Huseyin Aktas

Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trial

BACKGROUND AND STUDY AIMS Double-balloon enteroscopy (DBE) is the first choice endoscopic technique for small-bowel visualization. However, preparation and handling of the double-balloon enteroscope is complex. Recently, a single-balloon enteroscopy (SBE) system has been introduced as being a simplified, less-complex balloon-assisted enteroscopy system. PATIENTS AND METHODS This study was a randomized international multicenter trial comparing two balloon-assisted enteroscopy systems: DBE vs. SBE. Consecutive patients referred for balloon-assisted enteroscopy were randomized to either DBE or SBE. Patients were blinded with regard to the type of instrument used. The primary study outcome was oral insertion depth. Secondary outcomes included complete small-bowel visualization, anal insertion depth, patient discomfort, and adverse events. Patient discomfort during and after the procedure was scored using a visual analog scale. RESULTS A total of 130 patients were included over 12 months: 65 with DBE and 65 with the SBE technique. Patient and procedure characteristics were comparable between the two groups. Mean oral intubation depth was 253 cm with DBE and 258 cm with SBE, showing noninferiority of SBE vs. DBE. Complete visualization of the small bowel was achieved in 18 % and 11 % of procedures in the DBE and SBE groups, respectively. Mean anal intubation depth was 107 cm in the DBE group and 118 cm in the SBE group. Diagnostic yield and mean pain scores during and after the procedures were similar in the two groups. No adverse events were observed during or after the examinations. CONCLUSIONS This head-to-head comparison study shows that DBE and SBE have a comparable performance and diagnostic yield for evaluation of the small bowel.

Single-balloon enteroscopy, magnetic resonance enterography, and abdominal US useful for evaluation of small-bowel disease in children with (suspected) Crohn's disease

BACKGROUND The usefulness of single-balloon enteroscopy (SBE) has not been evaluated in children with known or suspected Crohns disease (CD). OBJECTIVE The objectives of this study are to evaluate the diagnostic yield of SBE for pediatric CD by comparing it with US and magnetic resonance enterography (MRE). DESIGN Single-center prospective study. SETTING Tertiary-care referral hospital. PATIENTS Between February 2009 and April 2010, 20 pediatric patients (ages 8-18 years) with suspected inflammatory bowel disease (IBD) or with a previous diagnosis of CD with suspected persistent small-bowel disease were enrolled. INTERVENTIONS All patients underwent proximal and distal SBE, 17 patients also underwent US combined with Doppler flow measurements, and 18 underwent MRE. MAIN OUTCOME MEASUREMENTS The findings of US with Doppler flow measurements and MRE were compared with those with SBE. RESULTS The mean patient age was 15.0 years (range 11.3-18 years, 70% male). Of 14 patients with suspected IBD, 8 had a diagnosis of CD made after SBE. Activity in the small bowel was found in 14 patients (70%) with both suspected and previously diagnosed CD. Twelve patients (60%) had small-bowel disease that was out of reach of conventional endoscopy. Three patients (15%) had small-bowel activity solely in the jejunum, which was not detected by either MRE or US. LIMITATIONS Single-center study with small sample size. CONCLUSIONS SBE can be used in children to accurately assess small-bowel disease and CD. Small-bowel activity may be identified by SBE in some patients in whom it may not be apparent despite use of conventional upper endoscopy, ileocolonoscopy, US with Doppler flow measurements, or MRE.

Impact of double-balloon enteroscopy findings on the management of Crohn's disease

Abstract Objective. It is estimated that 10%–30% of Crohns disease (CD) patients have small-bowel lesions, but the exact frequency and clinical relevance of these findings are unknown. Double-balloon enteroscopy (DBE) enables endoscopic visualization of the small bowel. The aim of this study was to evaluate the use of DBE for detecting small-bowel lesions in CD patients suspected of having small-bowel involvement. Furthermore, the clinical impact of adjusting treatment in these patients was assessed. Material and methods. A prospective study was performed in a tertiary referral center. CD patients suspected of small-bowel involvement and in whom distal activity had previously been excluded were included. All patients underwent DBE, followed by step-up therapy in patients with small-bowel lesions. The presence of small-bowel lesions during DBE was noted and clinical outcome was assessed after adjusting therapy. Results. Thirty-five patients (70%) showed small-bowel lesions; these lesions could not be assessed by conventional endoscopy in 23 (46%). At 1-year follow-up, step-up therapy in 26 patients (74%) led to clinical remission in 23 (88%). This was confirmed by a significant decrease in Crohns disease activity index and mucosal repair on second DBE. Conclusions. DBE showed a high frequency of small-bowel lesions in known CD patients with clinically suspected small-bowel activity. Most of these lesions were not accessible for conventional endoscopy. Adjusting treatment in patients with small-bowel CD involvement led to clinical remission and mucosal repair in the majority of cases.

Single-balloon–assisted colonoscopy in patients with previously failed colonoscopy

BACKGROUND Despite advances in training and equipment, complete colonoscopy fails, even in experienced hands, in up to 10% of cases. Double-balloon endoscopy (DBE) has been successfully used to complete colonoscopy in these patients. Single-balloon endoscopy (SBE) has become established for small-bowel enteroscopy. However, it has yet to be studied for use in colonoscopy. OBJECTIVE To assess the efficacy, performance, and safety of single-balloon colonoscopy. DESIGN Prospective cohort study. SETTING Academic tertiary referral center. PATIENTS Patients with previously failed conventional colonoscopy. RESULTS 23 single-balloon colonoscopy procedures were performed in 22 patients: median age 53 (range 19-75) years; 14 females, 8 males. SBE colonoscopy succeeded in cecal intubation in 22 (96%) procedures, with a median total procedure time of 30 (range 20-60) minutes. SBE colonoscopy was normal in 9 cases but resulted in a positive diagnosis in 13 (57%) procedures, including polyps (n = 6), active Crohns disease (n = 4), Crohns-related stricture (n = 1), and diverticulosis (n = 2). Seven (30%) procedures were therapeutic including 1 case with balloon dilation and 6 cases with polypectomy. No complications were encountered. LIMITATIONS Limited sample size, no direct comparison with double-balloon endoscopy. CONCLUSIONS Single-balloon-assisted colonoscopy seems a safe and effective method for completing colonoscopy in patients with previously failed or difficult colonoscopy. The outcomes are similar compared with previous studies with DBE colonoscopy in this patient group.

Low incidence of hyperamylasemia after proximal double-balloon enteroscopy: has the insertion technique improved?

BACKGROUND AND STUDY AIM Reported complications of double-balloon enteroscopy (DBE) include post-enteroscopy pancreatitis. Hyperamylasemia after proximal DBE is reported frequently, but the relationship to development of pancreatitis remains unclear. Hyperamylasemia may be related to balloon inflation in the pancreatic head region. The aims of the study were to identify risk factors for hyperamylasemia and to determine the incidence of hyperamylasemia and pancreatitis when a modified cautious DBE insertion protocol was used. PATIENTS AND METHODS In a prospective study, involving consecutive patients undergoing a proximal DBE, serum amylase activity was assessed immediately before and after the procedure. RESULTS 135 patients were included (men 78, women 57; mean age 49 years [range 17 - 88]). The mean total procedure time was 73 minutes (range 30 - 150 minutes), and mean number of passes during the proximal DBE was 14 (6 - 24). While patients (17 %) developed hyperamylasemia after the DBE procedure, only one patient with hyperamylasemia had clinical symptoms indicating a mild acute pancreatitis (0.7 %). Total procedure time and number of passes correlated significantly with the occurrence of hyperamylasemia. CONCLUSIONS We found a low incidence of hyperamylasemia and pancreatitis post-DBE. Theoretically, this could result from the modified insertion technique, with local strain and friction of the small bowel as remaining causes of hyperamylasemia, a notion supported by the significant relation between hyperamylasemia and duration of DBE and total number of passes. We therefore advise use of the cautious insertion technique and, if possible, reduction of duration and of number of passes in every proximal DBE.

Single-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy.

Direct percutaneous endoscopic jejunostomy (DPEJ) has emerged as a viable alternative for percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) in patients who cannot tolerate gastric feeding. Reportedly, DPEJ placement with regular endoscopes fails in up to one-third of cases. The aim of the current study was to assess the efficacy and safety of single-balloon enteroscopy (SBE)-assisted DPEJ. The DPEJ placement technique was comparable to conventional PEG placement. A total of 12 DPEJ procedures were performed in 11 patients (mean age 55 years [range 24-83 years]; seven males). SBE-assisted DPEJ was successful in 11 of the 12 procedures (92%). Post-procedural complications included gastroparesis and aspiration pneumonia in one case each. We conclude that SBE-assisted DPEJ placement seems a safe and successful approach for patients requiring jejunal enteral feeding.

Hyperamylasemia and pancreatitis following spiral enteroscopy

BACKGROUND Acute pancreatitis is a significant potential complication with double-balloon enteroscopy. Hyperamylasemia is frequently observed after both double-balloon enteroscopy and single-balloon enteroscopy but often without associated pancreatitis. Whether the same phenomenon occurs with spiral enteroscopy is currently unknown. AIMS To determine the incidence of pancreatitis and hyperamylasemia following spiral enteroscopy. METHODS A prospective cohort study of consecutive patients undergoing proximal spiral enteroscopy was conducted. Serum amylase levels were measured immediately before and following the procedure, combined with observation for clinical signs of pancreatitis. RESULTS A total of 32 patients underwent proximal spiral enteroscopy, with a mean total procedure time of 51 min (range 30 min to 100 min) and mean depth of insertion of 240 cm (range 50 cm to 350 cm). The diagnostic yield was 50%, with 31% of all procedures being therapeutic. While no patients exhibited signs that raised suspicion of pancreatitis, hyperamylasemia was common (20%). Hyperamylasemia was not significantly associated with procedure duration or depth of insertion but was linked to patients with Peutz-Jeghers syndrome and with the use of propofol sedation, suggesting that it may be more common in difficult cases. CONCLUSIONS Postprocedural hyperamylasemia occurred frequently with proximal spiral enteroscopy, while no associated pancreatitis was observed. This finding suggests that hyperamylasemia may not necessarily reflect pancreatic injury nor portend a risk for pancreatitis.

Small bowel diagnostics: Current place of small bowel endoscopy

The small intestine has been difficult to examine by traditional endoscopic and radiologic techniques. Until the end of the last century, the small bowel follow through was the primary diagnostic tool for suspected small bowel disease. In recent years capsule endoscopy, deep enteroscopy using balloon-assisted or spiral techniques, computerized tomography and magnetic resonance enteroclysis or enterography have facilitated the diagnosis, monitoring, and management of patients with small bowel diseases. These technologies are complementary, each with its advantages and limitations. In the present article, we will discuss the different options and indications for modern diagnostic methods for visualization of the small bowel. We also try to provide a clinical rationale for the use of these different diagnostic options in less established, newly emerging, indications for small bowel evaluation.

Therapeutic balloon-assisted enteroscopy.

Since the introduction of the first balloon-based enteroscopic technique in 2001, therapeutic balloon-assisted enteroscopy (BAE) using either the single or double balloon enteroscopy technique (respectively SBE and DBE) has evolved rapidly. Argon plasma coagulation (APC), polypectomy, dilation therapy of strictures, and therapy of the pancreatico-biliary system in patients with surgical altered proximal intestinal anatomy: all have been successfully introduced to treat pathological findings in all segments of the small bowel. The clinical impact of treatment of vascular malformations, strictures caused by chronic inflammation (especially Crohn’s disease) and polypectomy therapy (especially in the Peutz-Jeghers syndrome) seems evident. The decrease of, often repeated, surgical therapy after successful therapeutic BAE in the latter 2 patient groups appears to be a big step forward in treatment. The development of newer enteroscopes, specialized equipment and improved sedation of patients adds positively to the clinical management of undergoing therapeutic BAE. The overall complication rate of therapeutic BAE seems acceptable, but is higher compared to therapeutic colonoscopy which needs further attention in future.

Retrograde double balloon enteroscopy: Comparing performance of solely retrograde versus combined same-day anterograde and retrograde procedure

Abstract Objective. Retrograde double balloon enteroscopy (DBE) is important for evaluating the distal small bowel, but it is more challenging compared to the oral route. Optimizing small bowel insertion may enhance the diagnostic utility of the examination. We sought to determine if insertion depths achieved with retrograde DBE when performed as an isolated procedure differed significantly from when performed immediately following anterograde DBE. Material and methods. A retrospective analysis was conducted of all retrograde DBE procedures performed at our center with comparisons made between “distal-only” DBE without preceding anterograde DBE and “combined” DBE after a prior same-day anterograde DBE. Results. Two hundred ninety retrograde DBE procedures were performed in 264 patients over 5 years. Success of terminal ileal intubation exceeded 95%. The mean insertion depth into the distal small bowel differed significantly with 112 cm (95% CI 95–129) in the “distal-only” group and 92 cm (95% CI 85–98) in the “combined” group (p = 0.01), with a trend toward a corresponding increased diagnostic yield of 48% versus 37%, respectively (p = 0.15). Multivariate regression analysis identified both insertion route strategy (distal-only > combined; p = 0.01) and type of DBE endoscope (diagnostic > therapeutic; p = 0.02) as significant predictors of retrograde insertion depth. Conclusions. The insertion depth of retrograde DBE is significantly greater when carried out as a separate distal procedure and not in combination with a preceding anterograde DBE, and when performed using a diagnostic as opposed to the therapeutic DBE endoscope. This increased retrograde depth of insertion may be associated with an increased diagnostic yield.