Double-balloon Research Articles

Surgical Management of Benign Neoplasms of the Small Intestine

Small intestinal benign tumours are uncommon clinical conditions that frequently go asymptomatic for the entirety of a patient's life. The small bowel contains only a tiny number of primary neoplasms, while making up most of the surface area and most of the length of the gastrointestinal (GI) tract. There are the following subtypes: Hyperplastic polyps, hamartomas, adenoma, stromal tumours, lipomas, hemangiomas, and patients who have Peutz-Jeghers syndrome. Clinically, speaking, benign small-bowel lesions are distinguished by the absence of distinguishing symptoms. Up to the proximal duodenum lesions can be diagnosed with enteroscopy. Push or double-balloon enteroscopy methods can be used to reach the GI tract beyond the ligament of Treitz. The sole method of treatment for those who have small bowel adenocarcinoma is surgery. The majority of research state that between 40 and 65 percent of patients lend themselves to curative resection. The utilisation of laparoscopic surgery (LS) for small intestine gastrointestinal stromal tumours (GISTs) has expanded with the introduction of LS. There is currently no evidence to suggest a statistically significant difference between LS and open surgery in terms of prognosis. This review aims to summarize evaluation and management of benign neoplasms of the small intestine.

Cytomegalovirus Graft Duodenitis Diagnosed by Transanal Double-Balloon Endoscopy Technique in an Enteric-Drained Pancreas Transplant Recipient: A Case Report

Duodenal graft complications are not uncommon after pancreas transplant (PTx). Although direct visualization and biopsy of the duodenal graft are important for accurate diagnosis and management, endoscopic access is often limited in cases of enteric-drained PTx. Herein, we present a case of cytomegalovirus (CMV) graft duodenitis that was successfully diagnosed by transanal endoscopy using the double-balloon technique. The patient was a 54-year-old woman who underwent simultaneous pancreas and kidney transplant for type 1 diabetes mellitus and end-stage kidney disease. Enteric drainage was established by anastomosing the graft duodenum to her ileum. One month after the transplant, she developed fever and complained of lower abdominal pain. Graft duodenitis was suspected by laboratory test and imaging study results. Transanal double-balloon endoscopy was performed, and the biopsy specimen of the mucosa of the graft duodenum revealed CMV duodenitis without histopathologic findings of acute rejection. The postendoscopy course was uneventful. Treatment with ganciclovir was promptly initiated, and the CMV duodenitis was resolved with good function of the pancreas graft. In patients who undergo PTx with establishment of exocrine drainage by enteroanastomosis to the recipient ileum, transanal double-balloon endoscopy might be a feasible and safe technique for the surveillance of duodenal graft complications, including CMV duodenitis.

Obscure gastrointestinal bleeding from a large jejunal lipoma treated using an endoscopic unroofing technique with double balloon enteroscopy: a case study.

Small intestinal lipomas are rare, but may cause obscure gastrointestinal bleeding. The endoscopic unroofing technique excises only the upper third of the lipoma and allows both histological confirmation and complete treatment with minimal risk of perforation. We present a rare case of obscure gastrointestinal bleeding caused by a jejunal lipoma. A 75-year-old man on antiplatelet therapy presented to our department with melena and anemia. Computed tomography revealed he had a 45-mm jejunal submucosal tumor with fat attenuation. Endoscopic resection using an endoscopic unroofing technique with double balloon enteroscopy was successfully performed. The tumor was confirmed to be a lipoma.

Maternal Morbidity After Double Balloon Catheter Management of Cesarean Scar and Cervical Pregnancies.

We performed a retrospective cohort study of all Type 1 cesarean scar pregnancies (n=18) or cervical pregnancies (n=5) at an academic tertiary center after treatment with a cervical double balloon catheter from 2018 to 2022 to evaluate outcomes and maternal morbidity. Cervical double balloon catheter treatment was associated with no cases (95% confidence interval 0-16%) of maternal hemorrhage treated with transfusion, hysterectomy, or ICU admission. Treatment was successfully performed by nine different obstetrics and gynecology specialists.

Outcomes of endoscopic retrograde cholangiography and percutaneous transhepatic biliary drainage in liver transplant recipients with a Roux-en-Y biliary-enteric anastomosis.

Data regarding outcomes of endoscopic retrograde cholangiography (ERC) in liver transplant (LT) recipients with biliary-enteric (BE) anastomosis are limited. We report outcomes of ERC and percutaneous transhepatic biliary drainage (PTBD) as first-line therapies in LT recipients with BE anastomosis. All LT recipients with Roux-BE anastomosis from 2001 to 2020 were divided into ERC and PTBD subgroups. Technical success was defined as the ability to cannulate the bile duct. Clinical success was defined as the ability to perform cholangiography and therapeutic interventions. A total of 36 LT recipients (25 males, age 53.5 ± 13 years) with Roux-BE anastomosis who underwent biliary intervention were identified. The most common indications for a BE anastomosis were primary sclerosing cholangitis (n = 14) and duct size mismatch (n = 10). Among the 29 patients who initially underwent ERC, technical success and clinical success were achieved in 24 (82.8%) and 22 (75.9%) patients, respectively. The initial endoscope used for the ERC was a single balloon enteroscope in 16 patients, a double balloon enteroscope in 7 patients, a pediatric colonoscope in 5 patients, and a conventional reusable duodenoscope in 1 patient. Among the 7 patients who underwent PTBD as the initial therapy, six (85.7%) achieved technical and clinical success (p = 0.57). In LT patients with Roux-BE anastomosis requiring biliary intervention, ERC with a balloon-assisted enteroscope is safe with a success rate comparable to PTBD. Both ERC and PTBD can be considered as first-line therapies for LT recipients with a BE anastomosis.

Motorized spiral enteroscopy versus double-balloon enteroscopy: a case-matched study

Motorized spiral enteroscopy (MSE) has been postulated to ease the complexities of the standard-of-care double-balloon enteroscopy (DBE). However, there are no comparative studies between MSE and DBE. This study aimed to compare the therapeutic outcomes and safety between MSE and DBE. In this case-matched study, patients were matched 1:2 (MSE/DBE) by age, sex, body mass index, and American Society of Anesthesiology scores. Thirty-one patients who underwent MSE were compared with 62 patients who underwent DBE from 2014 to 2022. Our primary outcomes were to compare the technical and diagnostic success rates between DBE and MSE. Our secondary outcomes were to compare the therapeutic success and adverse event rates. The main indications for enteroscopy were suspected GI bleeding and positive radiologic findings. Prior abdominal surgery was reported in 35.5% and 22.6% of DBE and MSE patients, respectively. Most were antegrade enteroscopy (71%). We found no significant difference in the technical success (DBE 98.4% vs MSE 96.8%, P= .62), diagnostic success (DBE 66.1% vs MSE 54.8%, P= .25), and therapeutic success rates (DBE 62.8% vs MSE 52.9%, P= .62) between the groups. Adverse events occurred in 1 DBE and 11 MSE patients. Most were minor (n= 10, 25.6%). Two patients (5.1%) in the MSE group sustained deep lacerations in the proximal esophagus requiring hospitalization. One developed ileal perforation after MSE needing surgical repair. In patients requiring enteroscopy, the diagnostic and therapeutic performance of MSE is similar to DBE. An increased frequency of adverse events was observed with MSE. There are some restrictions in the indication because of the design of MSE.

Pain and satisfaction in women induced by vaginal dinoprostone, double balloon catheter and oral misoprostol

ObjectiveThe aim of this study was to evaluate the pain experience of women induced by intravaginal dinoprostone (Propess®), oral misoprostol (Angusta®) or double balloon catheter (Cook®). MethodsThis single-center prospective study was carried out in the obstetric gynecology department of the university hospital of Saint-Etienne from March 2018 to April 2021 in women requiring cervical ripening for the purpose of artificial labor induction. ResultsWe included 82 women in the oral misoprostol group, 35 in the vaginal dinoprostone group and 58 in the balloon group. The overall pain, assessed by a numerical scale from 0 to 10, was similar for the different methods of induction (p = 0.253). Pain at insertion was greater with the double balloon catheter compared to the vaginal dinoprostone (3.67 versus 5.75 p = 0.001). Pain in the 2 h prior to the delivery room was greater with vaginal dinoprostone and oral misoprostol compared with the double balloon catheter (7.91 and 7.4 versus 5.47 respectively, p = <0.0001). Women induced by balloon catheter would more often have preferred to be induced by another method compared to those induced by oral misoprostol or vaginal dinoprostone (p = 0.004). Adjusting for previous cesarian section, gestational age at delivery, need for oxytocin augmentation and indication for induction, women induced by balloon were five times more risk to prefer another induction method (OR 5.01 95% CI [1.09–23.03], p = 0.038). There was no significant difference in stress and overall experience of induction depending on the method. ConclusionIn order to improve the women experience, information, consent and participation in the decisions and choices of their induction method are essential.

Rhode Island gastroenterology video capsule endoscopy data set

Complete endoscopic evaluation of the small bowel is challenging due to its length and anatomy. Although several advances have been made to achieve diagnostic and therapeutic goals, including double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy, video capsule endoscopy (VCE) remains the least invasive tool for complete visualization of the small bowel and is the preferred method for initial diagnostic evaluation. At present, interpretation of VCE data requires manual annotation of landmarks and abnormalities in recorded videos, which can be time consuming. Computer-assisted diagnostic systems using artificial intelligence may help to optimize VCE reading efficiency by reducing the need for manual annotation. Here we present a large VCE data set compiled from studies performed at two United States hospitals in Providence, Rhode Island, including 424 VCE studies and 5,247,588 total labeled images. In conjunction with existing published data sets, these files may aid in the development of algorithms to further improve VCE.

S1097 Clinical Outcomes of Double Balloon Enteroscopy: An 8-Year Tertiary Center Experience

Introduction: The objectives of this study are to examine clinical characteristics of patients undergoing anterograde and retrograde double balloon enteroscopy (DBE) and to assess factors predicting 6-month readmission Methods: We conducted a retrospective cohort study of patients (n=1162) who underwent DBE at an academic tertiary care center between November to December 2020. Baseline patient data as well as DBE related variables were collected. Outcome variables included readmission rates, diagnostic and therapeutic yield. Measures of central tendency and frequency distributions were used for univariate analysis. Chi-square and student 2 sample t-test were performed to compare patient characteristics. Logistic regression was used for outcome variable analysis. Results: Of the 1162 DBE procedures, 50.95% were male (n= 592) with a mean age of 61.29 (15.33, SD). The most common indications for procedure being GI bleed (61%) and abnormal video capsule endoscopy findings (30%). The cohort’s rate of positive diagnostic yield was 65% and 57% for therapeutic yield. The mean procedural time was 39.80 (21.31, SD) minutes, and 77% of DBE patients received anterograde procedures. Compared to retrograde procedures, a higher proportion of DBE patients with anterograde procedures had positive diagnostic yield (66% vs. 62%, p=.254) (Table). Readmission rates at 30 days and 6 months were 11% and 18% respectively. Anterograde procedures were more likely to be inpatient (37% vs 29%, p=0.018) and associated with shorter procedure time (38.67 ± 204.5 vs 43.7 ± 23.7 minutes, p=0.0008) and higher therapeutic yield (60% vs 46%, p=0.00) ( Figure). Univariate analysis depicted inpatient status, total procedure minutes, and anticoagulation use to be associated with 6-month readmission (all P< 0.05). After controlling for each variable through multivariable analysis, inpatient status [OR:3.56, 95% CI (2.59-4.89), p=0.00] and total procedure minutes [OR:1.01, 95% CI (1.00-1.01), p=0.03] remained significant predictors of 6-month readmission Conclusion: DBE procedures has high efficacy for both diagnostic and therapeutic yield while evaluating GI bleed, abdominal pain, iron deficiency anemia, as well as performing ERCP in patients with altered upper GI anatomy. Patients undergoing anterograde DBE are associated with shorter procedure time and higher therapeutic yield compared to patients undergoing retrograde DBE. DBE patients who are inpatients and higher procedural times are more likely to be readmitted in 6 months.Figure 1.: Univariate and Multivariable Logistic Regression Analysis predicting 6-month readmission rate Table 1. - Patient characteristics and outcome variables stratified based on procedure type (anterograde vs retrograde) Variable Anterograde (n=900) Retrograde(n=262) P-Value Sex Male 459 (51%) 133 (51%) .95 Female 441 (49%) 129 (49%) Age, Range: 35-93, Mean (SD) 61.17 (15.30) 61.69 (15.49) .629 Patient Type Outpatient 571 (63%) 187 (71%) .018 Inpatient 329 (37%) 75 (29%) BMI Less than 25 304 (34%) 77 (29%) .183 25 or more 596 (66%) 185 (71%) Altered Anatomy No 695 (77%) 234 (89%) .000 Yes 205 (23%) 28 (11%) Anticoagulation No 780 (87%) 230 (88%) .636 Yes 120 (13%) 32 (12%) ESRD No 858 (95%) 247 (94%) .485 Yes 42 (5%) 15 (6%) Anesthesia Type General 809 (90%) 97 (37%) .000 Mac 91 (10%) 165 (63%) Total procedural time Mean (SD) 38.67 (20.45) 43.70 (23.70) .0008 Therapeutic Yield No 361 (40%) 141 (54%) .000 Yes 539 (60%) 121 (46%) Positive Finding No 305 (34%) 99 (38%) .244 Yes 595 (66%) 163 (62%) Readmission 30-day No 791 (88%) 238 (91%) .187 Yes 109 (12%) 24 (9%) Readmission 6 Month No 731 (81%) 219 (84%) .383 Yes 169 (19%) 43 (16%)

S2875 The Utility of Endoscopic Ultrasound and Fine Needle Biopsy in Diagnosing Remnant Gastric Cancer After Roux-en-Y Gastric Bypass Procedure

Introduction: Roux-en-Y gastric bypass (RYGB) procedure is commonly performed for severe obesity. These patients are at risk of developing remnant gastric cancer. Double-balloon endoscopy (DBE) is typically used to obtain a biopsy. We present two cases of remnant gastric cancer diagnosed using endoscopic ultrasound (EUS). Case Description/Methods: Case 1 is a 76-year-old female status post RYGB who presented with 40-pound weight loss, anorexia and constipation. Labs showed hemoglobin of 6.1 g/dL. Computed tomography (CT) of the chest, abdomen and pelvis revealed hepatic masses and gastric remnant thickening. CA 19-9 was 200,000 U/ml and CEA was 683 ng/dL. Esophagogastroduodenoscopy (EGD) revealed Roux-en-Y gastrojejunostomy with healthy appearing mucosa and a normal jejunum. Colonoscopy showed internal hemorrhoids. Liver biopsy was inconclusive. Concern for remnant gastric cancer, in light of no obvious primary, prompted transgastric EUS guided fine needle biopsy (FNB) of the remnant pouch which confirmed gastric adenocarcinoma.Case 2 is a 49-year-old female status post RYGB who presented with left flank pain,12-pound weight loss and fevers. Labs showed hemoglobin 9 g/dL. CT of the abdomen showed wall thickening involving the gastric pouch and gastric remnant. CEA was 96.6 ng/dL and CA-125 was 348.7 U/ml. EGD revealed a small gastric pouch, gastrojejunal anastomosis characterized by polypoid appearing lesions which were biopsied and found to be benign, and a normal jejunum. Colonoscopy showed inflammation in the cecum and transverse colon and biopsies revealed adenocarcinoma consistent with metastatic signet ring cell carcinoma. Transjejunal EUS guided FNB of the gastric remnant confirmed signet ring cell adenocarcinoma. (Figure) Discussion: EUS is a valuable tool for tissue acquisition especially because DBE has challenges of high operator dependence and long procedure times. Case reports have described EUS guided placement of lumen-apposing metal stents (LAMS) to create a conduit into the gastric remnant to obtain biopsies. However, LAMS are highly operator dependent and carry complications of stent migration, bleeding, infection and perforation. The EUS guided FNB technique is shown in image 1. There were no complications intra or post operatively. Our cases show that EUS with a trans-gastric or trans-jejunal approach provides a less invasive approach that is more operator-friendly, time saving and yields adequate tissue acquisition.Figure 1.: EUS images. A, Case 1: Transgastric view of thickened gastric remnant. B, Case 1: Fine needle biopsy of gastric remnant wall. C, Case 2: Transjejunal view of thickened gastric remnant. D, Fine needle biopsy of gastric remnant wall.

S2850 Migrated Esophageal Stent Obstructing the Distal Jejunum, Safely Removed by Double-Balloon Enteroscopy Using a Water Immersion Technique

S2850 Migrated Esophageal Stent Obstructing the Distal Jejunum, Safely Removed by Double-Balloon Enteroscopy Using a Water Immersion Technique

S3497 Tubulo-Villous Adenoma of the Distal Ileum Presenting With Small Bowel Obstruction-Like Symptoms

Introduction: Small bowel tumors (SBT) are rare and account for < 3% of all gastrointestinal tumors in the United States. Given their insidious presentation with non-specific symptoms, they can evade detection and cause delays in diagnosis. Case Description/Methods: A 74-year-old lady came to the ER with abdominal pain, nausea, vomiting and abdominal distention since two days. Past medical history included esophageal spasm, GERD, achalasia, hypertension, CKD with anemia and fibromyalgia and had undergone total abdominal hysterectomy. At her last colonoscopy 10 years ago a 5 cm tubular adenoma was excised and a repeat was advised after 5 years, which she did not follow up with. EGD 8 years ago showed grade 1 reflux esophagitis, normal stomach and small bowel. Pulse was 100/minute and BP was 132/77. Abdomen was soft and distended, with tenderness in the right upper quadrant and epigastrium. Hb was 9.2 g/dL, consistent with her baseline. Though abdominal CT suggested SBO with a transition point just proximal to the ileocecal valve, a small bowel series ruled out an SBO. The patient was made NPO and NGT was placed. Colonoscopy revealed a partially obstructing, medium-sized, fungating, friable, infiltrative, circumferential, villous mass, 8-10 cm away from the ileocecal valve. Histopathology confirmed tubulovillous (TV) adenoma with no signs of dysplasia or malignancy. The patient underwent robotic-assisted ileocecectomy and recovered well. Follow up colonoscopy 4 months later showed healing ileocolonic anastomosis, with no stricture or ulceration. (Figure) Discussion: Though the small bowel constitutes 90% of the surface area of the GI tract, it contributes to < 2% of GI malignancies. Reasons for this include the more liquid contents causing less mucosal irritation than solid colonic contents and rapid transit. Adenomatous polyps, the most common benign SBTs, have an epithelial origin. Histological types include tubular, villous and tubulovillous. Villous components, atypia or large size increase the risk for malignancy. Presenting symptoms are nonspecific and they are commonly found unexpectedly during surgery in patients with SBO. Evaluation in symptomatic patients includes endoscopy with biopsies. Push, double-balloon, or video capsule endoscopy may be needed. Diagnostic laparoscopy or surgical exploration can help establish a definitive diagnosis. Given their potential for malignant transformation, TV adenomas must be removed, and patients should be monitored for recurrence.Figure 1.: A: XR small bowel with oral contrast suggestive of mucosal irregularity with narrowing around distal ileum. B: Colonoscopy showing partially obstructing, circumferential villous mass, 8-10 cm from the ileocecal valve. C: Histo-pathology showing epithelial finger-like projections away from the muscularis mucosae, lined by dysplastic epithelium.

S3488 Symptomatic Meckel’s Diverticulum in an Adult Presenting With Recurrent Gastrointestinal Bleeding

Introduction: Meckel’s diverticulum is a gastrointestinal congenital malformation that results due to persistence of the vitelline duct, and is commonly diagnosed in children before the age of two. Rarely, symptomatic Meckel’s diverticulum can present in adults, as in this case with recurrent gastrointestinal bleeding. Case Description/Methods: A 51-year-old male with a history of iron deficiency anemia presented to the hospital with hematochezia associated with mild epigastric tenderness. He had a similar presentation one year ago with unrevealing EGD, colonoscopy, and video capsule endoscopy. Three months ago, repeat colonoscopy was notable for a single nonbleeding diverticulum in the terminal ileum and outpatient double balloon endoscopy was recommended, however not yet done due to current hospitalization. He presented with tachycardia and hypotension as well as a hemoglobin 10.6g/dL (previously 11.4g/dL few weeks prior) and mildly elevated BUN. CT abdomen and pelvis was negative for any active bleeding. Repeat EGD and colonoscopy was unremarkable except for blood-tinged fluid interspersed in the colon but again the source of bleeding remained obscure. Given the history of a previous finding of a terminal ileum diverticulum and persistence of hematochezia, a Meckel’s scan was performed revealing abnormal uptake in the right mid to lower abdomen suspicious for Meckel’s diverticulum containing ectopic gastric mucosa. Patient was taken to the operation room; a large Meckel’s diverticulum was noted at approximately two feet proximal to the ileo-cecal valve along with hemorrhagic inflammatory changes within the local mesentery. Patient underwent partial small bowel resection and appendectomy with pathology revealing a Meckel’s diverticulum of the ileum with gastric heterotopia. Patient had an uncomplicated recovery postoperatively along with resolution of hematochezia. Discussion: A finding of Meckel’s diverticulum is common in the pediatric population; however, it is a rare diagnosis in adults. This case highlights the importance of considering Meckel’s diverticulum for instances of recurrent gastrointestinal bleeding, especially in patients who are still symptomatic despite an extensive workup. It is also important to notice that Meckel's diverticulum can be missed on video capsule study.

S660 Algorithmic Approach to GI Bleed Using Video Capsule Endoscopy Prior to Double Balloon Enteroscopy Is Associated With Higher Therapeutic Yield and Decreased Readmission at a Tertiary Medical Center

S660 Algorithmic Approach to GI Bleed Using Video Capsule Endoscopy Prior to Double Balloon Enteroscopy Is Associated With Higher Therapeutic Yield and Decreased Readmission at a Tertiary Medical Center

S657 Risk of GI Bleed Recurrence in Dual Antiplatelet Therapy Compared to Antiplatelet Monotherapy in Patients Who Underwent Double Balloon Enteroscopy at a Tertiary Care Center

S657 Risk of GI Bleed Recurrence in Dual Antiplatelet Therapy Compared to Antiplatelet Monotherapy in Patients Who Underwent Double Balloon Enteroscopy at a Tertiary Care Center

S1583 Surveillance With Double Balloon Enteroscopy in Adult Patients With Peutz-Jeghers Syndrome: A Single Center Experience

Introduction: Peutz-Jeghers syndrome (PJS) is an inherited polyposis syndrome caused by mutation in the STK11 gene, and characterized by hamartomatous polyps throughout the gastrointestinal tract, most often in the small bowel (60-90%) and colon (50-64%). Presenting symptoms in PJS are often related to symptomatic polyps, including intestinal obstruction, abdominal pain, and bloody stools. For PJS patients, current recommendations support screening upper endoscopy, colonoscopy, and video capsule endoscopy at age 8-10, and if no polyps identified then again at age 18. Small bowel screening is recommended every 2-3 years. Deep enteroscopy, via antegrade or retrograde balloon enteroscopy, is often required for clearance of larger polyps visualized on video capsule endoscopy (VCE). The optimal follow-up strategy and modality of screening and surveillance of small bowel polyps is controversial. We aimed to evaluate if proactively performing deep enteroscopy vs serial VCE in adult PJS patients reduces risk of requiring subsequent surgical intervention. Methods: We retrospectively collected data from adult patients over 18 years of age with Peutz-Jeghers syndrome who underwent deep balloon enteroscopy for small bowel surveillance. Patients within this subset underwent proactive screening with antegrade double balloon enteroscopy performed approximately every one to 2 years. Data collected included number of prior small bowel surgeries before onset of and during deep enteroscopy surveillance, and complications. Results: Thirteen patients underwent deep enteroscopy from 2010 through 2021. Average number of prior small bowel surgeries was 1.9 (SD 1.4), average number of balloon enteroscopies during surveillance period 2.8 (SD 1.4), and average number of surgeries during balloon enteroscopy surveillance 0.46 (SD 0.66). There was a significant difference between number of surgeries before and during surveillance period (P=0.002). Conclusion: The initial standard screening modality for small bowel polyps and malignancy, VCE, can be complicated by increased risk of capsule retention given likelihood of prior surgery and possibility of obstructing polyps. Additionally, within the PJS cohort, there is a high yield for pathology which may ultimately require therapeutic deep enteroscopy anyhow. Our study, though small, does indicate that on a proactive balloon enteroscopy surveillance protocol there is a significantly lower risk of requiring small bowel surgery.

S2890 A Case for Endoscopic Ultrasound-Directed TransGastric ERCP (EDGE) Procedure: Removal of Choledocholithiasis in Gastric Bypass Patient

Introduction: Due to rise in obesity, there has been an increased number of gastric bypass surgeries. Around 36% morbidly obese patient develop cholelithiasis or choledocholithiasis (CDL) in their lifetime. Due to the anatomy, a conventional Endoscopic Retrograde Cholangio Pancreatography (ERCP) is often challenging and not possible. We present a case of an altered anatomy ERCP in a patient with CDL and Roux-en-Y gastric bypass (RYGB) who underwent Endoscopic ultrasound Directed trans-Gastric ERCP(EDGE) procedure. Case Description/Methods: A 69-year-old female with a history of RYGB admitted for Hartmann’s procedure. During the hospitalization, she complained of RUQ pain and CT abdomen showed a distended gallbladder with cholelithiasis and CBD dilation of 8.3mm; MRCP confirmed five or more CDL. A traditional attempt at an ERCP using a pediatric colonoscope was unsuccessful in reaching the papilla. She underwent cholecystectomy with an intraoperative cholangiogram re-demonstrating the CDL. Options were to do a laparoscopy assisted ERCP v/s double balloon assisted ERCP v/s EDGE. Due to already multiple surgeries patient opted for EDGE procedure. For stage 1 of the EDGE, the excluded stomach was identified under EUS and punctured using a 19-gauge-needle followed by a radiocontrast dye injection into the excluded stomach confirmed under fluoroscopy. Subsequently, a guidewire was advanced through the needle into the pylorus and duodenum to verify the patency of pylorus. After confirming access to the excluded stomach, a 20 x 10 mm (AXIOSTM) lumen apposing metal stent (LAMS) was placed and a gastro-gastric fistula between the gastric pouch and the excluded stomach was formed. The lumen of the stent was subsequently dilated using a CRE balloon confirming the direct visualization of the gastric rugae. (Figure). The LAMS was left for 4 weeks for the tract to mature. Stage 2 of the EDGE procedure was then completed by passing the duodenoscope through the LAMS and completion of the traditional ERCP followed by removal of the LAMS. Overall patient did well. Discussion: EDGE is a minimally invasive EUS guided technique for doing an ERCP in patients with RYGB. Comparison studies have shown EDGE to have similar or better technical success when compared to laparoscopy-assisted ERCP and balloon Enteroscopy-assisted ERCP. Due to the high technical skill required in doing an EDGE, it is best advisable to offer this at institutions where a trained advanced endoscopist well versed with a therapeutic EUS is available.Figure 1.: A: EGD showing gastric pouch post-RYGB B: EUS suggests decompressed excluded stomach C: Injecting contrast into the excluded stomach - to make cystic cavity D: 20 x 10 mm(AXIOS) lumen apposing metal stent placement E: CRE Baloon dilation of LAMS F: Confirmed visualization of excluded gastric mucosa - gastrogastric fistula

Study on the influence of balloon dilation mode on the intravertebral cleft of osteoporotic fracture

BackgroundIntravertebral cleft is common in osteoporotic vertebral compression fracture, and the bone sclerosis around the fissure brings difficulties to the surgical treatment. It is not known whether the balloon dilatation mode of percutaneous kyphoplasty affects the distribution of bone cement in the fracture vertebral body and further affects the surgical effect. The purpose of this study was to discuss the effect of balloon dilatation mode on percutaneous kyphoplasty in the treatment of osteoporotic vertebral fractures with intravertebral cleft.MethodsAccording to the inclusion criteria and exclusion criteria, a retrospective analysis of patients with osteoporotic vertebral fracture combined with intravertebral cleft treated by percutaneous kyphoplasty in our hospital was conducted. All patients were divided into two groups based on way of balloon dilation. The mode of balloon dilatation, imaging changes of vertebral body, VAS score, ODI score, bone cement distribution and postoperative complications were analyzed.ResultsA total of 96 patients with osteoporotic vertebral fracture combined with intravertebral cleft were included in the study, including 51 patients treated with single balloon bilateral alternating dilatation technique and 45 patients treated with double balloon bilateral dilatation technique. The vertebral height, Cobb’s angle of kyphosis, VAS score and ODI score were significantly improved in both groups after operation (P < 0.05). The postoperative vertebral height and Cobb’s angle of kyphosis in the double balloon bilateral dilatation group were better than those in single balloon bilateral alternating dilatation group (P < 0.05). The distribution of bone cement in the single balloon bilateral alternating dilatation group was more inclined to insert filling, while the double balloon bilateral dilatation group was more inclined to fissure filling. The VAS score and ODI score at the final follow-up in the single balloon bilateral alternating dilatation group were lower than those in the double balloon bilateral dilatation group (P < 0.05).ConclusionDouble balloon bilateral dilatation technique can better restore the injured vertebral height in patients with osteoporotic vertebral fracture combined with intravertebral cleft. However, the distribution of injured vertebral cement in patients with single balloon bilateral alternating dilatation technique is more likely to be inserted and filled, and the long-term analgesia and lumbar function of patients are better.

Gastrointestinal genetic reprogramming of vitamin A metabolic pathways in response of Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric surgical techniques. However, RYGB commonly results, as side effects, in nutritional deficiencies. This study aimed to examine changes in the expression of vitamin A pathway encoding genes in the gastrointestinal tract (GI) and to evaluate the potential mechanisms associated with hypovitaminosis A after RYGB. Intestinal biopsies were obtained through double-balloon endoscopy in 20 women with obesity (age 46.9±6.2 years; body mass index [BMI] 46.5±5.3 kg/m2 [mean±SD]) before and three months after RYGB (BMI, 38.2±4.2 kg/m2). Intestinal mucosal gene microarray analyses were performed in samples using a Human GeneChip 1.0 ST array (Affymetrix). Vitamin A intake was assessed from 7-day food records and serum retinol levels were evaluated by electrochemiluminescence immunoassay. Our results showed the following genes with significant downregulation (p≤0.05): LIPF (-0.60), NPC1L1 (-0.71), BCO1 (-0.45), and RBP4 (-0.13) in the duodenum; CD36 (-0.33), and ISX (-0.43) in the jejunum and BCO1 (-0.29) in the ileum. No significant changes in vitamin A intake were found (784±694 retinol equivalents [RE] pre-operative vs. 809±753 RE post-operative [mean±SD]). Although patients were routinely supplemented with 3500 international units IU/day (equivalent to 1050 μg RE/day) of oral retinol palmitate, serum concentrations were lower in the post-operative when compared to pre-operative period (0.35±0.14 μg/L vs. 0.52±0.33 μg/L, respectively - P=0.07), both within the normal range. After RYGB, the simultaneous change in expression of GI genes, may impair carotenoid metabolism in the enterocytes, formation of nascent chylomicrons and transport of retinol, resulting in lower availability of vitamin A.

Indication, Location of the Lesion, Diagnostic Yield, and Therapeutic Yield of Double-Balloon Enteroscopy: Seventeen Years of Experience.

Double-balloon enteroscopy (DBE) has become one of the standard methods in the diagnosis and treatment of small bowel (SB) disease. However, previous studies for DBE have limitations due to heterogeneity of indications and operators. The aim was to investigate the indication, location of the lesion, diagnostic yield, and therapeutic yield of DBE based on long-term data from a single operator. A retrospective study was performed by reviewing medical records of subjects who had received DBE at our unit in the past 17 years. Overall diagnostic yield was 78.7% (210/267). The diagnostic yield for obscure gastrointestinal bleeding (OGIB) was 68.3% (84/123). The diagnostic yield for OGIB was significantly lower (p < 0.001) than that for other indications. Therapeutic yield was 24.7% (66/267). Complications occurred in 7 (2.6%). Crohn’s disease, intestinal tuberculosis, nonsteroidal anti-inflammatory drug enteropathy, and diverticular lesions were mainly found in the ileum. Vascular lesions, non-specific inflammation, and neoplastic lesions were found more frequently in the jejunum. DBE is an excellent and safe endoscopic method for the diagnosis and treatment of SB lesions. DBE has a lower diagnostic rate for OGIB than for other indications. The location where a lesion is commonly found depends on the type of the lesion.