Enrique Pérez-Cuadrado

Double-balloon enteroscopy: a descriptive study of 50 explorations

AIM To evaluate the utility of double-balloon enteroscopy for small-bowel disease. DESIGN A prospective study of 50 consecutive enteroscopies performed from December 2004 to July 2005 to analyze diagnoses and treatments. PATIENTS 44 patients (33 had undergone a previous capsule endoscopy) with indications for obscure digestive hemorrhage, angiodysplasia, Peutz-Jeghers syndrome, ulcer, suspected Crohns disease, tumors, and refractory celiac disease. RESULTS We carried out enteroscopy studies in 44 patients by the oral route and, in 6 additional patients, by both the oral and anal routes. We reached the ileon with the oral route in all cases but one (jejunal stenosis), and in 4 cases out of 7 with the anal route, with an average duration of 73 minutes. We found angiodysplasia in 19 cases, as well as NSAID-related enteropathy, Crohns disease, diverticulosis, and Waldenströms disease. We performed biopsies in 31% of cases with diagnoses of adenocarcinoma, lymphangiectasia secondary to tumor in celiac disease, and Whipples disease. We treated 19 patients with angiodysplasia (1 to 20 synchronous lesions) with argon, and 4 patients with polyps using polipectomy (sporadic polyps or Peutz-Jeghers syndrome). A retained capsule in one patient with stenosis was removed. CONCLUSIONS Double-balloon enteroscopy is a useful and effective technique in the diagnosis and treatment of small intestine diseases, thus complementing capsule endoscopy. More studies are needed to analyze its impact on the management of this condition.

Effect of double-balloon enteroscopy on pancreas: An experimental porcine model

AIM To evaluate the effect of double-balloon enteroscopy (DBE) on pancreas histology and levels of pancreatic enzymes. METHODS Conventional upper gastrointestinal endoscopy was performed on five control pigs. Oral DBE was performed with an EN-450T5 enteroscope on 20 pigs. Two experimental groups (10 pigs each) were defined according to DBE duration: 90 min for Group 1 and 140 min for group 2. During oral insertion, the balloons were not inflated in the descending part of the duodenum to avoid the minor duodenal papilla. Serum amylase, lipase and C-reactive protein (CRP) levels were monitored before the procedure and repeated every 30 min until the exploration was finished, as well as 24 h and 7 d after. After the procedure and for a total of 7 d, the pigs were observed twice a day for signs of decreased activity, irritability, vomiting or anorexia. Gross and microscopic examination of the pancreas was performed on day 7. RESULTS All animals tolerated DBE without clinical manifestations of acute pancreatitis. Experimental groups had higher levels of enzymes than the control group at 24 h. Throughout the exploration, the amylase levels increased significantly above the baseline 24 h after DBE, although the increase was not statistically significant and did not reach 20% of the baseline. An increase in lipase and CRP was observed at 24 h after the procedure, although by day 7, all enzymatic levels had returned to baseline. No differences between groups 1 and 2 were found for any enzyme and sampling site during and after the procedure. Similarly, no correlation between insertion depth and enzyme levels was observed. Direct in situ and post-removal inspection of the pancreas did not show any evidence of fluid collection, abscesses or hemorrhage. Histological examination of the pancreas from groups 1 and 2 revealed the existence of focal areas (0.14-0.26 mm2) of ischemic necrosis in 47.4% of the animals. In the pigs with damaged pancreas, the left lobe (tail) was always affected. However, this only happened in 83.3% of the samples from the right lobe (head) and in 33.3% of the samples from the body of the pancreas. Significant differences were found between the left lobe (tail) and the body for the percentage of affected pancreas. Both the size of the lesions and the percentage of affected pancreas were higher in the left pancreatic lobe (tail). The presence of the lesions was not related to the exploration length. CONCLUSION The increase in pancreatic enzymes after DBE could be related to focal points of pancreatic ischemic necrosis due to mechanical stress.

Gastrojejunal anastomosis stricture after laparoscopic gastric bypass: Our experience with 62 patients

OBJECTIVE Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass (LGBP), but its frequency is about 15% according to bibliography. Our aim is to present our experience after 62 LGBP. PATIENTS AND METHOD From January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass (Wittgroves technique). The gastrojejunal anastomosis is performed with auto suture material type CEAA No 21 termino-lateral (ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy, perform the anastomosis in the same way. Monitoring has a range of 3-35 months, conducted in 61 patients because one patient died of pulmonary thromboembolism in the immediate postoperative period after reoperation, after two weeks of gastric bypass, by necrosis of a small fragment of the remnant gastric. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation (recommending dilate the anastomosis to a maximum 1.5 cm). RESULTS Five cases (8.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and in 1 case by endoscopy. Two patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion (circumferentially sclerosis within 48 hours of surgery and sclerosis of bleeding points). All cases were resolved by endoscopic dilatation. At follow-up has not been detected re-stricture. CONCLUSION Clinically, gastrojejunal stricture results in a progressive oral intolerance, revealing stenosis between 1 and 3 months postoperatively. The situations of sclerosis of the bleeding lesions favor, especially in cases of extensive sclerosis. In cases of suspected barium transit offers us a high diagnostic yield. Endoscopic dilatation resolved, so far, all cases.

Carbon dioxide insufflation safety in double-balloon enteroscopy: an experimental animal study.

The aim of the present study was to assess the safety and efficacy of CO2 during double‐balloon enteroscopy (DBE) in an experimental animal model study. In this study, insufflation with room air and with CO2 was compared.

Experimental laparoscopic evaluation of double balloon versus spiral enteroscopy in an animal model.

Four pigs were subjected to enteroscopic exploration and divided into two groups: Double Balloon Enteroscopy (DBE group) and Spiral Enteroscopy (SE group). The explored length from the pylorus, the feed rate and the time of withdrawal were measured. Simultaneous laparoscopic view allowed evaluation of the enteroscopy maneuvers. During laparoscopy control it was easy to see air trapped in the intestine bent over the overtube, mainly in the DBE group, whereas vascular stress of the bowel wall was higher in the SE group, which was probably related with the spiral torsion observed in the jejunal vessels and the root of the mesentery (Fig. 1). This was not observed in the DBE group. Nevertheless, subperitoneal ecchymosis was observed in both groups, but with higher significance in the SE group. Furthermore, a small tear in the visceral peritoneum appeared in one pig (Fig. 2). The small bowel examined was 219.6 12.7 and 180.0 14.1 cm long, the feed rate was 4.05 and 5.62 cm/min and the time of withdrawal was 67 and 138 s, for the DBE and SE groups, respectively. The vascular supply to the bowel was apparently more altered in the SE group, which is likely determined by a compressive effect of the DSB overtube on the intestinal wall and intense rotation of the root of the mesentery. Akerman et al. indicate that small-bowel pleating is accomplished without apparent twisting of the small bowel because the mesentery attachment to the small bowel resists its rotation; however the laparoscopic visualization in the porcine model suggested that this process could be more iatrogenic than expected. The clockwise rotation of the DSB overtube mimics the motion of a corkscrew and pleats the small bowel onto the overtube, hence twisting the bowel and the mesenteric vessels in a more compressive way. The longer time of withdrawal in the SE could represent a clinical problem.

Effect of the manipulation of the duodenal papilla during double balloon enteroscopy

AIM To determine the hypothesis that inflating the balloons in the duodenal papilla determines changes in the biochemical markers of pancreatitis. METHODS Four groups of pigs were used: Group papilla (GP), the overtubes balloon was inflated in the area of the papilla; GP + double balloon enteroscopy (GP + DBE), the overtubes balloon was kept inflated in the area of the papilla for 20 min before a DBE; Group DBE (GDBE), DBE was carried out after insuring the balloons inflation far from the pancreatic papilla; and Group control (GC). Serum concentrations of amylase, lipase and C-reactive protein (CRP) were evaluated. Pancreases were processed for histopathology examination. RESULTS Main changes occurred 24 h after the procedure compared with baseline levels. Amylase levels increased significantly in GP (59.2% higher) and were moderately higher in groups GP + DBE and GDBE (22.7% and 20%, respectively). Lipase increased in GP and GP + DBE, whereas it hardly changed in GDBE and in GC. CRP increased significantly in GP, GP + DBE and GDBE, while no changes were reported for GC. No statistically significant difference between groups GP and GP + DBE was found for the histopathological findings, except for vacuolization and necrosis of the pancreatic parenchyma that was higher in GP than in GP + DBE. CONCLUSION The manipulation of the duodenal papilla by the inflated overtubes balloon during DBE causes pancreatic structural damage and increased biochemical markers associated with pancreatitis.

A Case of Lymphocytic-Plasmacytic Jejunitis Diagnosed by Double Balloon Enteroscopy in a Dog

A 3 yr old male English setter dog was presented for evaluation of a 6-wk history of intermittent diarrhea. After standard gastroduodenoscopy and colonoscopy showed normal mucosa, double-balloon endoscopy (DBE) was used via both oral and anal approaches. Gross changes consistent with inflammation in the jejunum were seen, and biopsy specimens were obtained. Histologic analysis confirmed a diagnosis of lymphocytic-plasmacytic jejunitis. Clinical remission of the disease occurred after 3 mo of therapy with prednisone, metronidazole, and a novel protein diet. Use of DBE has not been previously reported in dogs with inflammatory bowel disease, and isolated lymphocytic-plasmacytic jejunitis has not been described. The described cases of intestinal inflammatory disease diagnosed by conventional endoscopy were related to pathologic changes in the duodenum, ileum or colon, but not the jejunum. The main advantage of the DBE technique allowed examination of portions of the small intestine (jejunum) that were not commonly accessible by standard endoscopic techniques, and permitted a minimally invasive collection of biopsy samples compared with surgical biopsy. This case highlights the need to consider using DBE in animals with gastrointestinal disorders, whose symptoms are not readily explained by routine tests, conventional endoscopy, and dietary or therapeutic trials.

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 280 casos en 8 años

OBJECTIVE Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass. PATIENTS AND METHOD From January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation. RESULTS Twenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture. CONCLUSION Structure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.

An endoscopic technique for treating symptomatic distal jejunum obstruction by leaving the overtube in place.

Double balloon enteroscopy has a limitation for positioning an enteral stent in the distal jejunum through its long, narrow biopsy channel. When the distal end of its overtube is left in place close to the neoplasia with the enteroscope removed, if we push an enteral stent introduction system, it tends to form loops so the techniquecannot be performed with this instrument. However, the double balloon colonoscope has a shorter overtube length and using the same push-and-pull technique we can reach the distal jejunum with this instrument by inserting the delivery stent system without loops through its overtube. We present a patient with neoplastic obstruction in the distal jejunum with resolution of his symptoms after positioning an enteral stent.

Enteroscopia de doble balón vía oral hasta ciego

doscopy. A double-balloon enteroscopy was performed for partially obstructive attacks of abdominal pain suspicious of small-bowel invaginations by big polyps; enteroscopy confirmed the diagnosis. A majority of polyps were localized in the jejunum, and a polypectomy of lesions greater than 1 cm was performed. Histology was consistent with harmatomatous polyps. The entire small bowel was explored using the oral route, and the cecum was reached through Bahuin’s valve (Figs. 1 and 2). Double-balloon enteroscopy, described by H. Yamamoto (1,2), is a first-line method small-bowel exploration that complements capsule endoscopy. Yamamoto described the total exploration of the small bowel by the oral route (the anal route is more common in Asian series). However, we have seen no references on the total exploration of the small bowel with this technique in our setting. In a study report of 635 enteroscopies (3) the median length of small bowel explored by double-balloon enteroscopy was 270 cm for the oral route and 150 cm for the anal route. Generally, a total exploration of the small bowel is possible using both the oral route and anal route in the same patient (4), but we found no references about the total exploration of the small bowel with this technique in our setting.