Stephen Hughes

OC-025 The first report of the UK multicentre double balloon enteroscopy registry: broadening the international deep enteroscopy experience

Introduction Double balloon enteroscopy (DBE) has been a pivotal endoscopic technology, transforming the investigation and management of small bowel (SB) disorders by facilitating direct endoscopic access of the entire small bowel. Methods We report the initial experience of the UK multicentre registry (six centres) since the introduction of DBE in the UK in 2005. Results 550 cases (322 men) were performed. Mean age was 56 years (16–94 years). 189 cases were done under general anaesthesia, 361 cases done under conscious sedation. 372 cases were performed via the oral route, 175 were performed via the rectal route while three cases were performed via an ileostomy. Calculated mean depth of insertion was 270±80 cm and 190±75 cm for oral and rectal routes, respectively. Mean time taken to complete procedures was 74±20 min. Carbon dioxide was used as the insufflating gas in 344 cases while air was used in the remaining 206 cases. DBE was preceded by capsule endoscopy (CE) in 403 cases. Concordance of diagnoses at CE and DBE was 66% and the overall diagnostic yield for DBE was 61%. The indications and therapies applied at DBE are shown (Abstract 025). Significant lesions missed by CE but diagnosed by DBE included large vascular lesions, polyps and other small bowel tumours. Endoscopic therapy at DBE was applied in 38% of procedures. There were three reported complications (2 perforations and 1 acute coronary syndrome); all complications occurred during therapeutic procedures. The overall complication rate for DBE in the series was 0.5%, with a complication rate for therapeutic procedures of 1.4%. There were no cases of acute pancreatitis. Limitations to DBE procedures included patient intolerance, the presence of adhesions and poor bowel preparation. Abstract OC-025 Indications and endotherapy applied Indictn. Cases Indictn. Cases Endo. Rx Cases OGIB 347 Rx-en-Y 2 - - APC 147 CD 58 - - Plpectmy 36 Polyps 49 - - Dilation 18 Strictr. 36 - - DPEJ 7 ?Tumour 28 - - Endoclip 2 Coeliac 15 - - Thrombin 1 DPEJ 8 - - Intussus 4 - - Ret. CE 3 - - Conclusion The initial UK experience is favourable and echoes the results of other national series published to date, showing that DBE is a feasible and safe and endoscopic advancement that enhances the management of small bowel disorders.

PTU-045 Device Assisted Enteroscopy in the United Kingdom: Description of A Large Tertiary Case Series Under Conscious Sedation

Introduction Device assisted enteroscopy (DAE) has developed rapidly over the past decade, particularly with the advent of double balloon enteroscopy (DBE). The present study reports a case series from a tertiary centre for enteroscopy in the Southwest of the UK serving approximately 1 million people. Data was collected across three modalities of enteroscopy - DBE, Spiral enteroscopy (SE) and push enteroscopy (PE) - under conscious sedation. Methods Observational study of 343 enteroscopy procedures in 271 patients referred for enteroscopy from 2008 to 2014. Data were collected on patient demographics, procedure indications, diagnosis, sedation requirements, extent, duration, complications, tolerance and types of therapy performed. Completion rate was defined as a DAE procedure that changed patient management via therapy, diagnosis or normal finding. All patients who had procedures during the study period were included in the analysis. Ethical review was obtained from North Bristol NHS Trust local ethics committee. Comparison of numerical data was performed using t-test or one-way ANOVA analysis for comparison of multiple means. Comparison of categorical data was performed using chi-squared testing or correlation testing. Results Obscure GI bleeding (OGIB) was the commonest indication for DAE (n = 205, 59.7%). The overall yield of DAE was low (48.5%), with greater likelihood of positive findings if the indication was OGIB (55% vs 37.6%, p < 0.001) and in older patients (mean age normal exam 60.0 vs. abnormal exam 66.5 years, p < 0.001). Higher mean doses of midazolam were used for DBE from above (DBEa) (5.4 mg) and SE (5.6 mg) with lower doses for DBE from below (DBEb) (4.4 mg) and PE (3.8 mg). No serious complications were reported over the study period. SE was associated with shorter procedure time and shorter depth of insertion when compared to DBEa. Tolerance of DAE under conscious sedation was good with the majority (313/343, 91.2%) of procedures tolerated with comfort score 0 or 1 (out of 3). PE was significantly better tolerated whilst DBEb and SE were significantly worse tolerated than DBEa (p < 0.001). Therapy was performed in 154/343 (44.9%) of procedures. Indications of OGIB (p = 0.021) and prior abnormal capsule endoscopy (p = 0.026) predicted performing therapy at DAE. Completion rates were more likely with DBEb (92.2% vs 69.9%, p < 0.001) and less likely with PE (63% vs 77.8%, p = 0.006). Conclusion Small bowel enteroscopy under conscious sedation is safe and generally well tolerated. The procedure is of low yield; however this is a complex and extensively investigated cohort of patients. Nonetheless, small bowel enteroscopy should be used primarily for therapy once a diagnosis has been made by other modalities such as wireless capsule endoscopy. Disclosure of Interest None Declared

PTH-037 Double balloon enteroscopy under conscious sedation is safe and well tolerated

Introduction Double balloon enteroscopy (DBE) has become the test of choice for complete investigation of the small bowel.1Southmead hospital is a large centre in the Southwest of the United Kingdom serving a population of 620,000. It acts as a tertiary referral centre for DBE serving in excess of 2 million people. We report the experience of this centre with 205 patients who underwent DBE under conscious sedation. Method The endoscopy database was interrogated for all DBE procedures performed from 04/2009 to 10/2014. During this period there were two Consultant operators and an additional Consultant operator started in 05/2013. Data was collected retrospectively on multiple factors associated with the procedure; these included dose of sedative agents, endoscopist and nursing comfort scores and serious complications. The data was analysed by chi-squared, ANOVA, Fisher transformation test and unpaired t-test. Results 205 procedures were performed over the study period: 139 DBE from above and 66 DBE from below. The mean age (+- standard deviation) was 62.8 (+-2.2) years, range 17–94. All procedures were performed under conscious sedation. The agents used were midazolam alone or with the addition of pethidine or fentanyl. Midazolam was used in 181 cases and the average dose was 5.2mg (+-0.3), range 1–12 mg. The dose was higher for DBE from above (mean 5.6 mg) versus DBE from below (mean 4.36mg) (p < 0.001). Lower doses of midazolam were used in older patients (p < 0.001) and there was no difference between the three endoscopists (p = 0.522). Pethidine was used in 176 cases. The average dose was 44.2 mg (+-1.6) (range 25–50 mg). This did not vary significantly between the two procedure types performed (p = 0.716). Fentanyl was used in 5 cases with a mean dose of 80mcg. Comfort scores recorded by nursing staff and endoscopists were compared using the departmental comfort score which rates discomfort during endoscopic procedures from 0 (comfortable) to 3 (severe discomfort). 50% of the procedures were performed with a rating of zero. Two was the maximum pain score attributed to any procedure and this occurred in only 11% of cases. Comfort scores were well correlated between nursing and endoscopist reporting (p < 0.001). DBE from above was significantly better tolerated than DBE from below (p < 0.001) and older patients tolerated the procedure significantly better than younger patients (p = 0.023). There were no cases of perforation, significant bleeding, 8 day readmission nor 30-day mortality. Conclusion We have demonstrated in this large cohort of patients that DBE under conscious sedation is safe and well tolerated without the need for general anaesthesia. Disclosure of interest None Declared. Reference Rahmi G, Samaha E, Vahedi K et al. Multicenter comparison of double-balloon enteroscopy and spiral enteroscopy. J Gastroenterol Hepatol. 2013;28:992–998

Comparison of the yield of spiral enteroscopy to wireless capsule endoscopy findings: report from a single UK centre

Introduction Spiral enteroscopy (SE) is used to evaluate and treat lesions affecting the small intestine. Abnormalities are often initially found using other diagnostic tools such as radiological imaging and wireless capsule endoscopy (WCE). There is little published data evaluating the findings of SE in patients with abnormalities seen at prior capsule endoscopy. The aim is to evaluate the diagnostic yield of spiral enteroscopy and compare findings in patients who had previously had wireless capsule endoscopy in a single UK centre. Methods A retrospective analysis of case notes of all patients undergoing WCE followed by SE was performed. Data regarding patient demographics, indications for WCE, WCE findings, subsequent SE findings and therapy performed was collected and analysed. Results 22 patients had capsule endoscopies followed by SE. Two patients had repeat WCE and two had SE twice. SE was performed orally on 23 occasions and once per rectum. There were 17 male and 7 female patients. Mean age was 70.6 (range 40–90). Indications for WCE were recurrent iron deficiency anaemia (11), gastrointestinal bleeding/melaena (5), occult gastrointestinal bleeding (5), anaemia and abdominal pain (2), and abdominal pain (1). Findings on WCE included angiodysplasia (9), normal examination (6), ulceration (3), small bowel diverticula (2), polyps (2), ulceration (2), findings suspicious for angiodysplasia (2), strictures (1) and nodular lymphoid hyperplasia (1). Two patients had more than one abnormality identified. The mean time from WCE to SE was 190.9 days (range 28–850). All SEs were performed under conscious sedation. The estimated depth of insertion was available for 20 patients, with a mean of 215.2 cm (range 100–300 cm) per oral, and 50 cm from the ICV per rectum. Mean time for the procedure in 20 patients was 40.5 min (range 25–65). Abnormalities were found by SE in 14 (70%) cases. Findings on WCE were reproduced at SE in 19 cases (79.2%). In three cases, SE found additional pathology not seen at WCE (two angiodysplasia, one jejunal diverticulae). In two cases SE clarified suspicious but non diagnostic abnormalities seen at WCE (angiodysplasia) and in two cases of small bowel polyps seen at WCE, SE confirmed a diagnosis of polypoid lymphangiectases. Thirteen cases (54.2%) underwent therapy in the form of APC with complete haemostasis in all. Conclusion In our experience, SE is able to locate pathology found on WCE in 79.2% of cases, but it may also find additional pathology and clarify non diagnostic findings. SE also permits therapy and complements WCE in the management of patients with suspected small bowel pathology.

OC-024 Spinning through the small bowel: first report of the UK (multicentre) experience of spiral enteroscopy

Introduction This decade has witnessed a revolution in small bowel (SB) endoscopy. Balloon assisted enteroscopy (double-balloon and later single-balloon) has dramatically expanded the capacity to endoscopically manage SB pathology. More recently, a novel device assisted enteroscopy named spiral enteroscopy (SE) is a promising alternative method of deep enteroscopy. SE uses a pliable plastic spiral threaded onto a flexible overtube (Spirus, Endoase Discovery SB, Spirus Medical, Massachusetts, USA). Rotational torque applied to the overtube allows the spiral thread to engage the SB. This advances the overtube and enteroscope deeper into the small bowel. Methods We report an early multicentre experience of SE since its introduction to the UK in November 2008. Results 23 procedures (12 male) were done at two tertiary referral centres. Mean age was 58 years (19–81 years). 11 procedures were done under conscious sedation while the remaining 12 were under general anaesthesia. 22 procedures were performed via the oral route; 1 procedure was done via the rectal route. Carbon dioxide was used as an insufflating gas in 13 procedures while air was used for rest. The most common indication for SE was mid-gut bleeding (n=17). Other indications included SB polyposis (n=5) and direct percutaneous endoscopic jejunostomy (DPEJ) feeding tube replacement (n=1). 22 procedures were continued to the maximal point of insertion until forward advancement of the enteroscope ceased. One oral procedure was aborted due to the presence of gastric contents despite a 14-hour fast. Mean duration of procedures was 42±12 min. In one patient, where the spiral engaged the SB throughout the procedure, pan-enteroscopy was achieved in 65 min. In the patient undergoing rectal SE, SB intubation distance was estimated to be 50 cm proximal to the ICV. Eight patients were treated with argon plasma coagulation for angioectasias and one patient had multiple polypectomies. In one patient, the overtube induced some minor submucosal bruising; the patient remained well after the procedure. No other complications ensued. The main limitation to SE was related to occasional inability of the spiral to engage the SB. In another two patients, the SE failed to reach the location of SB tattoos placed at previous DBEs. In another patient, SE failed to reach a proximal ileal polyp (subsequently reached by DBE in the same session). Conclusion The initial UK experience with SE suggests that where SB engagement readily occurs, deep SB intubation can be achieved in a relatively short time. Anecdotally, the SE also appears to provide a stable platform for therapeutic interventions. Further comparative studies would be helpful.

THE FIRST REPORT OF THE UK MULTICENTRE DOUBLE BALLOON ENTEROSCOPY REGISTRY

Introduction Double balloon enteroscopy (DBE) has been a pivotal endoscopic technology, transforming the investigation and management of small bowel (SB) disorders by facilitating direct endoscopic access of the entire small bowel. Methods We report the initial experience of the UK multicentre registry (six centres) since the introduction of DBE in the UK in 2005. Results 550 cases (322 men) were performed. Mean age was 56 years (16–94 years). 189 cases were done under general anaesthesia, 361 cases done under conscious sedation. 372 cases were performed via the oral route, 175 were performed via the rectal route while three cases were performed via an ileostomy. Calculated mean depth of insertion was 270±80 cm and 190±75 cm for oral and rectal routes, respectively. Mean time taken to complete procedures was 74±20 min. Carbon dioxide was used as the insufflating gas in 344 cases while air was used in the remaining 206 cases. DBE was preceded by capsule endoscopy (CE) in 403 cases. Concordance of diagnoses at CE and DBE was 66% and the overall diagnostic yield for DBE was 61%. The indications and therapies applied at DBE are shown (Abstract 025). Significant lesions missed by CE but diagnosed by DBE included large vascular lesions, polyps and other small bowel tumours. Endoscopic therapy at DBE was applied in 38% of procedures. There were three reported complications (2 perforations and 1 acute coronary syndrome); all complications occurred during therapeutic procedures. The overall complication rate for DBE in the series was 0.5%, with a complication rate for therapeutic procedures of 1.4%. There were no cases of acute pancreatitis. Limitations to DBE procedures included patient intolerance, the presence of adhesions and poor bowel preparation. Abstract OC-025 Indications and endotherapy applied Indictn. Cases Indictn. Cases Endo. Rx Cases OGIB 347 Rx-en-Y 2 - - APC 147 CD 58 - - Plpectmy 36 Polyps 49 - - Dilation 18 Strictr. 36 - - DPEJ 7 ?Tumour 28 - - Endoclip 2 Coeliac 15 - - Thrombin 1 DPEJ 8 - - Intussus 4 - - Ret. CE 3 - - Conclusion The initial UK experience is favourable and echoes the results of other national series published to date, showing that DBE is a feasible and safe and endoscopic advancement that enhances the management of small bowel disorders.

OC-025 The first report of the UK multicentre double balloon enteroscopy registry: broadening the international deep enteroscopy experience: Abstract OC-025

Introduction Double balloon enteroscopy (DBE) has been a pivotal endoscopic technology, transforming the investigation and management of small bowel (SB) disorders by facilitating direct endoscopic access of the entire small bowel. Methods We report the initial experience of the UK multicentre registry (six centres) since the introduction of DBE in the UK in 2005. Results 550 cases (322 men) were performed. Mean age was 56 years (16–94 years). 189 cases were done under general anaesthesia, 361 cases done under conscious sedation. 372 cases were performed via the oral route, 175 were performed via the rectal route while three cases were performed via an ileostomy. Calculated mean depth of insertion was 270±80 cm and 190±75 cm for oral and rectal routes, respectively. Mean time taken to complete procedures was 74±20 min. Carbon dioxide was used as the insufflating gas in 344 cases while air was used in the remaining 206 cases. DBE was preceded by capsule endoscopy (CE) in 403 cases. Concordance of diagnoses at CE and DBE was 66% and the overall diagnostic yield for DBE was 61%. The indications and therapies applied at DBE are shown (Abstract 025). Significant lesions missed by CE but diagnosed by DBE included large vascular lesions, polyps and other small bowel tumours. Endoscopic therapy at DBE was applied in 38% of procedures. There were three reported complications (2 perforations and 1 acute coronary syndrome); all complications occurred during therapeutic procedures. The overall complication rate for DBE in the series was 0.5%, with a complication rate for therapeutic procedures of 1.4%. There were no cases of acute pancreatitis. Limitations to DBE procedures included patient intolerance, the presence of adhesions and poor bowel preparation. Abstract OC-025 Indications and endotherapy applied Indictn. Cases Indictn. Cases Endo. Rx Cases OGIB 347 Rx-en-Y 2 - - APC 147 CD 58 - - Plpectmy 36 Polyps 49 - - Dilation 18 Strictr. 36 - - DPEJ 7 ?Tumour 28 - - Endoclip 2 Coeliac 15 - - Thrombin 1 DPEJ 8 - - Intussus 4 - - Ret. CE 3 - - Conclusion The initial UK experience is favourable and echoes the results of other national series published to date, showing that DBE is a feasible and safe and endoscopic advancement that enhances the management of small bowel disorders.