Antegrade versus Retrograde Single Balloon Enteroscopy - Which Is Better?

Abstract

Introduction: There are 2 major approaches of single balloon enteroscopy- through mouth or ante-grade approach (AG), or through anus or retrograde (RG)approach. Aim of this study was to assess the differences in performance and complications of both these approaches. Methods: A retrospective cohort study was conducted using a registry of consecutive cases of single balloon enteroscopy at the Cleveland Clinic over 8 years from January 1, 2008- December 31,2016. Electronic medical records were utilized to collect variables including patient demographic, status of antiplatelet agents (at time of procedure), and coexisting comorbid diseases (cardiovascular, renal, and hepatic). Data on endoscopic findings, intervention (if received) was also obtained. Performance of procedures was assessed on the basis of scope time (in minutes), extent reached and need for repeat procedures within 30 days. Numerical values were assigned based on the depth of scope insertion to assess extent reached: 1 = unable to reach small bowel, 2 = proximal jejunum for ante-grade and distal ileum for retro-grade, 3 = mid jejunum for ante-grade and mid ileum for retro-grade, and 4 = distal jejunum for ante-grade and proximal ileum for retro-grade studies. Results: Of 510 patients who underwent SBE, 124 386 (75.7%) patients underwent AG procedures. At baseline patients in both groups were similar, except for older age (68.5 for RG vs 71 for AG, p=0.043) and higher antiplatelet use (34.7% for RG vs 42.5% for AG, p=0.042) in AG group. Deeper scope insertion depth (depth level 3 for AG vs 1 for RG, p < 0.001) and lesser scope time (37.4 mins in AG vs 48.9 mins in RG, p<0.001) was observed with AG procedures. On multivariate analysis AG procedures were found to have 118 higher odds (95% CI 60.5-229.9, p <0.001) of having a deeper scope insertion than RG, and RG procedures had 11.9 higher odds (95% CI 6.7-17, p <0.001) of longer scope time compared to AG. No difference in the rates of adverse outcomes including, bleeding, perforation, aspiration and change in level of care were noted between the two modalities. (Table 1&2)2793_A Figure 1 No Caption available.Conclusion: AG approach is less time consuming and more likely to have a deeper extent of insertion compared to RG approach, with similar rates of complications. Unless the lesion of interest is in close proximity to the ileo-cecal valve, it may be more prudent to proceed with AG approach rather than RG approach.2793_B Figure 2 No Caption available.