Double-balloon enteroscopy and outcomes in patients older than 80

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.

Enteroscopy in the Elderly: Review of Procedural Aspects, Indications, Yield, and Safety

Background

As human longevity continues to increase, age-related diseases are more common, which leads to a higher use of gastroenterology services. Endoscopic procedures are generally considered to be of higher risk in the elderly with multiple comorbidities. However, some endoscopic techniques have already been proved to be well tolerated in the elderly.

Summary

<underline></underline>Enteroscopy enables the nonsurgical diagnosis and therapeutic management of a wide variety of small bowel diseases. Although it has been shown to be safe and effective, with high diagnostic yield and therapeutic success rate in the general population, its safety and efficacy in the elderly is largely unknown, and there are still some concerns about its use in these patients.

Key Messages

This review will focus on enteroscopy in elderly people, taking into account patient and procedure characteristics, indications, findings, yield, and complication rate.

Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study

OBJECTIVE

Evaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.

DESIGN

Prospective cohort study.

SETTING

All patients undergoing DBE over a 30-month period were recruited at our tertiary centre.

PATIENTS

215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.

INTERVENTIONS

Patients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.

RESULTS

Cardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (p<0.05). Common indications for DBE were occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease (elderly vs young: 50.7% vs 42.3%, 17.8% vs 12% and 19.2% vs 26.1%, respectively). Diagnostic yield was higher in elderly compared with young patients (75.3% vs 58.5%, p=0.016). The most common findings in elderly and young patients were angioectasia (30.1% and. 18.3%, respectively) and ulcers (17.8% and 9.2%, respectively), while therapeutic intervention rates were comparable (42.5% vs 32.4%, p=0.18). ASA status did not affect propofol dose (p=0.55) or procedure duration (p=0.31). Tolerance scores were favourable in those receiving propofol compared with conventional sedation (p<0.05). There was no difference in complications between the four groups (p=0.17).

CONCLUSION

Compared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Exploring the Small Bowel: Update on Deep Enteroscopy

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

Double-balloon enteroscopy in small bowel diseases: Eight years single-center experience in China

The aim of the study was to evaluate the diagnostic and therapeutic value of double-balloon entoroscopy (DBE) in small bowel diseases (SBDs) in China.A retrospective review of 674 consecutive patients who underwent DBE between January 2007 and November 2015 was conducted. Patients were divided into 3 groups by age, young group (<45 years), middle-aged group (45-65 years), and elderly group (>65 years). Data were collected with regard to demographics, clinical, endoscopic findings, complications, diagnostic yield, and management.A total of 729 DBE procedures were performed successfully in our series. More than 20 types of SBDs were found with the detection rate of 70.9%(517/729). The majority of patients were Crohn's disease (33.4%,225/674), followed by tumor (18.8%,127/674) and angioectasia (7.9%, 53/674). Endoscopic treatment was performed in 60 patients in which hemostasis (17,28.3%) and polypectomy (15,25%) were the predominant form of intervention used. Adverse events occurred in 6 patients (0.96%,6/729) including perforation, hemorrhage, aspiration pneumonia. No acute pancreatitis or other major complications occurred. Adenocarcinoma, GIST, and lymphoma were the most common tumor detected, the majority of tumors located in the jejunum (56.7%), The detection rate of angioectasia was also higher in the jejunum (54.7%),77.8% of Crohn's disease was located in the ileum. The positive rate of DBE in small bowel tumor and Crohn's disease were significantly higher than that of angioectasia (P<0.05). In young cohort, Crohn's disease (48.1%) was the most commonly diseases followed by tumor (10.4%) and nonspecific enteritis (7.1%). Yet in the elderly group, the majority of patients were tumor (27.6%); angioectasia (21.3%) was also detected frequently. The positive rate of capsule endoscopy was 75.44 %(202/268) which was a little high than DBE (67.9%, 182/268) (P > 0.05). The obscure gastrointestinal bleeding (OGIB) was the most common indication, and the diagnostic yield was 71.8%.DBE is a useful diagnostic and therapeutic tool with high clinical practice value for the investigation of SBDs. With growing experience of endoscopist, we believe that DBE must be kept in mind as the first-line modality for suspected SBDs.

Multicenter survey on the use of device-assisted enteroscopy in Portugal

BACKGROUND

Device-assisted enteroscopies (DAEs) are recent endoscopic techniques that enable direct endoscopic small-bowel evaluation.

OBJECTIVE

The objective of this article is to evaluate the implementation of DAEs in Portugal and assess the main indications, diagnoses, diagnostic yield, therapeutic yield and complication rate.

METHODS

We conducted a multicenter retrospective series using a national Web-based survey on behalf of the Portuguese Small-Bowel Study Group. Participants were asked to fill out two online databases regarding procedural data, indications, diagnoses, endoscopic therapy and complications using prospectively collected institutional data records.

RESULTS

A total of eight centers were enrolled in the survey, corresponding to 1411 DAEs. The most frequent indications were obscure gastrointestinal bleeding (OGIB), inflammatory bowel disease and small-bowel tumors. The pooled diagnostic yield was 63%. A relation between the diagnostic yield and the indications was clear, with a diagnostic yield for OGIB of 69% (p = 0.02) with a 52% therapeutic yield. Complications occurred in 1.2%, with a major complication rate of 0.57%. Perforations occurred in four patients (0.28%).

CONCLUSION

DAEs are safe and effective procedures, with complication rates of 1.2%, the most serious of which is perforation. Most procedures are performed in the setting of OGIB. Diagnostic and therapeutic yields are dependent on the indication, hence appropriate patient selection is crucial.