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

Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative - Update 2025

Quality markers and patient experience are being implemented to ensure standardization of practice across gastrointestinal (GI) endoscopy procedures. The set benchmarks ensure high quality procedures are delivered and linked to measurable outcomes.There has been an increase in the demand for small-bowel endoscopy. In 2019, the European Society of Gastrointestinal Endoscopy (ESGE) embarked on setting performance measures for small-bowel endoscopy. This included major (key) and minor performance indicators for both small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE). These suggested quality indicators cover all procedure domains, from patient selection and preparation, to intraprocedural aspects such as pathology identification, appropriate management, the patient experience, and post-procedure complications. Since 2019, there has been an increase in published studies looking at different aspects of small-bowel endoscopy, including real-world data. This paper provides an update on the 2019 performance measures, considering the latest literature.

Clinical value of capsule endoscopy, CT enterography and enteroscopy in the diagnosis of suspected small bowel bleeding

BACKGROUND

Fewer studies have been conducted on the diagnostic value of capsule endoscopy, CT enterography and enteroscopy in suspected small bowel bleeding. This study aimed at analyzing the diagnostic and clinical value of capsule endoscopy, CT enterography and enteroscopy for suspected small bowel bleeding.

METHODS

This retrospective study compared the diagnostic rate and consistency of findings among groups. In addition, diagnostic rates were compared between combined enteroscopy versus uncombined enteroscopy associated with capsule endoscopy or CT enterography, as well as the influencing factors of diagnostic outcomes. The complete enteroscopy rates and diagnostic rates were analyzed for the one-day enteroscopy group and the non-one-day enteroscopy group.

RESULTS

There was no significant difference in diagnostic rates between capsule endoscopy (n = 70) and CT enterography (n = 122) (χ2 = 3.334; p = 0.068), while the diagnostic rate of enteroscopy (n = 396) is higher than capsule endoscopy (χ2 = 10.064; p = 0.002) and CT enterography (χ2 = 42.661; p < 0.001). Diagnostic rates were much higher in patients with a successful completion of docking inspection (n = 64) than in undocked patients (n = 60) (85.9% vs 46.7%; p < 0.001), even though these patients still had combined capsule endoscopy or CT enterography. The complete enteroscopy rates (χ2 = 0.364; P = 0.546) and diagnostic rates (χ2 = 2.511; P = 0.113) of enteroscopy in the one-day group (n = 55) were not significantly different from those in the non-one-day group (n = 25).

CONCLUSIONS

Enteroscopy is the more reliable method of diagnosing suspected small bowel bleeding among enteroscopy, capsule endoscopy and CT enterography. Moreover, uncompleted enteroscopy combined with capsule endoscopy or CT enterography may not yet be a substitute for successful completion of docking enteroscopy in clinical practice.

Motorized spiral enteroscopy: A cautious step forward in technological innovation

With the continuous advancement in medical technology, endoscopy has gained significant attention as a crucial diagnostic tool. The introduction of motorized spiral enteroscopy (MSE) represents a significant advancement in the diagnosis and treatment of small bowel diseases. While there are safety concerns and a high reliance on the operator's skills, MSE should not be disregarded entirely. Instead, it should be considered as a supplementary endoscopic technique, particularly in situations where conventional endoscopy proves ineffective. Through continuous research and technical optimization, MSE has the potential to become an important addition to the endoscopy toolbox in the future. We call on colleagues in the industry to work together to promote the improvement of MSE technology through continuous research and practice, with the aim to bring out its unique value in endoscopy while ensuring patient safety.

Inpatient Small Bowel Capsule Endoscopy: Not Associated With Bleeding Site Identification or 30-Day Readmission Prevention

Background The utility of small bowel capsule endoscopy (SBCE) in the inpatient setting is controversial due to retention rates and costs. Aim This study aims to evaluate whether using SBCE significantly improved the identification of potential bleeding sites or reduced the risk of 30-day readmission for overt or occult gastrointestinal bleeding. Methods This was a single-center retrospective cohort study involving inpatients who underwent SBCE at a suburban tertiary care hospital from January 1, 2012, to January 1, 2022, for suspected small bowel bleeding. There was no control group used in this observational study. We used chi-square testing to determine the significance among our categorical variables and t-tests to compare means for our numerical variables. We also did multivariable logistic regression to analyze risk factors for increased hospital stay. All statistical analysis was done in R (R Core Team, 2020, R Foundation for Statistical Computing, Vienna, Austria). Results We identified 514 inpatients who underwent SBCE from January 1, 2012, to January 1, 2022, including 300 (58.4%) men and 214 (41.6%) women. Most (305/514, 59.3%) had no notable findings on SBCE, but 209/514 (40.7%) subsequently underwent endoscopic procedures, and a bleeding site was identified and treated in 168/209 (80.4%). Undergoing a subsequent procedure significantly increased the average number of days between capsule deployment and discharge (9.6 vs. 4.9 days, p < 0.005) without significantly reducing the risk for 30-day readmission (OR 1.33, 95% CI 0.9-1.9, p = 0.2). Among the 209 patients who had a subsequent procedure, identifying and treating a bleeding site did not significantly change readmission rates (OR 1.35, 95% CI 0.6-3.1, p = 0.5) compared to patients who did not have a procedure. Conclusion We did not find that inpatient SBCE significantly affected 30-day readmission rates even if an endoscopic procedure was subsequently done or a potential bleeding site was treated.

Yield of capsule endoscopy and subsequent device-assisted enteroscopy: experience at an Australian tertiary centre

BACKGROUND

Small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) have an established role in the investigation and management of small bowel pathology. Previous studies have reported on the yield of SBCE (60%) and DAE (57%), but none have been in an Australian setting.

AIMS

To determine the yield of SBCE and any DAE performed as a direct consequence of SBCE in an Australian referral centre.

METHODS

A single-centre retrospective study was conducted at a tertiary hospital in Australia, enrolling consecutive patients between 1 January 2009 and 31 December 2021 undergoing SBCE. Data were collected with respect to demographics, procedural factors and findings, as well as findings and interventions of any DAE procedures performed after the SBCE.

RESULTS

1214 SBCEs were performed, with a median age of 66 years old (60.8% men). The predominant indications were anaemia (n = 853, 70.2%) and overt gastrointestinal bleeding (n = 320, 26.4%). Of the complete small bowel studies (1132/1214, 93.2%), abnormal findings were detected in 588 cases (51.9%), most commonly angioectasias (266/588, 45.2%), erosions (106/588, 18.0%) and ulcers (97/588, 8.6%). 165 patients underwent a DAE (117 antegrade, 48 retrograde). Antegrade DAE had a higher yield than retrograde DAE (77.8% vs 54.2%; P = 0.002) and a higher rate of intervention (69.2% vs 37.5%; P < 0.001).

CONCLUSION

In this largest single-centre cohort of patients undergoing SBCE to date, there is a similar yield of abnormal findings compared to existing literature. DAE, especially with an antegrade approach, had high diagnostic and therapeutic yield when pursued after a positive SBCE study.

Role of Device-Assisted Enteroscopy in Crohn's Disease

Crohn's Disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract, posing diagnostic and management challenges due to its potential involvement of any segment from the mouth to the anus. Device-assisted enteroscopy (DAE) has emerged as a significant advancement in the management of CD, particularly for its ability to access the small intestine-a region difficult to evaluate with conventional endoscopic methods. This review discusses the pivotal role of DAE in the nuanced management of CD, emphasizing its enhanced diagnostic precision and therapeutic efficacy. DAE techniques, including double-balloon enteroscopy (DBE), single-balloon enteroscopy (SBE), and the now-withdrawn spiral enteroscopy, enable comprehensive mucosal assessment, targeted biopsies, and therapeutic interventions like stricture dilation, bleeding control, and foreign body removal. Despite its benefits, DAE carries risks such as perforation, bleeding, and pancreatitis, which require careful procedural planning and a skilled execution. The review highlights DAE's impact on reducing surgical interventions and improving patient outcomes through minimally invasive approaches, thereby enhancing the quality of life for patients with CD. Continuous improvement and research are essential in order to maximize DAE's utility and safety in clinical practice.

Device-assisted enteroscopy performance measures in the United Kingdom: DEEP-UK quality improvement project

BACKGROUND

Device-assisted enteroscopy (DAE) has become a well-established diagnostic and therapeutic tool for the management of small-bowel pathology. We aimed to evaluate the performance measures for DAE across the UK against the quality benchmarks proposed by the European Society of Gastrointestinal Endoscopy (ESGE).

METHODS

We retrospectively collected data on patient demographics and DAE performance measures from electronic endoscopy records of consecutive patients who underwent DAE for diagnostic and therapeutic purposes across 12 enteroscopy centers in the UK between January 2017 and December 2022.

RESULTS

A total of 2005 DAE procedures were performed in 1663 patients (median age 60 years; 53% men). Almost all procedures (98.1%) were performed for appropriate indications. Double-balloon enteroscopy was used for most procedures (82.0%), followed by single-balloon enteroscopy (17.2%) and spiral enteroscopy (0.7%). The estimated depth of insertion was documented in 73.4% of procedures. The overall diagnostic yield was 70.0%. Therapeutic interventions were performed in 42.6% of procedures, with a success rate of 96.6%. Overall, 78.0% of detected lesions were marked with a tattoo. Patient comfort was significantly better with the use of deep sedation compared with conscious sedation (99.7% vs. 68.5%; P<0.001). Major adverse events occurred in only 0.6% of procedures.

CONCLUSIONS

Performance measures for DAE in the UK meet the ESGE quality benchmarks, with high diagnostic and therapeutic yields, and a low incidence of major adverse events. However, there is room for improvement in optimizing sedation practices, standardizing the depth of insertion documentation, and adopting marking techniques to aid in the follow-up of detected lesions.

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.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.

Evaluation of the diagnostic and therapeutic utility of retrograde through-the-scope balloon enteroscopy and single-balloon enteroscopy

BACKGROUND

Retrograde single balloon enteroscopy (SBE) is a minimally invasive procedure which is less frequently performed compared with antegrade SBE. There are few studies on the retrograde through-the-scope enteroscopy (TTSE), a novel technique for evaluation of the small bowel.

AIM

To compare the clinical utility and safety of retrograde TTSE with retrograde SBE.

METHODS

Clinical data and complications of retrograde TTSE (2014-2018) and retrograde SBE (2011-2018) performed in a community hospital were reviewed and presented as mean ± SD or frequency (%) and compared using proper statistical tests. Technical success was defined as insertion of the enteroscope > 20 cm beyond ileocecal valve.

RESULTS

Data obtained from 54 retrograde SBE in 49 patients and 27 retrograde TTSE in 26 patients were studied. The most common indication for retrograde enteroscopy was iron deficiency anemia (41 patients) followed by gastrointestinal bleeding (37 patients), and chronic diarrhea (7 patients). The duration of retrograde SBE procedure (91.9 ± 34.2 min) was significantly longer compared with retrograde TTSE (70.5 ± 30.7 min) (P = 0.04). Technical success was comparable in TTSE [23/27 (85.2%)] and SBE [41/54 (75.9%) (P = 0.33)]. The mean depth of insertion beyond the ileocecal valve in retrograde SBE (92.5 ± 70.0 cm) tended to be longer compared with retrograde TTSE (64.6 ± 49.0 cm) (P = 0.08). No complication was observed in this study.

CONCLUSION

Both retrograde TTSE and retrograde SBE are feasible and safe. Retrograde TTSE takes a shorter time and has a comparable technical success with SBE. TTSE has a lower capacity of small bowel insertion.