic non-specific multiple ulcers of the small intestine (CNSU) and non-granulomatous ulcerating jejunoileitis (NGUJI). The article will elucidate their epidemiology, pathogenesis, clinical features, diagnosis, differentiating features and management.

RECENT FINDINGS

Recent papers have published the clinical features and diagnostic criteria of CMUSE/CNSU and NGUJI. CNSU/CMUSE is caused by gene mutations involved in the prostaglandin pathways. Although capsule endoscopy can detect these lesions, it carries a risk of retention. TNF antagonists and azathioprine have shown response in few cases. CMUSE/CNSU and NGUJI are uncommon diseases that cause relapsing SI obstruction and bleed due to short-segment strictures and multiple shallow ulcers. This article focuses on current knowledge and novel insights regarding their pathogenesis, genetics, clinical features, diagnostic criteria and management. Multicentric clinical and genetic studies are the need of the hour.

Device assisted enteroscopy in the elderly - A systematic review and meta-analysis

BACKGROUND

Device assisted enteroscopy (DAE) is increasingly being carried out in elderly patients. This provides a challenge due to the underlying varied physiology and comorbidities these patients have.

METHODS

We performed a systematic literature search for studies on elderly patients undergoing DAE. We calculated the pooled diagnostic (DY) and therapeutic yields (TY), major adverse events, length of small bowel examined and sedation administered. These were also compared to younger patients.

RESULTS

Fourteen high quality articles on DAE in the elderly were included in this analysis (3289 total, 1712 elderly) patients. Nine of these studies were included in the final meta-analysis (681 elderly, 1577 young patients). The overall DY of DAE, double balloon enterosocpy (DBE) and single balloon enteroscopy (SBE) were 0.68 (p = 0.000001), 1.74 (p = 0.0001) and 1.90 (p = 0.009). The TY of DAE, DBE and SBE were 0.45 (p = 0.00001), 2.20 (p = 0.00001) and 2.36 (p = 0.00001). On comparison of elderly and young patients, DY (1.83; 95% CI: 1.49, 2.24; p = 0.00001) and TY (2.28; 95% CI: 1.79, 2.89) were better in elderly patients. There was no difference in adverse events in both groups (2.16; 95% CI: 0.82, 5.69, p = 0.12). Elderly patients were given less sedation than younger patients during DAE.

CONCLUSIONS

DAE has a higher DY and TY in the elderly than younger patients. DAE can be safely carried out in the elderly with less sedation.

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.

Double-balloon enteroscopy-facilitated cyanoacrylate-injection endotherapy of small-bowel varices: an international experience from 2 European tertiary centers (with videos)

BACKGROUND AND AIMS

Small-bowel varices (SBVs) are an uncommon consequence of portal hypertension. Radiologic intervention is usually considered for first-line management. When radiologic intervention is not possible, management options become very limited. The aim of this study was to evaluate the usefulness of double-balloon enteroscopy (DBE)-facilitated cyanoacrylate-injection endotherapy of SBVs.

METHODS

This was a retrospective review of DBE-facilitated cyanoacrylate-injection endotherapy of SBVs (December 2015 to October 2016).

RESULTS

Ten DBEs were performed in 6 patients (4 women; median age, 68.5 years). No radiologic or surgical options were deemed feasible. Thirteen nests of SBVs were identified and injected with cyanoacrylate glue without hemorrhagic or embolic adverse events. At the 30-day follow-up after therapy, only 1 patient had experienced a mild recurrence of mid-gut bleeding; this was managed conservatively. One patient presented with acute GI bleeding 7 months later, and a repeat DBE with cyanoacrylate-injection endotherapy was successfully performed. One patient succumbed to his underlying advanced cholangiocarcinoma after 2 months. The remaining patients had a median follow-up of 12 months without any recurrent GI bleeding.

CONCLUSIONS

DBE-facilitated cyanoacrylate-injection endotherapy of SBVs appears to be a safe and effective option when other first-line options are not feasible.

Endoscopic features of gastrointestinal stromal tumor in the small intestine

Background/Aims

Gastrointestinal stromal tumor (GIST) is one of the most common types of submucosal tumors (SMTs). Because of GIST’s malignant potential, it is crucial to differentiate it from other SMTs. The present study aimed to identify characteristic endoscopic findings of GISTs in the small intestine.

Methods

We reviewed the clinicopathological and endoscopic findings of 38 patients with endoscopically or surgically resected SMTs in the small intestine. SMTs were classified into GIST and non-GIST groups, and clinicopathological and endoscopic findings were compared between the 2 groups.

Results

Fifteen patients had GIST and 23 patients had other types of SMTs in the small intestine. Comparison of the endoscopic findings between the 2 groups revealed that dilated vessels in the surrounding mucosa were significantly more in number in the GIST group than in the non-GIST group (P<0.05). However, there were no other differences in endoscopic findings between the 2 groups. Among patients with GISTs, the presence of dilated vessels in the surrounding mucosa was not associated with bleeding risk, tumor size, or metastasis rate at diagnosis.

Conclusions

Dilated vessels in the surrounding mucosa, identified during balloon-assisted endoscopy, may be a diagnostic indicator for GIST in the small intestine. However, its clinical significance should be further analyzed.

Device-assisted enteroscopy: A review of available techniques and upcoming new technologies

The advent of video capsule endoscopy into clinical routine more than 15 years ago led to a substantial change in the diagnostic approach to patients with suspected small bowel diseases, often indicating a deep enteroscopy procedure for diagnostical confirmation or endoscopic treatment. Device assisted enteroscopy was developed in 2001 and for the first time established a practicable, safe and effective method for evaluation of the small bowel. Currently with double-balloon enteroscopy, single-balloon enteroscopy and spiral enteroscopy three different platforms are available in clinical routine. Summarizing, double-balloon enteroscopy seems to offer the deepest insertion depth to the small bowel going hand in hand with the disadvantage of a longer procedural duration. Manual spiral enteroscopy seems to be a faster procedure but without reaching the depth of the DBE in currently available data. Finally, single-balloon enteroscopy seems to be the least complicated procedure to perform. Despite substantial improvements in the field of direct enteroscopy, even nowadays deep endoscopic access to the small bowel with all available methods is still a complex procedure, cumbersome and time-consuming and requires high endoscopic skills. This review will give an overview of the currently available techniques and will further discuss the role of the upcoming new technology of the motorized spiral enteroscopy (PowerSpiral).

Milk Fermented with Lactobacillus fermentum Ameliorates Indomethacin-Induced Intestinal Inflammation: An Exploratory Study

The aim of this study was to evaluate the effect of milk fermented with Lactobacillus fermentum J20 (FMJ20) or J28 (FMJ28) on ameliorating indomethacin-induced inflammation. Twenty-eight male C57Bl/6 mice were divided into four experimental groups: indomethacin, indomethacin + FMJ20, indomethacin + FMJ28, and untreated (control). Groups were fed fermented milk for 15 days, followed by administration of indomethacin supplied in three sub-doses over experimental period. Body weight, and food consumption were recorded. Additionally, spleen, kidney, and liver were weighed, and the small intestine length was measured. The cytokines in serum (IL-2, IL-4, IL-6, IL-10, IL-17, IL-23 and TNFα) and in intestinal mucosa (IL-17 and IFNγ) were also determined. Compared to the control, all indomethacin-supplemented groups lost weight (~2.7 g; p < 0.05), but no changes were found in the organ-specific morphometry analysis. FMJ28 showed better results in attenuating serum and intestinal IL-17 levels. Furthermore, showed less epithelial cell loss and inflammatory infiltrates than the other indomethacin-treated groups. These results suggest that FMJ28 may be effective in reducing intestinal and systemic acute inflammation, specifically in mice.

Capsule Endoscopy and Small Bowel Enteroscopy: Have They Rendered the Radiologist Obsolete?

Capsule endoscopy (CE) provides visualization of small bowel mucosa for evidence of inflammation. Given its ability to detect subtle mucosal changes, CE is recommended in the diagnostic work-up of small bowel Crohn disease (CD) and also in monitoring mucosal response to therapy in nonstricturing CD. Patency capsule and cross-sectional imaging can reduce risk of capsule retention in patients with suspected stenotic disease. CE is complementary to magnetic resonance enterography, which can provide extraintestinal information. Device-assisted enteroscopy has limited role in CD.

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.

Recurrent intestinal inflammation with a perianal abscess is not always Crohn's disease: a patient with a complex Meckel's diverticulum diagnosed by double-balloon endoscopy

Recurrent intestinal inflammation and refractory perianal abscesses are typical manifestations of Crohn's disease. However, these conditions are not always due to Crohn's disease. A 25-year-old male with recurrent perianal abscesses for 1 year, suspected to be due to Crohn's disease, was referred for further evaluation. Computed tomography scan showed a perianal abscess abutting the small intestine. A complicated Meckel's diverticulum was suspected based on these findings. Meckel's diverticulum scintigraphy was negative. Bidirectional double-balloon endoscopy (DBE) identified a long diverticulum in the ileum. In this long diverticulum, a tight stricture was seen 5 cm distal to the diverticular opening. A selective contrast study showed a 10 cm diverticulum distal to the stricture, with three strictures in the long diverticulum. Inflammation of the Meckel's diverticulum due to bacterial overgrowth was suspected as a cause of the refractory perianal abscesses. Laparoscopic diverticulectomy was performed, and the specimen showed a 10 cm diverticulum containing post-inflammatory changes with scar formation. The perianal abscess was confirmed to be caused by an inflamed Meckel's diverticulum. The patient has been asymptomatic for 6 years after resection. DBE before exploratory laparotomy should be considered to investigate the cause of an abscess that could be secondary to small intestinal pathology.

Experience with Balloon Dilatation in Crohn's and Non-Crohn's Benign Small-Bowel Strictures: Is There a Difference?

Background/Aim

Endoscopic balloon dilation (EBD) has been effective for small-bowel strictures in patients with Crohn's disease (CD). However, its efficacy and indication for small-bowel strictures in non-CD patients have not been established. This study evaluated the clinical efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients.

Methods

Ninety-eight consecutive patients (mean age, 53 years; average observation period, 45 months) with small-bowel strictures diagnosed by double-balloon endoscopy were retrospectively evaluated at Hiroshima University Hospital from August 2003 to April 2017. The average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups were examined.

Results

Surgery was selected as the initial treatment in 44 cases (45%) (non-CD group, 27 (61%); CD group, 17 (39%)) as EBD is not indicated. Fourteen non-CD patients had strictures due to malignant tumors, while 13 patients had benign strictures. Twenty-three patients (non-CD, 12; CD, 11) underwent EBD. Forty-three EBD procedures were performed for 17 stricture sites (average: 2.5 procedures/site) in non-CD patients and 41 EBD procedures for 18 stricture sites (average: 2.3 procedures/site) in CD patients. The short-term success rate was 100% (23/23), whereas the long-term success rate was 92% (11/12) in non-CD patients and 82% (9/11) in CD patients. No significant differences in the surgery-free rate occurred between both groups. Furthermore, one adverse event, bleeding after EBD, was encountered in the non-CD group (8%, 1/12).

Conclusion

EBD for small-bowel strictures demonstrated good clinical outcomes in non-CD patients.

Small Bowel Gastrointestinal Bleeding Diagnosis and Management-A Narrative Review

Background: Small bowel bleeding accounts for 5-10% of all gastrointestinal bleeding. Despite advances in imaging, endoscopy and minimally invasive therapeutic techniques, its diagnosis and treatment remains a challenge and a standardized algorithm for approaching suspected small bowel bleeding remains elusive. Furthermore, the choice of investigation is subject to timing of presentation and accessibility to investigations. The aim of this study was to construct a narrative review of recent literature surrounding the diagnosis and management of small bowel bleeding. Methods: A literature review was conducted examining the database pubmed with the following key words and Boolean operators: occult GI bleed OR mesenteric bleed OR gastrointestinal hemorrhage OR GI hemorrhage AND management. Articles were selected and reviewed based on relevance to the research topic. Where necessary, the full text was sought to further assess relevance. Results: In overt GI bleeding, CT angiography and red cell scintigraphy are both feasible and reliable diagnostic imaging modalities if standard endoscopy is negative. Red cell scintigraphy may be advantageous through detection of lower bleeding rates but it is subject to availability. Overt bleeding and a positive CT angiogram or red cell scan improves the diagnostic yield of formal angiography ± embolization. Video capsule endoscopy or double balloon endoscopy can be considered in occult GI bleeding following normal upper and lower endoscopy. Conclusions: Small bowel bleeding remains a rare but significant diagnostic and therapeutic challenge. Technological advances in diagnostics have aided evaluation but have not broadened the range of therapeutic interventions.

The Clinical Usefulness of the PillCam Progress Indicator for Route Selection in Double Balloon Endoscopy

Objective The utility of capsule endoscopy (CE) findings in the route selection for double balloon endoscopy (DBE) has not been adequately discussed. The PillCam Progress Indicator in the RAPID 6.5 software program graphically demonstrates the progress of the capsule endoscope through the small-bowel. This study aimed to clarify the usefulness of the PillCam Progress Indicator in choosing the initial DBE route. Methods We retrospectively examined 50 consecutive patients with 50 target lesions detected on both CE and DBE at Hiroshima University Hospital from January 2011 to February 2018. In this study, we selected antegrade DBE on the basis of % Capsule Progress <50% as a clinical trial. The association between the PillCam Progress Indicator data and the DBE route to the target lesion was analyzed. Results The target lesion was reached via the initial DBE route in 96% (48/50) of cases. The cutoff values for selecting an antegrade route for DBE were 50% for % Capsule Progress and 42% for % SB Time. At the cutoff value, the sensitivity, specificity, and positive and negative predictive values for route selection were 100%, 91%, 93%, and 100% for % Capsule Progress and 96%, 91%, 93%, and 95% for % SB Time. Conclusion The PillCam Progress Indicator was useful for determining the appropriate initial DBE route.

Distinction between Chronic Enteropathy Associated with the SLCO2A1 Gene and Crohn's Disease

Background/Aims

We recently identified recessive mutations in the solute carrier organic anion transporter family member 2A1 gene (SLCO2A1) as causative variants of chronic nonspecific multiple ulcers of the small intestine (chronic enteropathy associated with SLCO2A1, CEAS). The aim of this study was to investigate the gastroduodenal expression of the SLCO2A1 protein in patients with CEAS and Crohn’s disease (CD).

Methods

Immunohistochemical staining for SLCO2A1 was performed with a polyclonal antibody, HPA013742, on gastroduodenal tissues obtained by endoscopic biopsy from four patients with CEAS and 29 patients with CD.

Results

The expression of SLCO2A1 was observed in one of four patients (25%) with CEAS and in all 29 patients (100%) with CD (p<0.001). The three patients with CEAS without SLCO2A1 expression had a homozygous splice-site mutation in SLCO2A1, c.1461+1G>C (exon 7) or c.940+1G>A (exon 10). The remaining one CEAS patient with positive expression of SLCO2A1 had compound heterozygous c.664G>A and c.1807C>T mutations.

Conclusions

Immunohistochemical staining for SLCO2A1 in gastroduodenal tissues obtained by endoscopic biopsy is considered useful for the distinction of CEAS from CD.

Endoscopic Management of Acute Biliopancreatic Disorders

PURPOSE

Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders.

METHODS

Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders.

RESULTS

Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders.

DISCUSSION

Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.

The role of small bowel endoscopy for Crohn's disease

PURPOSE OF REVIEW

The review discusses the roles of small bowel capsule endoscopy and deep enteroscopy in patients with Crohn's disease. It highlights recent advances in the field and identifies areas where evidence is lacking.

RECENT FINDINGS

Small bowel capsule endoscopy has an important role in the follow-up of patients with Crohn's disease after escalation of therapy and in the postoperative assessment period following surgical resection. Device-assisted enteroscopy offers the therapeutic advantage of small bowel dilatation, which may result in a reduction in the number of surgical resections required, thus avoiding long-term complications, such as short bowel syndrome and malabsorption.

SUMMARY

Capsule endoscopy has an established role in the diagnosis and management of small bowel Crohn's disease. It is used in the setting of suspected Crohn's disease when ileocolonoscopy is negative and for the assessment of extent of small bowel disease in established Crohn's disease. It is relatively well tolerated because of the provision of patency capsule endoscopy to minimize the risk of inadvertent capsule retention. Device-assisted enteroscopy aids with the diagnosis of Crohn's disease as it enables histology to be taken from inflamed areas within the small bowel. Therapeutic procedures can be carried out during device-assisted enteroscopy including dilatation of Crohn's disease-related strictures and retrieval of retained capsules.

Optimal management of the patient presenting with small bowel bleeding

The management of small bowel bleeding, also known as obscure gastrointestinal bleeding, has changed substantially over the past two decades due to revolutionary technological advances in small intestinal endoscopy. This clinical review will summarize the evolving definition of small bowel bleeding, how to perform a detailed initial assessment of patients with the condition, the strengths and limitations of small bowel endoscopy, and the treatment of small bowel bleeding.

Measurement of prostaglandin metabolites is useful in diagnosis of small bowel ulcerations

BACKGROUND

We recently reported on a hereditary enteropathy associated with a gene encoding a prostaglandin transporter and referred to as chronic enteropathy associated with SLCO2A1 gene (CEAS). Crohn's disease (CD) is a major differential diagnosis of CEAS, because these diseases share some clinical features. Therefore, there is a need to develop a convenient screening test to distinguish CEAS from CD.

AIM

To examine whether prostaglandin E major urinary metabolites (PGE-MUM) can serve as a biomarker to distinguish CEAS from CD.

METHODS

This was a transactional study of 20 patients with CEAS and 98 patients with CD. CEAS was diagnosed by the confirmation of homozygous or compound heterozygous mutation of SLCO2A1. We measured the concentration of PGE-MUM in spot urine by radioimmunoassay, and the concentration was compared between the two groups of patients. We also determined the optimal cut-off value of PGE-MUM to distinguish CEAS from CD by receiver operating characteristic (ROC) curve analysis.

RESULTS

Twenty Japanese patients with CEAS and 98 patients with CD were enrolled. PGE-MUM concentration in patients with CEAS was significantly higher than that in patients with CD (median 102.7 vs 27.9 μg/g × Cre, P < 0.0001). One log unit increase in PGE-MUM contributed to 7.3 increase in the likelihood for the diagnosis of CEAS [95% confidence interval (CI) 3.2-16.7]. A logistic regression analysis revealed that the association was significant even after adjusting confounding factors (adjusted odds ratio 29.6, 95%CI 4.7-185.7). ROC curve analysis revealed the optimal PGE-MUM cut-off value for the distinction of CEAS from CD to be 48.9 μg/g × Cre with 95.0% sensitivity and 79.6% specificity.

CONCLUSION

PGE-MUM measurement is a convenient, non-invasive and useful test for the distinction of CEAS from CD.

Case report of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE): a rare disease may contribute to endoscopy-capsule retention in the small intestine

Background

CMUSE is a rare disease whose diagnosis remains difficult because the lesion is confined to the small bowel.

Case presentation

Here, we present a case of 43-year-old female patient suffered chronic abdominal pain for 20 years, and finally diagnosed with CMUSE. Capsule endoscopy was performed when general endoscopic investigation failed to find the lesion, but the capsule was stranded in the small intestine. Moreover, capsule retention results in acute intestinal obstruction. Thus, surgery was performed and CMUSE was confirmed. The patient was recovered after partial small intestine resection.

Conclusions

Capsule retention occurred in nearly 60% of patients with CMUSE. Capsule endoscopy should be avoided when the patient is suspected of CMUSE, especially with severe anemia and radiologic finding in the ileum.

Clinical Safety and Utility of Pediatric Balloon-assisted Enteroscopy: A Multicenter Prospective Study in Japan

OBJECTIVES

The benefit of balloon-assisted enteroscopy (BAE) had been recently documented in pediatric patients, but previous reports are based on single institution experiences. We evaluated the feasibility of pediatric BAE in 8 tertiary referral hospitals throughout Japan.

METHODS

This was a prospective, multi-institutional study. Patients younger than 18 years were enrolled between April 2014 and March 2017 to undergo double-balloon or single-balloon enteroscopy. Data were collected prospectively using a standardized questionnaire.

RESULTS

We enrolled 79 pediatric patients (96 procedures, 70 boys, 26 girls; median age 12.7 years, range 1-17 years). Antegrade (oral-route) BAE was performed in 20 procedures (lowest body weight 12.9 kg, youngest age 3.7 years), and retrograde (anal-route) BAE in 76 (lowest body weight 10.8 kg, youngest age 1.6 years). Severe adverse events were associated with BAE in 2 patients: 1 with hemorrhage due to polypectomy and 1 with pancreatitis after double-balloon endoscopic retrograde cholangioscopy. No intestinal perforation was reported. Procedure duration of oral-route BAE for diagnosis was significantly longer than anal-route for diagnosis (P < 0.001). The overall diagnostic yield for rectal bleeding/positive fecal occult blood test and abdominal pain was 48%. Among 40 patients referred for diagnosis who did not undergo capsule endoscopy, diagnoses were confirmed in 17 (42.5%) patients after BAE.

CONCLUSIONS

This prospective multicenter observational study documents the efficacy of BAE in pediatric patients.

Capsule Endoscopy and Enteroscopy in Celiac Disease

Celiac disease predominantly involves the proximal small bowel, but villus atrophy can be patchy, spare the duodenum, and be present more distally. Video capsule endoscopy is more sensitive than standard endoscopy to detect villus atrophy, and can define extent of disease, though it cannot obtain biopsies. Duodenal biopsy is the gold standard for diagnosis. Video capsule endoscopy assists in special circumstances when biopsy is not possible, and in equivocal diagnosis. Video capsule endoscopy and enteroscopy are recommended for evaluating complicated celiac disease, especially refractory celiac disease type II. Future developments include computer-assisted capsule programs and advanced capsule and enteroscope design.

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.

Double-balloon enteroscopy for pediatric patients: Application and feasibility evaluation in a medical center in northern Taiwan

BACKGROUND/PURPOSE

The diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) in adults are established, but few data are available on pediatric patients. The aim of this study was to evaluate the clinical efficacy and safety of DBE in pediatric patients in Taiwan.

METHODS

From April 2005 to September 2015, DBE procedures performed for diagnosis or therapy of small-bowel disease in children less than 18 years of age at Linkou Chang Gung Memorial Hospital, Taiwan were evaluated. The clinical decision to perform DBE via the oral or anal approach was based on the patient's primary clinical presentation. Data on indications, endoscopic findings, treatment outcome, and complications associated with the procedure were collected and reviewed retrospectively.

RESULT

In total, 20 pediatric patients underwent a total of 29 DBEs due to suspicion of small-bowel disease. Among them, nine patients were evaluated for suspected small-bowel bleeding, six for Peutz-Jeghers syndrome, two for chronic abdominal pain, two for chronic diarrhea, and one for suspected protein-losing enteropathy. After excluding the six Peutz-Jeghers syndrome patients, 9 of the 14 patients (64%) got a positive endoscopic finding and diagnosis in 8 of the 14 patients (57%). DBE resulted in a further therapeutic intervention (endoscopic or surgical) in 50% of the patients (10/20) without serious complications.

CONCLUSION

DBE has a high diagnostic yield and leads to therapeutic interventions in pediatric patients and shows promise for assessment and treating small-intestinal diseases in children in Taiwan.

Usefulness of the "newly designed" short-type single-balloon enteroscope for ERCP in patients with Roux-en-Y gastrectomy: a pilot study

Background and aims  In recent years, the short single-balloon enteroscope (SBE) has been used during endoscopic retrograde cholangiopancreatography (ERCP) for patients with surgically altered anatomy and has been reported to be useful. However, difficulties remain, and the procedures and devices need improvements. We assessed the usefulness and superiority of a new short SBE equipped with passive bending and high-force transmission by comparisons with outcomes using the conventional short SBE. Methods  This study evaluated short SBE-assisted ERCP-related procedures for Roux-en-Y gastrectomy between September 2011 and October 2017. Outcomes including the procedural success rate, which was the primary outcome, were assessed to compare the conventional short SBE (SIF-Y0004 [prototype]) and the new short SBE (SIF-H290S). Results  Of 74 procedures performed in 61 patients, 51 procedures in 39 patients involved the SIF-Y0004, and 23 procedures in 22 patients involved the SIF-H290S. The procedural success rates were 70.6 % for SIF-Y0004, and 95.7 % for SIF-H290S, representing better results for the new short SBE ( P  = 0.02). The new short SBE also had a superior diagnostic success rate ( P  = 0.047) and median time to reach the blind end ( P  < 0.001). Conclusions  Roux-en-Y gastrectomy patients treated with the new short SBE had better outcomes than those treated with conventional short SBE. More cases need to be studied; however, the new short SBE has the potential to improve ERCP outcomes in patients with surgically altered anatomy.

False-negative double-balloon enteroscopy in overt small bowel bleeding: long-term follow-up after negative results

BACKGROUND AND AIM

Double-balloon enteroscopy (DBE) performed to investigate overt small bowel bleeding can miss the source of bleeding. We investigated the clinical outcomes of patients with negative DBE results for suspected overt small bowel bleeding, which is defined in the current guidelines as obscure gastrointestinal bleeding.

METHODS

We reviewed the prospectively collected medical records of patients who underwent DBE at our hospital between May 1, 2004 and April 30, 2016. During this period, 297 patients underwent DBE for suspected overt small bowel bleeding. The first DBE yielded negative results for 83 patients (27.9%). Written interviews, telephone interviews, and medical records of these patients were reviewed in April 2017. Follow-up data were collected for 63 patients (75.9%).

RESULTS

During a mean follow-up period of 83.5 months, re-bleeding occurred in 21 of 63 patients (33.3%) after a mean of 23.0 months after the first DBE yielded negative results. The bleeding source was identified in 19 of 21 patients (90.5%). In 15 of these 19 patients (78.9%), the source was the small intestine. Among these 15 patients, 14 (93.3%) had bleeding sites within reach of the first DBE and 3 (20%) experienced their first incidence of re-bleeding more than 3 years after the first DBE. The need for transfusion for the first bleeding episode was a predictor of re-bleeding (odds ratio 7.5; 95% confidence interval 1.7-33.0).

CONCLUSIONS

False-negative DBE results for overt small bowel bleeding are not rare, and the first re-bleeding episode can occur 3 years later. Repeat DBE when re-bleeding occurs should be considered, even if the first DBE results were negative.

Evolving techniques for endoscopic retrograde cholangiopancreatography in gastric bypass patients

PURPOSE OF REVIEW

The present review describes the current and evolving techniques available in approaching endoscopic retrograde cholangiopancreatography (ERCP) for patients with Roux-en-Y gastric bypass (RYGB) anatomy.

RECENT FINDINGS

Recent studies have demonstrated that device-assisted enteroscopy (DAE) approaches have high failures rates when performing ERCP, but are currently considered the first-line approach for patients with RYGB anatomy because of lower costs and risks compared to surgery. In contrast, laparoscopicy-assisted-ERCP (LA-ERCP) exhibits high technical success rates but carries surgical risks and requires a high degree of scheduling coordination. A novel, completely endoscopic approach called endoscopic ultrasound directed transgastric ERCP (EDGE), also known as gastric access temporary for endoscopy (GATE), has in recent years shown high ERCP success rates comparable to LA-ERCPs while obviating the need for surgical assistance.

SUMMARY

ERCP is technically difficult in patients with RYGB anatomy. Numerous approaches to ERCP exist, although availability of these techniques may be limited and depend on institutional expertise. The best initial approach should be considered based on patient history and institutional factors.

Endoworm: A new semi-autonomous enteroscopy device

Using enteroscopes with therapeutic capacity to explore the small intestine entails certain limitations, including long exploration times, patient discomfort, the need for sedation, a high percentage of incomplete explorations and a long learning curve. This article describes the advances and setbacks encountered in designing the new Endoworm enteroscopy system, a semi-autonomous device consisting of a control unit and three cavities that inflate and deflate in such a way that the bowel retracts over the endoscope. The system can be adapted to any commercial enteroscope. Endoworm was tested in different intestine models: a polymethyl methacrylate rigid tube, an in vitro polyester urethane model, an ex vivo pig model and an in vivo animal model. The general behavior of the prototype was evaluated by experienced medical personnel. The mean distance covered through the lumen was measured in each cycle. The system was found to have excellent performance in the rigid tube and in the in vitro model. The ex vivo tests showed that the behavior depended largely on the mechanical properties of the lumen, while the in vivo experiments suggest that the device will require further modifications to improve its performance.