Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial

Guidelines for endoscopic diagnosis and treatment of inflammatory bowel diseases

In recent years, we have seen a considerable increase in the number of patients with inflammatory bowel diseases of unknown etiology, including both Crohn's disease and ulcerative colitis. Inflammatory bowel diseases can cause intestinal lesions throughout the gastrointestinal tract, necessitating gastrointestinal endoscopy for examining all relevant aspects, especially lesion characteristics, for differential diagnosis and histological diagnosis, to select the appropriate treatment options, determine treatment effectiveness, etc. Specific guidelines are necessary to ensure that endoscopy can be performed in a safe and more tailored and efficient manner, especially since gastrointestinal endoscopy, including enteroscopy, is a common procedure worldwide, including in Japan. Within this context, the Japan Gastroenterological Endoscopy Society has formulated the "Guidelines for the Endoscopic Diagnosis and Treatment of Inflammatory Bowel Diseases" to provide detailed guidelines regarding esophagogastroduodenoscopy, enteroscopy, and colonoscopy procedures for definitive diagnosis, as well as determination of treatment effectiveness in clinical cases of inflammatory bowel diseases.

Viscosity Characteristics of Ideal Lubricants to Reduce Stress on Intestinal Mucosa During Balloon-Assisted Enteroscopy

Balloon-assisted enteroscopy (BAE) is highly invasive and carries a higher risk of complications such as pain and perforation during enteroscope insertion. Applying lubricants to the small intestinal mucosa and reducing the dynamic friction coefficient (DFC) between the small intestinal mucosa and endoscopic shaft (ES) (or overtube (OT)) can minimize the invasiveness of BAE. However, the ideal viscosity characteristics of these lubricants remain unknown. In this study, a model is developed to measure the DFC using human small intestines from forensic autopsies and determine the ideal viscosity of low-friction lubricants that exhibit a minimal DFC, thus reducing the pressure on the intestinal lining during the procedure. The results reveal that the DFC is strongly correlated to the lubricant's viscosity rather than its chemical composition. Low-friction lubricants with viscosities within 0.20-0.32 and 0.35-0.58 Pa·s (at shear rates of 10 s-1) for the OT and ES, respectively, can significantly reduce the DFC, yielding optimal results. These findings highlight the role of viscosity in minimizing the friction between the equipment and small intestinal mucosa. The ideal low-friction lubricants satisfying the aforementioned viscosity ranges can minimize the invasiveness of BAE by decreasing the friction between the equipment and intestinal lining.

Single-operator single-balloon enteroscopy is safe and effective: A 6-year retrospective study

OBJECTIVES

Single-balloon enteroscopy (SBE) is an effective tool for the detection of small intestine lesions. Because it is conventionally performed by two operators, the efficacy of single-operator SBE method has not yet been elucidated. We aimed to evaluate the diagnostic yield, total enteroscopy rate, procedure time, and complications of single-operator SBE for small intestinal disease.

METHODS

This was a single-center, retrospective study including consecutive patients who underwent single-operator SBE for suspicious small intestinal disorders or required therapeutic interventions between December 2014 and January 2019. The SBE procedures were performed by four endoscopists. Diagnostic yield, total enteroscopy rate, procedure time, incubation depth, and complications were analyzed, and stratification analysis was performed.

RESULTS

Altogether 922 patients with 1422 SBE procedures were included for analysis, among whom 250, 172, and 500 patients underwent SBE via the oral route, the anal route and a combined route, respectively. The overall diagnostic yield was 78.52% (724/922). And 253 patients achieved total enteroscopy, with a total enteroscopy rate of 56.10%. The average procedure time for the oral and anal routes were 69.28 ± 14.72 min and 64.95 ± 13.87 min, respectively. While the incubation depth was 389.95 ± 131.42 cm and 191.81 ± 83.67 cm, respectively. Jejunal perforation was observed in one patient, which was managed by endoclips. Stratification analysis showed that the diagnostic yield and total enteroscopy rate significantly increased with operation experience together with decreased procedure time.

CONCLUSION

Single-operator SBE is effective and safe for the detection of small intestinal lesions, and is easy to master.

Video capsule endoscopy in overt and occult obscure gastrointestinal bleeding: Insights from a single-center, observational study in Japan

OBJECTIVE

This study aimed to evaluate the use of video capsule endoscopy (VCE) in patients with obscure gastrointestinal bleeding (OGIB), compare cases of overt and occult OGIB, assess the rates of balloon-assisted enteroscopy (BAE) interventions and rebleeding, and identify predictive markers of positive VCE findings.

METHODS

Medical records of 430 patients who underwent VCE for OGIB between 2004 and 2022 were analyzed. Occult OGIB was defined as IDA or positive fecal occult blood, whereas overt OGIB was defined as clinically imperceptible bleeding. We retrospectively analyzed demographics, VCE findings based on Saurin classification (P0, P1, and P2), outcome of BAE interventions, and rebleeding rates.

RESULTS

A total of 253 patients with overt OGIB and 177 with occult OGIB were included. P1 findings were predominant in both groups, with a similar distribution. The percentage of patients receiving conservative therapy was higher in P1 than in P2 for both overt and occult OGIB. BAE was more frequently performed in P2 than in P1 VCE (83.0% vs. 35.3% in overt OGIB, 84.4% vs. 24.4% in occult OGIB). The percentage of positive findings and intervention in total BAE performed patients were comparable in P1 and P2 of overt OGIB, whereas these percentages in P2 were more than P1 of occult OGIB.

CONCLUSION

VCE effectively identified OGIB lesions requiring intervention, particularly occult OGIB lesions, potentially reducing unnecessary BAE. Rebleeding rates varied according to the VCE findings, emphasizing the importance of follow-up in high-risk patients.

Role of Novel Motorized Enteroscopy in the Evaluation of Small Bowel Diseases: A Systematic Review and Meta-analysis

BACKGROUND AND AIM

Motorized spiral enteroscopy (MSE) has recently been introduced for small bowel evaluation. In this systematic review and meta-analysis, we aim to evaluate the safety and efficacy of MSE for evaluation of small bowel diseases.

METHODS

A literature search was performed in Embase, PubMed, Medline databases for studies evaluating MSE between January -2010 and October-2022. The primary outcome of the study was diagnostic yield with MSE. Secondary outcomes included technical success, procedure duration, depth of maximum insertion (DMI), rate of pan-enteroscopy and adverse events.

RESULTS

10 studies with 961 patients [581 (60.5%) males] were included in the analysis. 1068 MSE procedures were performed by antegrade route in 698, retrograde route in 215 and bidirectional in 155 patients. Technical success was achieved in 94.9% (95% CI 92.9% to 96.4%) procedures. The pooled diagnostic yield of MSE was 73.7% (95% CI 70.7% to 76.4%). Pooled rate of pan-enteroscopy by antegrade route was 21.9% (95% CI 18.1% to 26.1%), retrograde route was 6.9% (95% CI 2.4% to 18.3%) and combined route was 61.2% (95% CI 52.4% to 69.3%). Pooled rate of major adverse events was 1.9% (95% CI 1.2% to 3.2%).

CONCLUSIONS

MSE is a safe and effective tool for evaluating small bowel disorders. High diagnostic yield and low rate of adverse events make it a potential alternative to balloon enteroscopy. However, comparative trials are required in the future.

Stricture dilation via balloon-assisted endoscopy in Crohn's disease: approach and intraprocedural outcomes with the single-balloon and double-balloon systems

Background

Despite recent emerging literature involving the utility of endoscopic balloon dilation (EBD) of strictures via balloon-assisted endoscopy (BAE), specifically regarding the management of Crohn's disease (CD), the optimal clinical approach with balloon systems has been largely neglected in academic literature.

Objectives

This study assesses the intra-procedural success and safety of EBD via BAE for small bowel CD strictures while detailing our clinical approach and technique. Secondarily, we compare the single-balloon endoscope (SBE) and double-balloon endoscope (DBE) systems for EBD-related outcomes.

Design

Retrospective consecutive patient cohort analysis.

Methods

We retrospectively assessed a consecutive small bowel CD patient cohort undergoing BAE at the University of Alberta Hospital endoscopy unit from 2013 to 2020. The primary endpoint discerned the safety and immediate success rate of EBD during endoscopy, and comparisons of the dilation parameters and efficacy of SBE versus DBE were assessed as secondary outcomes.

Results

During the study period, 87 patients (44 male) with a mean age of 56 ± 14.7 years underwent 179 endoscopic procedures (92 DBE and 87 SBE). Of 358 strictures encountered, 320 (89.4%) were successfully dilated and traversed. The mean maximum dilation diameter was 15.76 ± 2.10 mm. There were no perforations or major adverse events.

Conclusion

EBD via BAE is a safe procedure in small bowel CD with a high intraprocedural success rate. Overall, SBE had a higher success rate in traversing strictures before and after dilation using our technique. This analysis is limited by the retrospective nature of our study and must be balanced against the inherent benefits of the DBE system.

Small Bowel Capsule Endoscopy and Enteroscopy: A Shoulder-to-Shoulder Race

Traditional methods have their limitations when it comes to unraveling the mysteries of the small bowel, an area historically seen as the "black box" of the gastrointestinal tract. This is where capsule endoscopy and enteroscopy have stepped in, offering a remarkable synergy that transcends the sum of their individual capabilities. From their introduction, small bowel capsule endoscopy and device-assisted enteroscopy have consistently evolved and improved, both on their own and interdependently. Each technique's history may be told as a success story, and their interaction has revolutionized the approach to the small bowel. Both have advantages that could be ideally combined into a perfect technique: safe, non-invasive, and capable of examining the entire small bowel, taking biopsies, and applying therapeutical interventions. Until the realization of this perfect tool becomes a reality, the key for an optimal approach lies in the right selection of exploration method. In this article, we embark on a journey through the intertwined development of capsule endoscopy and enteroscopy, exploring the origins, technological advancements, clinical applications, and evolving inquiries that have continually reshaped the landscape of small bowel imaging.

Effect of Abdominal Compression on Total Single-Balloon Enteroscopy Rate: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether abdominal compression significantly increased the total enteroscopy rate in single-balloon enteroscopy (SBE).

METHODS

Consecutive patients who underwent SBE at 2 hospitals were prospectively included between June 1, 2020, and September 30, 2021. They were randomly divided into an abdominal compression group and a non-abdominal compression group with use of sealed envelopes generated by a computer. Total enteroscopy rates were compared between the groups.

RESULTS

The study included 200 patients. The total enteroscopy rates were 73% and 16% in the abdominal compression and non-abdominal compression groups, respectively (relative risk, 13.55; 95% CI, 6.79 to 27.00; P<.001). The total enteroscopy rate was higher in the 70 patients who were identified to have undergone no previous abdominal surgery or small intestinal stenosis than in the 32 patients who had undergone such procedures in the abdominal compression group (84% vs 47%; relative risk, 6.08; 95% CI, 2.36 to 15.67; P<.001). Relevant positive findings were not significantly different between the groups (58% vs 45%; P=.07). Binary logistic regression analysis found abdominal compression to be associated with a better total enteroscopy rate (odds ratio, 16.68; 95% CI, 7.92 to 35.15; P<.001), and the presence of previous abdominal surgery or small intestinal stenosis was associated with difficulty in completing the total enteroscopy procedure (odds ratio, 0.26; 95% CI, 0.12 to 0.58; P<.01).

CONCLUSION

Abdominal compression significantly increased the total enteroscopy rate in SBE. Complete total enteroscopy may be challenging in patients with a history of abdominal surgery or small intestinal stenosis.

Effectiveness and safety of novel motorized spiral enteroscopy: a systematic review and meta-analysis

BACKGROUND

Motorized spiral enteroscopy (MSE) is a novel advance in small bowel examination that is characterized as fast with a deep insertion. The aim of this study was to elucidate the effectiveness and safety of MSE.

METHODS

Relevant articles that were published before November 1, 2022 were identified by searching PubMed, EMBASE, Cochrane, and the Web of Science. The technical success rate (TSR), total (pan)-enteroscopy rate (TER), depth of maximum insertion (DMI), diagnostic yield, and adverse events were extracted and analyzed. Forest plots were graphed based on random effects models.

RESULTS

A total of 876 patients from 8 studies were eligible for analysis. The pooled results of the TSR were 95.0% [95% confidence interval (CI) 91.0-98.0%, I2 = 78%, p < 0.01] and the pooled outcome of the TER was 43.1% (95% CI 24.7-62.5%, I2 = 95%, p < 0.01). The pooled results of the diagnostic and therapeutic yields were 77.2% (95% CI 69.0-84.5%, I2 = 84%, p < 0.01) and 49.0% (95% CI 38.0-60.1%, I2 = 89%, p < 0.01), respectively. The pooled estimates of adverse and severe adverse events were 17.2% (95% CI 11.9-23.2%, I2 = 75%, p < 0.01) and 0.7% (95% CI 0.0-2.1%, I2 = 37%, p = 0.13), respectively.

CONCLUSION

MSE is a novel alternative approach for small bowel examination that can achieve high TER and diagnostic and therapeutic yields, and relatively low rates of severe adverse events. Head-to-head studies comparing MSE and other device-assisted enteroscopies are warranted.

The effect of butylscopolamine on [18F]FDG uptake in the gastrointestinal tract is negligible and regionally variable

BACKGROUND

Butylscopolamine (or hyoscine butylbromide, trade name Buscopan^®) is occasionally administered as a premedication to reduce non-specific FDG uptake in the gastrointestinal tract based on its antiperistaltic effect. To date, there are no consistent recommendations for its use. The aim of this study was to quantify the reduction in intestinal and non-intestinal uptake by butylscopolamine administration and to derive relevance for clinical evaluation.

RESULTS

458 patients (PET/CT for lung cancer) were retrospectively reviewed. 218 patients with butylscopolamine and 240 patients without butylscopolamine had comparable characteristics. While the SUV_mean in the gullet/stomach and small intestine was significantly reduced with butylscopolamine, the colon and rectum/anus showed no difference. The liver and salivary glands showed a reduced SUV_mean, while skeletal muscle and blood pool were unaffected. An effect of butylscopolamine was particularly evident in men and patients under 65 years of age. There was no difference in the perceived confidence in the assessment of intestinal findings in the subjective evaluation, although in the butylscopolamine group further diagnostics appeared advisable more frequently.

CONCLUSIONS

Butylscopolamine reduces gastrointestinal FDG accumulation only in selected segments and, despite a significant effect, only to a small extent. A general recommendation for the use of butylscopolamine cannot be derived from these results, its use for specific issues could be considered individually.

Efficacy and safety of double- versus single-balloon retrograde enteroscopy

INTRODUCTION

Data on the safety and efficacy of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE) are conflicting. We aimed to compare the efficacy and safety of retrograde DBE to SBE.

METHODS

We performed a retrospective analysis of all patients who underwent retrograde DBE or SBE at a large tertiary referral center from 2008 to December 2018. Outcomes assessed included technical success, diagnostic yield, therapeutics, depth of insertion, and procedural duration.

RESULTS

A total of 523 (403 DBE, 120 SBE) patients underwent retrograde enteroscopy during the study period. The mean age was 59.4 ± 17.24 and 59.57 ± 16.94 years in DBE and SBE groups, respectively. There was no difference in technical success (91.0% vs. 92.5%, P = 0.85), diagnostic yield (40.9% vs. 40.8%, P = 0.95), and therapeutics (17.1% vs. 19.1%, P = 0.61) between DBE and SBE. Compared to SBE, DBE had significantly shorter mean procedure time (26.5 ± 34.5 min vs. 34.8 ± 29.4 min, P = 0.01) and higher maximal depth of insertion from ileocecal valve (108.1 ± 84.1 cm vs. 73.3 ± 63.4 cm, P = 0.001). Safety events were rare and similar in both groups.

CONCLUSION

Retrograde DBE is associated with a significantly higher depth of insertion and shorter procedural duration, but similar diagnostic yield and technical success compared to SBE.

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.

Epidemiología, diagnóstico y tratamiento de las angiectasias gastrointestinales

Las angiectasias son las malformaciones vasculares mas comunes en el tracto gastrointestinal en la población general. Hasta el momento, la patogénesis de este tipo de malformaciones vasculares no ha esclarecida totalmente. Su incidencia ha venido en aumento debido a la mayor disponibilidad de métodos diagnósticos en gastroenterología, principalmente la videocápsula endoscópica (VCE) y la enteroscopia profunda asistida para el estudio del intestino delgado. La terapia endoscópica es la estrategia de tratamiento inicial más efectiva, sin embargo existen otras alternativas terapéuticas como lo son la terapia farmacológica, la angiografía más embolización selectiva o la resección quirúrgica.

[Use of Device-Assisted Enteroscopy in Small Bowel Disease: An Expert Consensus Statement by the Korean Association for the Study of Intestinal Diseases]

The introduction of device-assisted enteroscopy (DAE) in the beginning of the 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of small bowel diseases, DAE has the unique advantages of allowing the observation of the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how it is to be performed and what technical factors should be taken into consideration. In response to these needs, the Korean Association for the Study of Intestinal Diseases has developed an expert consensus statement on the performance of DAE by reviewing current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Endoscopic characteristics of Meckel's diverticulum in adults: a retrospective case-series from two tertiary general hospitals in China

BACKGROUND

To analyze the diversity in endoscopic manifestations of Meckel's diverticulum (MD) in adults by using balloon-assisted enteroscopy (BAE) and supply more information on the application of BAE.

METHODS

A retrospective study was carried out on adult patients diagnosed with MD by BAE in two tertiary general hospitals in China, from May 2007 to September 2021. The patients were divided into a small bowel bleeding (SBB) group and a control group according to their main symptoms. Clinical charts and endoscopic images were reviewed, analyzed, and summarized.

RESULTS

Single diverticulum in the ileum and double-lumen sign were observed in all patients. The SBB group consisted of 51 patients, among which 35 cases of ulcerative lesions, 9 cases of erosive lesions, 9 cases of active bleeding/blood clots, and 4 cases of lumps inside the diverticulum were observed respectively. Majority of ulcerative lesions were inside the diverticulum (23/35). A circumferential stricture inside the diverticulum was discovered in 11 cases, and ulcerative lesions tended to occur at this structure (10/11). In the control group consisting of 15 patients, 1 case of erosive lesions at the orifice edge was observed. The percentage of patients with MD-associated ulcerative lesions was significantly higher in the SBB group than that in the control group (p < 0.001).

CONCLUSIONS

The endoscopic manifestations of MD in adults are extraordinarily complex and connected with the patients' primary symptoms. The internal features of MD should be regarded as crucial observational objectives in adult patients.

Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases

The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Clinical Features and Management of Small Bowel Masses Detected During Device-Assisted Enteroscopy: A Multi-Center Experience

Background

Small bowel mass lesions (SBMLs) are rare, span a range of different histologies and phenotypes, and our understanding of them is limited. Some lesions occur in patients with recognized polyposis syndromes and others arise sporadically. The current literature regarding SBMLs is limited to small retrospective studies, case reports, and small case series. This large multi-center study aims to understand the various clinical presentations, histologies and management options for SBMLs.

Methods

After obtaining Institutional Review Board (IRB) approval, electronic records were used to identify all device-assisted enteroscopy (DAE) performed for luminal small bowel evaluation in adult patients at three US referral centers (Duke, LSU and UMass) from January 1, 2014, to October 1, 2020. We identified all patients within this cohort in whom a SBML was detected. Using a focused electronic medical record chart review, we collected patient, procedure, and lesion-related data and used descriptive statistics to explore relationships between these data and outcomes.

Results

A total of 218 patients (49 at Duke, 148 at LSU, and 21 at UMass) in this cohort had at least one SBML found on DAE. The most common presenting symptoms were iron-deficiency anemia/bleeding (73.3%) and abnormal imaging (33.6%). Thirty-five percent of patients had symptoms for more than a year prior to their diagnosis. Most patients (71.6%) underwent video capsule endoscopy (VCE) prior to DAE and 84% of these exams showed the lesion. The lesion was seen less frequently (48.9%) on computed tomography (CT) scan performed prior to DAE. The majority of lesions were found on antegrade (56%) or retrograde (29.8%) double-balloon enteroscopy (DBE). The most common lesion phenotypes were submucosal (41.3%) and pedunculated (33%) with a much smaller number being sessile (14.7%) or obstructing/invasive (11%). They were found equally as commonly in the jejunum (46.3%) and ileum (49.5%). Most lesions were 10 - 20 mm in size (47%) but 22.1% were larger than 20 mm. The most common histologies were neuroendocrine tumors (NETs, 20.6%) and hamartomas (20.6%). Primary adenocarcinoma of the small bowel was rare, constituting only 5% of lesions. The majority of polyps (78.4%) were sporadic, compared to 21.7% associated with a polyposis or hereditary cancer syndrome, most commonly Peutz-Jeghers syndrome (18.3%). After DAE, 37.6% were advised to undergo surgical resection and 48% were advised to undergo endoscopic surveillance or no further management because of benign histology or successful endoscopic resection.

Conclusions

In this multi-center retrospective study we found that SBMLs are more likely to be sporadic than syndromic, medium in size and either pedunculated or submucosal. NETs and hamartomas predominated and symptoms, most commonly anemia, can be present for more than a year prior to diagnosis. Close to one half of lesions required either no further intervention or only endoscopic surveillance.

Quality indicators for capsule endoscopy and deep enteroscopy

BACKGROUND AND AIMS

Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method.

METHODS

An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method.

RESULTS

The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE.

CONCLUSIONS

Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

The performance and safety of motorized spiral enteroscopy, including in patients with surgically altered gastrointestinal anatomy: a multicenter prospective study

BACKGROUND

Data are scarce on the efficacy and safety of motorized spiral enteroscopy (MSE). No data are available on the utility of this technique in patients with surgically altered gastrointestinal (GI) anatomy. We aimed to evaluate the safety and efficacy of MSE in patients with suspected small-bowel disease, including those with surgically altered GI anatomy.

METHODS

A multicenter prospective observational, uncontrolled study evaluated MSE in consecutive patients with suspected small-bowel pathology and an indication for diagnostic and/or therapeutic intervention.

RESULTS

A total of 170 patients (102 men; median age 64 years, range 18-89) were included. The overall diagnostic yield was 64.1 %. Endotherapy was performed in 53.5 % of procedures. The median total procedure times for the antegrade and retrograde approaches were 45 minutes (interquartile range [IQR] 30-80) and 40 minutes (IQR 30-70), respectively. When total (pan)enteroscopy was intended, this was achieved at rate of 70.3 % (28.1 % by antegrade approach and 42.2 % by a bidirectional approach). Surgically altered GI anatomy was present in 34 /170 of all procedures (20.0 %) and in 11 /45 of the successful total enteroscopy procedures (24.4 %). Propofol sedation or general anesthesia were used in 92.9 % and 7.1 % of the procedures, respectively. Minor adverse events were observed in 15.9 % of patients, but there were no major adverse events.

CONCLUSION

MSE seems to be an effective and safe endoscopic procedure. Total (pan)enteroscopy can be achieved, in one or two sessions, even in the presence of surgically altered GI anatomy. The total procedure time is relatively short. For both antegrade and retrograde MSE procedures, propofol sedation seems sufficient and safe.

Quality Indicators for Capsule Endoscopy and Deep Enteroscopy

INTRODUCTION

Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method.

METHODS

An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method.

RESULTS

The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE.

DISCUSSION

Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Safety and efficacy of the novel motorized power spiral enteroscopy: A single-center experience

Objective

Evaluation and management of small bowel disorders have always been challenging due to the limitations of the existing technology. Motorized power spiral enteroscopy (PSE) is an innovative new technique that offers easier, faster, and more complete small bowel evaluation with the ability to perform therapeutics. We aimed to evaluate the safety and efficacy of PSE in various indications.

Methods

Retrospective analysis of prospectively collected data of consecutive patients, who underwent PSE at a tertiary care center. Primary outcome measures were technical success rate, pan-enteroscopy rate, diagnostic and therapeutic yield, and the secondary outcomes measures were the depth of maximal insertion, median insertion time, and adverse events.

Results

Fifty-four patients (mean age of 49.38 ± 16.26 years) underwent PSE for small bowel evaluation. Technical success rate was 95.55% (antegrade route) and 93.10% (retrograde route).  Pan-enteroscopy rate is 46.29% and antegrade enteroscopy to the cecum was achieved in eight patients.  Overall diagnostic and therapeutic yields were 85.18% and 30.76%, respectively. The most common findings were ulcero-stricturing lesions (51.92%) followed by vascular lesions (9.61%). The most common histopathologic diagnosis was Crohn's disease in 29.62%. Median depth of maximal insertion was 400 cm (range 150-550 cm; antegrade route) and 180 cm (range 50-350 cm; retrograde route). The median insertion time to depth of maximal insertion was 70 min (range 30-110 min; antegrade route) and 45 min (range 20-70 min; retrograde route).  PSE-associated major adverse events occurred in one patient and minor adverse events were seen in 48.14%.

Conclusion

PSE is a safe and effective modality for the evaluation of small bowel disorders with a high diagnostic yield.

Water exchange-assisted versus carbon dioxide-insufflated single-balloon enteroscopy: a randomized controlled trial

BACKGROUND

Single-balloon enteroscopy (SBE) is a valuable but difficult modality for the diagnosis and treatment of small-bowel disease. The water exchange method has the advantage of facilitating intubation during colonoscopy. Here, we evaluated the effects of water exchange on procedure-related variables related to SBE.

METHODS

This randomized controlled trial was conducted in a tertiary-care referral center in China. Patients due for attempted total enteroscopy were randomly allocated to undergo water exchange-assisted (water exchange group) or carbon dioxide-insufflated enteroscopy (CO2 group). All patients were planned to undergo both anterograde and retrograde procedures. The primary outcome was the total enteroscopy rate. Secondary outcomes included the maximal insertion depth, positive findings, procedural time, and adverse events.

RESULTS

In total, 110 patients were enrolled, with 55 in each group. Baseline characteristics between the two groups were comparable. Total enteroscopy was achieved in 58.2 % (32/55) of the water exchange group and 36.4 % (20/55) of the control group (P = 0.02). The mean (standard deviation) estimated intubation depth was 521.2 (101.4) cm in the water exchange group and 481.6 (95.2) cm in the CO2 group (P = 0.04). The insertion time was prolonged in the water exchange group compared with the CO2 group (178.9 [45.1] minutes vs. 154.2 [27.6] minutes; P < 0.001). Endoscopic findings and adverse events were comparable between the two groups.

CONCLUSIONS

The water exchange method improved the total enteroscopy rate and increased the intubation depth during SBE. The use of water exchange did not increase the complications of enteroscopy.

[Results of motorized spiral enteroscopy in 83 consecutive patients]

INTRODUCTION

For motorized spiral enteroscopy, only limited data are available. We report about our early experiences with the motorized spiral enteroscopy in a retrospective case series. The present worldwide study reported the results of motorized spiral enteroscopy in 68 patients with small bowel diseases and in 15 patients with ERCP and surgically altered anatomy.

PATIENTS AND METHODS

This retrospective single-centre study was performed between 01/2020 and 09/2021 in 83 consecutive patients. Indications were known or suspected small bowel diseases or diseases of the bile or pancreatic duct after surgical altered anatomy with Roux-Y anastomosis.

RESULTS

In 68 patients (38 m/30 f; mean age 66.4 years) with an indication for small bowel enteroscopy, diagnostic and therapeutic yield was 86.8% and 41.2%, respectfully. The average depth of maximum insertion was 279 cm with an average insertion time of 64.3 min. In 13 patients (19.7%), complete panenteroscopy was achieved. In patients without prior abdominal surgery, the rate of complete enteroscopy was 46.2%.In 15 patients (9 m; 6 f; mean age 61.8 years) with surgically altered anatomy and Roux-Y anastomosis (the papilla resp.), the biliodigestive anastomosis could be reached in 60%.In the entire case series, the total complication rate was 15.7%. There were no severe complications, such as perforation or major bleeding.

DISCUSSION

The present case series shows a high rate of panenteroscopies with a short examination time. To confirm these data, further comparative studies for ERCPs in patients with surgically altered anatomy are necessary.

Achieving Total Enteroscopy by Consecutive Bidirectional Double-balloon Enteroscopy Procedures

OBJECTIVE

To investigate the feasibility and safety of achieving total enteroscopy by consecutive bidirectional double-balloon enteroscopy (DBE) procedures.

METHODS

The demographic data, indication, initial insertion route, examination time for each insertion and the entire procedure, total enteroscopy rate, diagnostic yield and adverse events of patients who attempted to achieve total enteroscopy by consecutive bidirectional DBE procedures from January 2014 to December 2019 were retrospectively analyzed.

RESULTS

A total of 189 patients were included, and the total enteroscopy rate was 87.3%. Initiating the DBE procedure via the retrograde approach as the initial insertion route achieved a higher total enterosocpy rate (90.9% vs. 78.9%, P=0.023), with shorter overall examination time (134.2±36.2 vs. 156.9±47.6 min, P=0.017) and shorter examination time for the opposite insertion route (23.8±19.9 vs. 53.1±27.6 min, P=0.000) compared with anteograde approach as the initial insertion route. The overall diagnostic yield was 37.6%. The diagnostic yield for successfully achieving total enteroscopy was higher, when compared to the yield for not successfully achieving total enteroscopy (39.4% vs. 25%, P=0.029). The overall rate of adverse events was 2.1% (4/189). There was no significant difference in adverse event rate between the overall examination time ≥2 h group and <2 h group (2.1% vs. 2.0%, P=0.593).

CONCLUSION

Consecutive bidirectional DBE procedure is an effective and safe strategy for achieving total enteroscopy with a considerable success rate. This may be a promising option and alternative to traditional methods, and helpful to more promptly establish a definite diagnosis. The retrograde approach, as the initial insertion route, is preferred in clinical practice.

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

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

Use, Yield, and Risk of Device-assisted Enteroscopy in the United States: Results From a Large Retrospective Multicenter Cohort

INTRODUCTION

Since 2001, device-assisted enteroscopy (DAE) has revolutionized the diagnostic and therapeutic capabilities for managing small bowel pathology. Though commonly performed, there have been no recent large studies to assess the use, yield, and risks of DAE and none that include all 3 DAE modalities. We hypothesized that DAE is safe with high diagnostic and therapeutic yields achieved within reasonable procedure duration and here we present a large retrospective multicenter US study evaluating the use, yield, and complications of DAE.

METHODS

After obtaining institutional review board approval, electronic records were used to identify all DAE's performed for luminal small bowel evaluation in adult patients at 4 US referral centers (Duke University Medical Center, New York University Langone Medical Center, Louisiana State University Health Sciences Center, and University of Massachusetts Medical Center) from January 1, 2014 to January 1, 2019. Electronic medical records were reviewed to collect and analyze a variety of procedure-related outcomes. Using the data pooled across centers, descriptive statistics were generated for the patient and procedure-related characteristics and outcomes; relationships between characteristics and outcomes were explored.

RESULTS

A total of 1787 DAE's were performed over this 5-year period (392 at Duke University Medical Center, 887 at Louisiana State University Health Sciences Center, 312 at New York University Langone Medical Center, and 195 at University of Massachusetts Medical Center). Of these, there were 1017 (57%) double-balloon, 391 (29%) single-balloon, and 378 (21%) spiral enteroscopies. The mean age of patients undergoing DAE was 66 years and 53% of examinations were performed on women; 18% of patients in the cohort underwent >1 DAE over this time span. A total of 53% of examinations were performed for suspected small bowel bleeding, 31% were directly guided by video capsule endoscopy findings and 8% were performed for abnormal imaging. A total of 85% of examinations used an antegrade approach and DAE took a mean of 45 minutes to complete; 76% of examinations revealed abnormal findings, with vascular, inflammatory, and neoplastic findings seen in 49%, 17%, and 15% of the cohort, respectively. Older age was significantly associated with any abnormal finding, including arteriovenous malformations (P<0.0001); 50% of examinations included a therapeutic maneuver, most commonly argon plasma coagulation/cautery (43%). There were complications in 16 examinations (0.9%) including 2 perforations (0.1%), 6 cases with bleeding (0.3%) and 1 episode of pancreatitis (0.1%).

CONCLUSIONS

DAE is most commonly performed to evaluate suspected small bowel bleeding and is commonly directed by video capsule findings. DAE is safe, has a high diagnostic yield, with 76% of examinations showing abnormal findings, and frequently features therapeutic maneuvers. Advancing age is associated with abnormal findings on DAE.

Total motorized spiral enteroscopy: first prospective clinical feasibility trial

BACKGROUND AND AIMS

Motorized spiral enteroscopy (MSE) was recently introduced into clinical practice and shown to be safe and effective for antegrade enteroscopy. The aim of the current trial was to prospectively study the efficacy and safety of MSE for visualization of the entire small bowel.

METHODS

All consecutive patients with indications for complete enteroscopy meeting the inclusion criteria were enrolled in a prospective observational bicentric trial, starting with antegrade MSE; a retrograde approach was performed if MSE remained incomplete from antegrade. The primary objective was to ascertain the total enteroscopy rate (TER); secondary objectives were diagnostic yield, procedural success, time, depth of maximum insertion (DMI), therapeutic yield, and adverse events (AEs).

RESULTS

Thirty patients (16 women, 14 men; median age 64 years [range, 37-100]) were enrolled. Technical success rate of antegrade MSE (advancement beyond the ligament of Treitz) and retrograde MSE (advancement beyond the ileocecal valve [ICV]) were 100% and 100%, respectively. Overall TER was 70%: 16.6% antegrade approach alone and 53.4% bidirectional approach. Median antegrade DMI distal from the ligament of Treitz was 490 cm (range, 160-600); median insertion time 26 minutes (range, 15-110). The median retrograde DMI beyond the ICV was 120 cm (range, 40-600), and median insertion time was 17 minutes (range, 1-68). Overall diagnostic and therapeutic yields were 80% and 86.7%, respectively. Overall AE rate was 16.7%. No serious AEs occurred.

CONCLUSIONS

This prospective study showed that complete enteroscopy is feasible with MSE, either from antegrade alone or bidirectionally, with high success rates and short procedural duration. These results justify further evaluation of MSE in a large prospective multicenter study, preferably with inclusion of a control group. (Clinical trial registration number: NCT03438695.).

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.

Inspecting the total gastrointestinal tract by consecutive bidirectional double-balloon enteroscopy in patients with suspected small bowel bleeding

BACKGROUND/AIMS

This study aimed to investigate the feasibility, efficiency, and clinical significance of examining the total gastrointestinal (GI) tract by consecutive bidirectional double-balloon enteroscopy (DBE) within 1 day in patients with suspected small-bowel bleeding.

MATERIALS AND METHODS

From January 2016 to January 2018, the clinical and endoscopic data of 41 patients with suspected small-bowel bleeding undergoing DBE aimed at inspecting the total GI tract within 1 day.

RESULTS

A success rate of 87.8% (36/41) for examining the total GI tract with no adverse event was achieved by consecutive bidirectional DBE performed within 1 day. The total examination time was 140.61±36.41 (range, 82-270) minutes. Positive or negative findings of bleeding were detected in 51.2% (21/41) and 48.8% (20/41) patients, respectively. Single bleeding etiology with non-small-bowel lesions (NSBLs) or small-bowel lesions (SBLs) was detected in 12.2% (5/41) and 26.8% (11/41) of patients, respectively. Dual bleeding etiologies, including NSBLs and SBLs, were detected in 12.2% (5/41) of patients. A re-bleeding rate of positive or negative findings was different (4.8% vs. 40.0%; p<0.05).

CONCLUSION

Consecutive bidirectional DBE within 1 day can achieve complete vision of the total GI tract with a considerable success rate and high safety. This strategy may provide an option for detecting bleeding etiology throughout the GI tract. A negative finding with this method cannot absolutely exclude missed bleeding etiology and re-bleeding.

Diagnosis and therapy using double-balloon endoscopy for small bowel disease: experience from a Chinese tertiary hospital

OBJECTIVE

To evaluate the clinical efficacy of double-balloon endoscopy (DBE) for small bowel disease (SBD).

METHODS

The clinical and endoscopic data of patients who underwent DBE in a Chinese tertiary hospital from January 2006 to December 2019 were retrospectively reviewed. The patients were divided into three groups by age: the young group (<45 years), middle-aged group (45-65 years), and older group (>65 years).

RESULTS

In total, 1177 patients who underwent 2134 DBE procedures were included. The anterograde and retrograde route was used in 1111 and 1023 procedures, respectively. The most common reason for performing DBE was suspected small bowel bleeding (SSBB) (53.1%), and the most common SBD was Crohn's disease (CD) (18.1%). Hemostasis was the predominant endoscopic therapy (54.3%). The total complication rate was 0.8%. The incidence of CD was highest in the young group, and the incidence of tumors was highest in the older group; these findings were consistent both among the overall patient population and among patients with SSBB.

CONCLUSIONS

DBE is effective and safe for the diagnosis and treatment of SBD and is considered to have great potential as a first-line method for diagnosing SBD.

Inflammatory myofibroblastic tumor of ileum with intussusception in adult

A 62-year-old man was referred to our department with suspected intussusception due to an ileal tumor. Tumor markers including soluble interleukin-2 receptor were not elevated. Contrast-enhanced computed tomography and color Doppler ultrasonography showed a distinct ileal tumor without intratumoral blood flow or surrounding lymphadenopathies. Retrograde single-balloon enteroscopy revealed a submucosal tumor in the ileum that was hard and ulcerated. Partial intestinal resection was performed, and the lesion was diagnosed as an inflammatory myofibroblastic tumor. The patient had no recurrence over 2 years without additional treatment after surgery. This rare tumor should be kept in mind as a cause of ileal intussusception in adult and a multidisciplinary approach is vital to characterize it.

Diagnostic agreement between video capsule endoscopy and single and double balloon enteroscopy for small bowel bleeding at a tertiary care hospital in Bogota, Colombia

INTRODUCTION

Video capsule endoscopy and balloon-assisted enteroscopy are complementary diagnostic methods in the study of small bowel bleeding, and different factors can affect their diagnostic yield.

AIMS

To define the level of agreement between video capsule endoscopy and enteroscopy in small bowel bleeding, according to the type of lesion, in a cohort of patients at a tertiary care referral center.

MATERIALS AND METHODS

A retrospective study was conducted that included 428 capsule endoscopies performed within the time frame of 2011 and 2019 at our healthcare institution. Seventy-four video capsule endoscopies, followed by enteroscopy, in 71 patients suspected of presenting with small bowel bleeding, were analyzed.

RESULTS

Mean patient age was 63.9 ± 13.5 years and 42 patients were women. The two diagnostic procedures were performed. Overall diagnostic yield of positive findings between video capsule endoscopy and enteroscopy was 86.5% vs. 58.1%, respectively (p = 0.0527). Agreement between video capsule endoscopy and enteroscopy for positive pathologic findings was weak (Ik = 0.17, 95% CI: -0.0097-0.3543), but according to lesion type, it was good for inflammatory lesions (Ik = 0.71, 95% CI: 0.5182-0.9119) and moderate for angiectasias (Ik = 0.45, 95% CI: 0.2469-0.6538) and tumors (Ik = 0.40, 95% CI: 0.1217-0.6794). The results between the two methods differed in 38 patients (51.3%). There was complete intestinal capsule retention in one patient (1.4%) and active bleeding in 13 (17.6%).

CONCLUSIONS

The present study showed that the two techniques had a similar overall detection rate for small bowel lesions, but the type of lesion was the main factor that could modify diagnostic agreement.

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.

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.

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

BACKGROUND

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

STUDY

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

RESULTS

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

CONCLUSIONS

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

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 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.

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.

Diagnostic Value and Safety of Emergency Single-Balloon Enteroscopy for Obscure Gastrointestinal Bleeding

BACKGROUND

This study assesses the diagnostic performance of emergency single-balloon enteroscopy (SBE) for obscure gastrointestinal bleeding (OGIB) under general anesthesia versus conscious sedation.

STUDY

The data of 102 OGIB in-patients from June 2015 to June 2018 were retrospectively analyzed. The diagnosis and detection rates and adverse events were calculated overall and in relation to age, gender, type of operation and anesthesia, bleeding type, different times of examination, and SBE route. All statistical analyses were performed using SPSS 24.0, and the diagnosis and detection rates were compared using the Chi-square test.

RESULTS

Among the 102 patients, 66 patients had positive findings, while 11 patients had suspected positive findings, and the diagnosis and detection rates were 64.7% and 75.5%, respectively. Ulcers (19.6%) and tumors (16.7%) were the most common causes of OGIB. There were no statistical differences in diagnosis and detection rates between the ages of ≥60 and <60 and between different genders. Patients with emergency SBE had higher diagnosis and detection rates (68.6% vs. 35.3%, P = 0.023; 80.0% vs. 47.1%, P = 0.016, respectively), when compared with nonemergency SBE patients. The diagnosis rate at 24 hours was higher than that at 2-7 days and one week (88.0% vs. 61.5%, P = 0.030; 88.0% vs. 53.8%, P = 0.007). For overt bleeding, the difference in diagnosis rates at 24 hours, 2-7 days, and one week was statistically significant (100.0% vs. 57.1%, P = 0.006; 100.0% vs. 57.1%, P = 0.006). For occult bleeding, the pairwise comparison revealed no statistical difference. Patients with general anesthesia had a higher detection rate, when compared to patients with conscious sedation (87.9% vs. 63.9%, P = 0.004). In addition, adverse events under general anesthesia were lower, when compared to adverse events under conscious sedation (28.8% vs. 69.4%, P = 0.020). There was no significant difference in adverse events at the different time points (P > 0.05).

CONCLUSION

Emergency SBE under general anesthesia achieves higher diagnosis and detection rates, and fewer adverse events under conscious sedation, when compared to nonemergency SBE, regardless of the route. For patients with overt bleeding, it is easier to find lesions by emergency SBE within 24 hours.

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).

Diagnosis and therapeutic strategies for small bowel vascular lesions

Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.

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.

The Clinician's Guide to Suspected Small Bowel Bleeding

Small bowel bleeding accounts for 5-10% of gastrointestinal bleeding. With the advent of capsule endoscopy, device-assisted enteroscopy, and multiphase CT scanning, a small bowel source can now be found in many instances of what has previously been described as obscure gastrointestinal bleeding. We present a practical review on the evaluation and management of small bowel bleeding for the practicing clinician.

Anisakiasis in the Small Intestine with Excessive Bleeding That Was Difficult to Diagnose Endoscopically

Anisakiasis involves the stomach in most cases and occurs rarely in the small intestine. Anisakiasis in the small intestine is associated with abdominal pain and obstruction and is rarely associated with intestinal bleeding. Unlike in the stomach, anisakiasis in the small intestine is difficult to diagnose anatomically. The patient in this case study developed hypovolemic shock due to excessive bleeding and underwent emergency surgery. With the recent increase in the consumption of raw fish around the world, this report provides an important finding of bleeding in the small intestine due to an unknown cause.