Colon and Ileum Intubation Times Are a Significant Component of the Time it Takes to Perform Retrograde Overtube-Assisted Enteroscopy and May Affect Procedure Efficiency

Abstract

Introduction: Retrograde double balloon overtube-assisted enteroscopy (rDBE) is used to investigate distal small bowel pathology. These are time-intense procedures, and most centers allocate 90-min blocks for them. The database was reviewed to determine rDBE total procedure time, the fraction of time it took to reach the cecum and intubate the ileum, and potential factors for incomplete rDBE. Methods: All rDBE are performed using a Fujinon EN-450T5 enteroscope and TS-13140 balloon overtube (Fujinon, Inc, Saitama, Japan) with propofol sedation. Data were captured from August 2012 to November 2013. Patients with unaltered intestinal anatomy and recorded total procedure time, time to cecum, time to ileum intubation, and estimated depth of insertion (in cm) were included. Means and medians were compared and p<0.05 was considered significant. Results: Sixteen patients were identified (7 females; 62.6 ± 16 years; 10 had previous abdominal/pelvic surgeries). Indications: occult GI bleeding 13, mid SB stricture 1, SB polyps 1, abnormal imaging 1. Ten patients had abnormal video capsule endoscopy (blood 4, mass 3, polyps 2, ulcer 1). There were no strictures of the IC valve. Mean total procedure time (from anal insertion to anal withdrawal) was 52.8 min (SD 16.6); median depth of insertion was 120 cm from IC valve (IQR 45-235). Time to reach cecum was 6.5 minutes (SD 3.5), or 12.3% of the total procedure time. Time to achieve ileal intubation was 13.5 minutes (SD 11.6 minutes), or 25.5% total procedure time. Pathology was found in 7/16 pts (44%): mass in 3, angioectasia 3, polyp 1. In 3 patients (all female and previous abdominal/pelvic surgeries) where the target depth of ileum insertion was not achieved, ileum intubation took longest and they had the shortest depth of SB insertion compared to the cohort. Conclusion: The data showed that 38% of the total procedure time was spent outside the small bowel (reaching the IC valve and intubating ileum). Diagnostic yield was 44%, within reported range, but it would be ideal to find ways to shorten the interval outside of the small bowel to maximize endoscopy efficiency. This could improve the length and time of SB visualization and potentially the diagnostic yield. Interestingly, the time it took to intubate the ileum was inversely related to depth of ileum intubation. Difficult ileum intubation may predict a lower yield or incomplete rDBE, but more data will be needed to confirm this.Table 1: Comparison Between Incomplete and Complete Retrograde Enteroscopies