Enteroscopy Techniques Research Articles

Should Capsule Endoscopy Be the First Test for Every Obscure Gastrointestinal Bleeding?

Obscure gastrointestinal bleeding (OGIB) refers to gastrointestinal (GI) bleeding of unclear origin that persists or recurs after negative findings on esophagogastroduodenoscopy and colonoscopy. OGIB accounts for approximately 5% of all types of GI bleeding. More than 80% of OGIB cases originate in the small bowel. The ability to detect OGIB in the small bowel has significantly advanced and been revolutionized since the introduction of the capsule endoscopy and double-balloon enteroscopy techniques in 2000 and 2001, respectively. With these new methods for small-bowel evaluation, new guidelines have been proposed for the diagnosis and management of OGIB. However, some issues remain unsolved. The purpose of this article is to review the various modalities used for evaluating OGIB, including capsule endoscopy and double-balloon enteroscopy, and to help guide clinicians in their decisions on which modality will be the most effective.

Biliary self-expandable metallic stent using single balloon enteroscopy assisted ERCP: overcoming limitations of current accessories

Device assisted enteroscopy (DAE) techniques have been recently developed for the diagnosis and treatment of small bowel diseases. These techniques can also be used to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomies. The main difficulties with DAE-ERCP are related to type of surgery, to the different dimensions and lack of frontal view of the enteroscope and to the resulting limitations with the use of standard accessories, resulting in the need of dedicated accessory devices. Although most ERCP techniques have been successfully performed with DAE-ERCP, biliary self-expandable metallic stents (SEMS) have not yet been used, as dedicated biliary SEMS for the enteroscope are lacking. The authors present a case report showing a new method to place standard biliary trough-the-scope SEMS with DAE-ERCP, using a different technique of stent deployment.

Endoscopic Retrograde Cholangiography with Balloon-Assisted Enteroscopy in a Patient with Roux-Y Anastomosis: How to Reach the Papilla and How to Enter It

Operatively altered anatomy might provide a challenge for endoscopic retrograde cholangiopancreatography. However, with the support of the balloon-assisted enteroscopy technique the access route to the biliary system even in long-limb Roux-Y anastomosis is feasible in most cases.In this video case report, an 81-year-old woman was symptomatic for stone obstruction of the common bile duct (CBD). Complete gastrectomy had been performed in this patient for stomach cancer many years earlier. Balloon-assisted enteroscopy was used for retrograde access of the duodenum via a Roux-Y anastomosis. There was major difficulty in intubating the CBD via the native papilla in this case because access was prevented by the tangential approach of the enteroscope. After performing an incomplete papillectomy, the insertion of a guidewire into the CBD was feasible and the bile duct stone was removed. This article is part of an expert video encyclopedia.

Double- vs. single-balloon enteroscopy: single center experience with emphasis on procedural performance

This study aims to compare double- (DBE) and single-balloon enteroscopy (SBE) in small bowel disorders with respect to procedural performance and clinical impact. This retrospective analysis at a tertial referral center included 1,052 DBEs and 515 SBEs performed in 904 patients over 7years. Procedural and patients' characteristics were precisely analyzed. Significantly more patients with anemia and gastrointestinal bleeding were investigated by DBE (P < 0.01). Oral insertion depth and length of investigated small bowel in the combined approach were significantly higher in the DBE compared to the SBE group (245 ± 65.3 vs. 218 ± 62.6 and 355 ± 101.9 vs. 319 ± 91.2, respectively; P < 0.001, each). By analyzing only recent years of enteroscopy (2008-2011), no difference in small bowel visualization could be observed. The anal insertion depths and complete enteroscopy rates (CER) were comparable. Procedure times were significantly shorter within the SBE procedure (oral: 50 vs. 40min; anal: 55 vs. 46min, P < 0.001) and the usage of sedation was significantly less (propofol: P < 0.001; pethidine: P < 0.05). Diagnostic yield was significantly higher in the SBE, compared to the DBE group (61.7 vs. 48.2%; P < 0.001). The rate of severe adverse events was close to zero. Both enteroscopy techniques are safe diagnostic tools and proved to be indispensable in the daily gastroenterological practice. The lower insertion depths, but higher diagnostic yield, of SBE may reflect the more focused selection of patients scheduled for small bowel diagnostics in recent years.

Deep Enteroscopy: Which Technique Will Survive?

The advent of deep enteroscopy (DE) has dramatically changed diagnostic and therapeutic approaches to small bowel diseases. Unlike capsule endoscopy, which is unable to obtain biopsies or treat a disease, DE techniques have diagnostic and therapeutic capabilities. Double-balloon enteroscopy (DBE) was introduced in 2001, and single-balloon enteroscopy (SBE) and spiral enteroscopy (SE) were subsequently developed for small bowel investigation. In published reports comparing these different enteroscopy techniques, most comparative parameters (depth of insertion, complications, learning curve, diagnostic yield, and therapeutic yield) were comparable among DBE, SBE, and SE. However, the procedure duration appears to be shorter for SE than for DBE and SBE. The rate of complete enteroscopy is clearly superior for DBE, compared with SE and SBE. Because these results do not indicate an increase in diagnostic or therapeutic yield, the clinical impact of complete enteroscopy remains controversial. According to previous studies, the three DE methods seem to be equally effective and safe in the clinical setting. Although larger randomized controlled trials are needed to evaluate the procedural characteristics and clinical impact, the selection of an enteroscopic technique should be based on availability and the endoscopist's experience.

Endoscopic closure of a gastrocolic fistula using the over-the-scope-clip-system

Gastrointestinal (GI) defects such as fistulas and leaks can be potentially closed endoscopically using hemoclips and loops. However, hemoclips may not allow for closure of large defects and they do not exert enough tensile force to keep fibrotic defects larger than 5 mm approximated. Herein we present a case of successful endoscopic closure of a gastrocolic fistula in a severely malnourished patient with complex post-surgical upper GI anatomy. We strongly believe that this device is a major breakthrough for the management of various types of discontinuity defects or fistulas. In addition, we show the usefulness of placing a direct jejunostomy using the double balloon enteroscopy (DBE) technique during the same procedure. The concept of providing direct jejunal feedings while allowing for upper gastrointestinal bowel rest to promote the healing of the minimally invasive endoscopic operation is novel. Thus, our case is unique and exemplifies the utility of minimally invasive endoscopic endoluminal surgery.

Endoscopic solutions to challenging enteral feeding problems

Enteral nutrition support is often required in patients who are unable to meet their own nutritional requirements. Endoscopists play a key role in the placement of enteral feeding catheters. This review focuses on the recently published solutions to common problems encountered during endoscopic placement of enteral feeding devices. Case reports and case series describe solutions for overcoming common problems encountered during the placement of enteral feeding devices. Transnasal techniques can simplify nasojejunal tube placement, whereas deep enteroscopy techniques provide more reliable jejunostomy placement. Endoscopic ultrasound can help when transillumination is not possible or in the setting of postsurgical anatomy like Roux-en-Y. Laparoscopic-assisted procedures are useful when endoscopic techniques have failed in adults or in select high-risk pediatric patients. The American Society for Gastrointestinal Endoscopy and the American Gastroenterology Association both published comprehensive guidelines that outline the indications, contraindications, technical aspects of feeding catheter placement, and complications. Advances in endoscopic techniques, including deep enteroscopy, endoscopic ultrasound, ultra-slim transnasal endoscopes and laparoscopic-assisted procedures, have enabled endoscopists to successfully place enteral feeding tubes in patients who previously required open procedures.

Single-balloon enteroscopy in managing Peutz Jeghers syndrome polyps

Single-balloon enteroscopy in managing Peutz Jeghers syndrome polyps

Spiral enteroscopy: Prime time or for the happy few?

Spiral enteroscopy is the newest of the deep enteroscopy techniques. The current technique employs an overtube with a raised spiral at the distal end to pleat the small intestine and achieve deep small bowel intubation. Although spiral enteroscopy is a novel technique, the learning curve is comparable to the balloon enteroscopy techniques. There is some evidence of improved speed of spiral enteroscopy procedures with superior control compared to the balloon endoscopy technologies. Altered surgical anatomy deep enteroscopy has been shown to have similar safety and efficacy to competitive technologies, particularly in cases of Roux-en-Y ERCP cases. Spiral enterosopy is safe and effective for deep small bowel enteroscopy and diagnostic yield and therapeutic yields are similar to alternate technologies. There are bright future applications of the technology with enteroscopes and an integrated spiral. Spiral enteroscopy is an advanced technique that can be performed by any skilled endoscopist.

Small bowel endoscopy in children

Endoscopic investigation of small bowel pathology in children has historically been difficult due to location, length and tortuosity of the small bowel. Recently, video capsule endoscopy and balloon-assisted enteroscopy techniques have evolved as new diagnostic tools and are increasingly used in the paediatric population. In this review the current literature is appraised to define the clinical indications and practical aspects of capsule endoscopy and balloon-assisted enteroscopy in children.

Double- vs. single-balloon vs. spiral enteroscopy

Starting with the introduction of the double-balloon enteroscope in 2001, two more techniques have been successfully developed for small bowel investigation (single-balloon enteroscopy, spiral enteroscopy). To compare the different enteroscopy systems, within this review, 68 studies were analyzed and put into context. The procedural characteristics (mean insertion depth, diagnostic yields, adverse events) were comparable for DBE, SBE or SE. The higher panenteroscopy rate in DBE might not have any clinical relevance. Therapeutic procedures, such as argon-plasma coagulation, polypectomy, dilation therapy and foreign body extraction are described with the DBE and SBE procedure. With regard to the present literature, the balloon-assisted devices as well as spiral enteroscopy technique seem to be equally suitable in clinical routine for imaging of the small bowel. The choice of the method should be based on availability, physicians' experience and clinical implications. Future randomized, controlled trials with large numbers of patients are needed to work out the subtleties of every single method.

Sa1714 Correlation Between the Findings of Video Capsule Endoscopy and Single Balloon Enteroscopy in Patients With Obscure Gastrointestinal Bleeding

Over the past decade video capsule endoscopy (VCE) has become the diagnostic procedure of choice for evaluating obscure gastrointestinal bleeding (OGIB) originating from the small bowel (SB). Single balloon enteroscopy (SBE) is a deep enteroscopy technique that offers both diagnostic and therapeutic potential for patients with OGIB. As with other deep enteroscopy techniques, SBE is typically performed after VCE. However, there is little data comparing the findings of VCE with those of SBE in patients with OGIB.

Use of Capsule Small Bowel Transit Time to Determine the Optimal Enteroscopy Approach.

BackgroundCapsule small bowel transit time (SBTT) is used to select the most effective enteroscopy approach when targeting capsule endoscopy (CE) findings. Aim of this study was to determine if capsule SBTT can be used to guide the choice of enteroscopy technique for reaching CE abnormalities.MethodsSingle center, retrospective study involving 60 patients. Data were abstracted from medical records of patients with abnormal CE who proceeded to enteroscopy which included push enteroscopy (PE) single balloon enteroscopy (SBE) and double balloon enteroscopy (DBE).ResultsNinety five findings were documented on CE with presumed identification of 56 (59%) of these abnormalities by enteroscopy. Majority were angioectasias on CE (42%) and enteroscopy (59%). Optimal cutoff values for selection of enteroscopy procedure were: 0-21% SBTT for PE (80% sensitivity, 74% specificity, 83% PPV); 0 - 36% SBTT for antegrade SBE (93% sensitivity, 40% specificity, 82% PPV); 0 - 57% SBTT for antegrade DBE (75% sensitivity, 80% specificity, 75% PPV); and 74 - 100% SBTT for retrograde DBE (88% sensitivity, 78% specificity, 78% PPV).ConclusionCapsule SBTT may be used to guide the selection of enteroscopy approach. PE, antegrade SBE, antegrade DBE and retrograde DBE are optimal when abnormalities on CE are seen at ≤ 21%, ≤ 36%, ≤ 57% and ≥ 74% SBTT respectively.

Prospective, cross-over, single-center trial comparing oral double-balloon enteroscopy and oral spiral enteroscopy in patients with suspected small-bowel vascular malformations

Spiral enteroscopy is a new, promising rapid enteroscopy technique. A prospective cross-over study was carried out to compare this new method with the established technique of double-balloon enteroscopy (DBE). From an initial group of 18 patients with suspected mid-gastrointestinal bleeding due to vascular malformations but no previous history of small-bowel or colonic surgery, 10 patients (mean age 69 years) completed the study. Patients underwent both enteroscopy techniques with an oral approach, in a randomized sequence. The deepest point reached during advancement in the first enteroscopy was marked with India ink. The primary end point of the study was the total examination time. For spiral enteroscopy, the mean examination time was significantly shorter than with DBE (43 minutes vs. 65 minutes; P = 0.007), as was the mean time required for advancement of the enteroscope to the deepest point (24 minutes vs. 43 minutes; P = 0.03). However, the median maximum insertion depth was greater in the DBE group than in the spiral enteroscopy group (310 cm vs. 250 cm; P = 0.004). In all cases in which DBE followed spiral enteroscopy, DBE passed the India ink mark by a mean of over 100 cm. When DBE was performed first, spiral enteroscopy was either unable to reach the mark or else unable to advance deeper into the small bowel. No severe complications occurred. The results confirm that the new spiral enteroscopy technique reduces the examination time, although the insertion depth with DBE is at present superior.

Gastroenterologische Endoskopie

Endoscopy is often used in gastroenterology. It can prevent early recurrence of bleeding from esophageal varices. Computed virtual chromoendoscopy can diagnose pathological changes at the esophagogastric transitional zone in non-erosive reflux disease. In the buried bumper syndrome the internal bumper, which has migrate into the gastric wall, should be removed endoscopically. Double-balloon enteroscopy is one of the flexible enteroscopy techniques with an acceptable complication rate and remains the diagnostic and therapeutic gold standard for small bowel endoscopy. Hyperplastic polypoidal lesions of more than 1 cm in the colon should be removed, because it is not possible to distinguish definitively between hyperplastic polyps and serrated adenoma. Endoscopic ultrasound of the biliary tract makes it possible to remove biliary tract stones cost-effectively and without radiology. Endoscopic ultrasound-guided necrosectomy of the pancreas has become the standard method and has replaced percutaneous drainage and operative intervention.

Initial Experience Using a Rotational Overtube System (ROS) in the Retrograde Examination of the Small Bowel

Purpose: Direct examination of the distal small bowel is limited with conventional colonoscopy and antegrade enteroscopy techniques. We report our experience using a rotational overtube system (ROS) for examination of the distal small bowel using the retrograde approach. Methods: Patients in need of direct visualization of the distal small bowel underwent retrograde examination following a standard colonoscopy prep using the Spirus Endo-Ease Vista® ROS (Spirus Medical, Stoughton, MA), a 90 cm overtube with a raised spiral on the distal end, with either a pediatric colonoscope or a standard enteroscope. The system was introduced per rectum and intubation of the terminal ileum was attempted once in the cecum. The ROS was then used to splint and advance the endoscope per manufacturer recommendations. Results: Between 6/09 and 7/10, 8 patients (4F, mean age 48±16y) underwent 9 retrograde small bowel exams using the ROS. Indications included obscure-overt GI bleeding (n=4, 44%), suspected small bowel tumor (n=3, 33%), foreign body (n=1, 11%) small bowel stricture/obstruction (n=2, 22%). Some patients had multiple indications. Prior evaluation included CT scan (n=4, 44%), capsule endoscopy (n=3, 33%), antegrade overtube-assisted enteroscopy (n=6, 67%), colonoscopy (n=7, 78%), barium enema (n=1, 11%). Retrograde enteroscopy was performed immediately following antegrade enteroscopy in the same session in 4 (44%). Cecal intubation was achieved in 100%. Intubation of the terminal ileum was achieved in 8/9 procedures (89%). In one patient with GI bleeding, large cecal angiodysplasia was seen; repeated attempts at ileal intubation were not performed. Endoscopes used included a pediatric colonoscope (n=3, 33%) or a 260 cm enteroscope (n=6, 67%). Median length of examined ileum was 70 cm (range 0-100 cm). Findings included cecal angiodysplasia (n=1, 11%), small bowel angiodysplasia (n=1, 11%), ileal stricture (n=2, 22%), normal (n=4, 44%), foreign body not reached (n=1, 11%), ileal ulceration and edema (n=1, 11%). Colonic diverticulosis was found in one patient with obscure-overt bleeding which could represent the bleeding source. Therapeutic interventions performed included argon-plasma coagulation of angiodysplasia (n=2, 22%), balloon dilation of ileal stricture (n=2, 22%), and forceps biopsy (n=1, 11%). One minor complication of transient post-procedure hypoxia (not requiring intubation) occurred. Conclusion: 1. Retrograde enteroscopy using a rotational overtube system is safe and technically successful in the majority of patients in this initial experience. 2. Ileal intubation was achieved in most examinations. 3. In this small experience, the utility of retrograde enteroscopy for obscure GI bleeding was limited. 4. Larger experience is needed.

Spiral enteroscopy: prospective U.S. multicenter study in patients with small-bowel disorders

The performance characteristics of spiral enteroscopy have not been well-described. To determine the technical performance, diagnostic and therapeutic yields, and safety of oral spiral enteroscopy in patients with suspected or established small-bowel pathology. Prospective, multicenter, cohort study, with centralized database. Ten U.S. tertiary-care medical centers. This study involved 148 participants, of whom 101 were referred for obscure bleeding. All participants referred for antegrade deep enteroscopy were considered eligible. Spiral enteroscopy. Examination duration, depth of insertion, spiral enteroscopy findings, mucosal assessment upon withdrawal, and patient symptom assessment (day 1 and day 7 after the procedure). Spiral enteroscopy was successful in 93% of patients, with a median depth of insertion beyond the angle of Treitz of 250 cm (range 10-600 cm). The mean (± standard deviation) total procedure time was 45.0 ± 16.2 minutes for all procedures, and 35.4 minutes for diagnostic procedures. The diagnostic yield was 65%, of which 48% revealed more than one abnormality. The most common findings were angiectasias (61.5%), inflammation (7.5%), and neoplasia (6.8%). Argon plasma coagulation ablation accounted for 64% of therapeutic interventions. This was not a randomized, controlled trial of deep enteroscopy modalities. Spiral enteroscopy appears to be safe and effective for evaluation of the small bowel. The procedure duration, depth of insertion, and diagnostic and therapeutic yields compare favorably with previously published data on other deep enteroscopy techniques such as single-balloon and double-balloon enteroscopy. Comparative studies are warranted.

Balloon-assisted enteroscopy: unifying double-balloon and single-balloon enteroscopy

Tsujikawa and colleagues have presented a new technique for performing enteroscopy, namely “single-balloon enteroscopy” (SBE) [1]. This technique expands our endoscopic possibilities of exploring and treating diseases of the small bowel. A SBE technique may also be useful to investigate the colon or perform endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy [2] [3]. Yamamoto et al. described the technique of double-balloon enteroscopy (DBE) in 2001 [4]. Both DBE and SBE have replaced push enteroscopy as the methods of choice for performing deep small-bowel investigation and for carrying out endoscopic interventions within the small intestine. Both SBE and DBE, like push enteroscopy, use the principle of the push-and-pull technique: the endoscope is advanced (pushed), then the overtube is slid towards the tip of the endoscope, and then both endoscope and overtube are pulled back, hence “push and pull”.

A New in Vitro Porcine Model for Spiral Enteroscopy Training: The Akerman Enteroscopy Trainer

Benchtop model training for enteroscopy is critical to teach techniques and concepts. The most common in vitro model for enteroscopy consists of the esophagus/stomach and 100-200 cm of small bowel (sb) with mesentery removed. This model attempts to reproduce the mesentery of the sb to better mimic the in vivo pleating and unpleating seen in spiral enteroscopy. Methods and Model: The Akerman Enteroscopy Trainer consists of 2 major components. The upper component corresponds to the esophagus, stomach and doudenum. The lower component corresponds to the freely mobile small bowel past the LOT. An artificial mesentery is formed with clips hanging from a curving metal rod that attaches to the mesenteric side of the small bowel along its entire length. Clips are attached every 3 cm along the length of the small bowel and at the terminal end of the small bowel an elastic band is attached and gives mild resistance to pleating. Findings: In one setting 24 trainees used the device over the course of 4 hours. The small bowel length was 130 cm. SE pleating techniques for advancement and controlled withdrawal were demonstrated. The endoscopic appearance with SE exactly mimics that seen in vivo. The model showed no appreciable dimunition of function or performance after 4 hours of continous use. Conclusion: This new porcine in vitro benchtop model is very useful to demonstrate spiral advancement and pleating techniques along with counterclockwise withdrawal. The model exactly mimics the endoscopic images seen with spiral pleating enteroscopy in vivo. The model is a durable and rapid way to demonstrate SE. The model may be very useful to demonstrate other enteroscopy techniques including single and double balloon enteroscopy.

Multiple cavernous hemangiomas with iron deficiency anemia successfully treated with double-balloon enteroscopy

The new technique of double-balloon enteroscopy (DBE) has improved both the diagnosis and therapeutic options in patients with previously unexplained obscure GI bleeding. This is the first reported case of obscure occult GI bleeding secondary to multiple cavernous hemangiomas diagnosed and treated by using DBE without requiring surgery.