Overtube-assisted Enteroscopy Research Articles

Endoscopic retrograde cholangiopancreatography: Current practice and future research.

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

Percutaneous single-operator video cholangioscopy using a novel short disposable endoscope: first clinical case with treatment of a complex biliary stone and inaccessible papilla after Roux-en-Y reconstructive surgery.

Author commentary on Jagpal Singh Klair et al.

Jagpal Singh Klair et al. ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis

ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events. We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone. 10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted. OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.

Sa1469 ERCP WITH OVERTUBE-ASSISTED ENTEROSCOPY IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS ANATOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Unlike other post-surgical altered anatomies like Whipple surgery, Billroth II or Roux-en-Y hepatico-jejunostomy, overtube assisted enteroscopy (OAE) is usually needed to perform ERCP in RYGB anatomy as the combined length of Roux limb and biliopancreatic limb needs to be traversed to access the papilla. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to estimate the pooled rate of success and adverse events.

A multicenter experience of through-the-scope balloon-assisted enteroscopy in surgically altered gastrointestinal anatomy.

Surgically altered gastrointestinal anatomy poses challenges for deep enteroscopy. Current overtube-assisted methods have long procedure times and utilize endoscopes with smaller working channels that preclude use of standard accessories. A through-the-scope balloon-assisted enteroscopy (TTS-BAE) device uses standard endoscopes with a large working channel to allow metallic and plastic stent insertion. We aim to determine the efficacy and safety of TTS-BAE in patients with altered surgical anatomy. A retrospective, multicenter study of TTS-BAE in altered anatomy patients at two USA and one German institution was performed between January 2013 and December 2014. Type of anatomy, procedure indication and duration, adverse events, and target, technical, and clinical success were recorded. A total of 32 patients (mean age 54years, Caucasian 81.6%, female 42.1%, mean BMI 25.4kg/m2) underwent 38 TTS-BAE procedures. Thirty-two percent of cases had a prior attempt at conventional enteroscopy which failed to reach the target site. The target was successfully reached in 23 (60.5%) cases. Of the 23 cases that reached the intended target, 22 (95.7%) achieved technical success and 21 (91.3%) achieved clinical success. The median procedure time was 43min. Target, technical, and clinical success rates for TTS-BAE-assisted ERCP (n=31) were 58.1, 54.8 and 54.8%. Seven self-expandable metallic stents (five biliary, two jejunal) were attempted, and all successfully deployed. Adverse events occurred in 4 (10.4%) cases, including one luminal perforation. TTS-BAE is an alternative to overtube-assisted enteroscopy that is comparable in safety in patients with surgically altered anatomies. Technical success in the instances where the target had been reached was excellent. TTS-BAE confers an advantage over overtube-assisted enteroscopy as it can facilitate the deployment of self-expandable metallic stents in the biliary tree and deep small bowel.

Tu1572 Overtube-Assisted Enteroscopy ERCP Compared With Percutaneous Transhepatic Biliary Drains for Treatment of Biliary-Enteric Anastomotic Strictures in Patients With Long Limb Surgical Biliary Bypass

Tu1572 Overtube-Assisted Enteroscopy ERCP Compared With Percutaneous Transhepatic Biliary Drains for Treatment of Biliary-Enteric Anastomotic Strictures in Patients With Long Limb Surgical Biliary Bypass

Overtube-assisted enteroscopy and capsule endoscopy for the diagnosis of small-bowel polyps and tumors: a systematic review and meta-analysis.

Background and study aims: Several studies have evaluated the utility of double-balloon enteroscopy (DBE) and capsule endoscopy (CE) for patients with small-bowel disease showing inconsistent results. The aim of this study was to determine the sensitivity and specificity of overtube-assisted enteroscopy (OAE) as well as the diagnostic concordance between OAE and CE for small-bowel polyps and tumors. Patients and methods: We conducted a systematic review and meta-analysis of studies in which the results of OAE were compared with the results of CE for the evaluation of small-bowel polyps and tumors. When data for surgically resected lesions were available, the histopathological results of OAE and surgical specimens were compared. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for the diagnosis of small-bowel polyps and tumors were analyzed. Secondarily, the rates of diagnostic concordance and discordance between OAE and CE were calculated. Results: There were 15 full-length studies with a total of 821 patients that met the inclusion criteria. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were as follows: 0.89 (95 % confidence interval [CI] 0.84 – 0.93), with heterogeneity χ2 = 41.23 (P = 0.0002) and inconsistency (I 2) = 66.0 %; 0.97 (95 %CI 0.95 – 0.98), with heterogeneity χ2 = 45.27 (P = 0.07) and inconsistency (I 2) = 69.1 %; 16.61 (95 %CI 3.74 – 73.82), with heterogeneity Cochrane’s Q = 225.19 (P < 0.01) and inconsistency (I 2) = 93.8 %; and 0.14 (95 %CI 0.05 – 0.35), with heterogeneity Cochrane’s Q = 81.01 (P < .01) and inconsistency (I 2) = 82.7 %, respectively. A summary receiver operating characteristic curve (SROC) curve was constructed, and the area under the curve (AUC) was 0.97. Conclusion: OAE is an accurate test for the detection of small-bowel polyps and tumors. OAE and CE have a high diagnostic concordance rate for small-bowel polyps and tumors.This study was registered in the PROSPERO international database (www.crd.york.ac.uk/prospero/) with the study number CRD42015016000.

Effect of a quality program with adverse events identification on airway management during overtube-assisted enteroscopy.

Adverse events associated with overtube-assisted enteroscopy are similar to those with routine endoscopy. Our endoscopy quality program identified a number of respiratory adverse events resulting in emergency resuscitation efforts. The aim is to report all adverse events identified by quality monitoring and outcomes of adverse events associated with overtube-assisted enteroscopy. A retrospective study used data prospectively obtained from consecutive patients undergoing overtube-assisted enteroscopy between December 2008 and July 2012. Patient characteristics, medical history, procedure indication, and procedure outcomes, including diagnosis, endoscopic therapy, and complications, were obtained. In 432 overtube-assisted enteroscopies, 15 adverse events (most frequently hypoxemia, 9 /15, 60 %) occurred in 14 patients (3.2 % of total cohort; 12 were outpatients) mostly during antegrade enteroscopy. Four patients required endotracheal intubation and 4 /12 outpatients required intensive care. The procedure was aborted in 13 /14 patients, and only 1 of 10 patients scheduled for repeat antegrade enteroscopy returned. There was no mortality. Based on the frequency of adverse events, and in consultation with anesthesia providers, from August 2012 all antegrade overtube-assisted enteroscopies at our institution were done with general anesthesia. From then till September 2013, 145 antegrade and 52 retrograde overtube-assisted enteroscopies have been done, with no adverse events. Monitoring of endoscopy practice identified adverse events associated with overtube-assisted enteroscopy. The peer-review prompted a change in practice: all patients undergoing antegrade overtube-assisted enteroscopy at our institution now have endotracheal intubation which has dramatically decreased the rate of respiratory adverse events. The impact of endoscopic quality measurements on practices, procedures, and outcomes will be of further interest.

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

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

ERCP with the overtube-assisted enteroscopy technique: a systematic review.

Overtube-assisted enteroscopy (OAE) techniques have increased the ability to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass. The aim of this study was to compare the efficacy and safety of OAE-ERCP in patients with different configurations of upper gastrointestinal anatomy. A systematic review was performed following a literature search for papers published between 1966 and August 2013. The following databases were searched: MEDLINE (via PubMed), Embase, Cochrane library, and Scopus. The following end points were analyzed: diagnostic and therapeutic success rates, cannulation success rate, ERCP success rate, type of enteroscopy, types of intervention, complications. A total of 23 relevant reports on OAE procedures, including single-balloon, double-balloon, and spiral enteroscopy, were analyzed. Studies included a total of 945 procedures in 679 patients (age 2 - 91 years) who had a variety of postsurgical upper gastrointestinal anatomical configurations. Among patients who underwent Roux-en-Y with gastric bypass, endoscopic success was 80 % and ERCP success was 70 %. In patients who had undergone a Roux-en-Y with either a pancreaticoduodenectomy, pylorus-preserving pancreaticoduodenectomy, or hepaticojejunostomy, endoscopic success was 85 % and ERCP success was 76 %. In patients who had undergone a Billroth II procedure, endoscopic success was 96 % and ERCP success was 90 %. In patients with native papilla who underwent successful endoscopy, cannulation was successful in 90 % of patients compared with 92 % in patients with an anastomosis. Overall ERCP success for all attempts was approximately 74 %. Interventions included sphincterotomy, pre-cut papillotomy, anastomotic stricturoplasty, stone removal, stent insertion, stent replacement, and balloon dilation of stenotic anastomosis. There were 32 major complications among the 945 procedures (3.4 %). Both endoscopic and ERCP success rates were highest in patients with Billroth II anatomy, followed by those with pancreaticoduodenectomy and Roux-en-Y hepaticojejunostomy; the lowest success rates were in patients with Roux-en-Y gastric bypass. Cannulation rates appeared to be equivalent in patients with both native papilla and biliary-enteric or pancreaticoenteric anastomoses. The diagnostic and therapeutic potential of balloon-assisted ERCP were high and the adverse event rate was low.

An Old Problem with a New Therapy

Conventional algorithms for diagnosis and treatment of gastrointestinal bleeding (GIB) in patients with nonpulsatile ventricular assist devices (VADs) may take days to perform while patients require transfusions. We developed a new algorithm based on deep overtube-assisted enteroscopy (DOAE) to facilitate a rapid diagnosis and treatment. From 2004 to 2012, 84 patients who underwent VAD placement in our institution, were evaluated for episodes of GIB. Our new algorithm for the management of GIB using DOAE was evaluated by dividing the episodes into three groups: group A (traditional management without enteroscopy), group B (traditional management with enteroscopy performed >24 hours after presentation), and group C (new management algorithm with enteroscopy performed <24 hours after presentation). Gastrointestinal bleeding was observed in 14 (17%) of our study patients for a total of 45 individual episodes of which 28 met our criteria for subanalysis. Forty-one (84%) lesions were confined to the upper gastrointestinal tract with more than 91% of these lesions being arteriovenous malformations. Average number of transfusions in groups A, B, and C were 4.1, 6.3, and 1.3, respectively (p = 0.001). The number of days to treatment was significantly shorter in group C than group B (0.4 vs. 5.3 days, p = 0.0002). Our new algorithm for the management of GIB using DOAE targets the most common locations of bleeding found in this patient population. When performed early, DOAE has the potential to decrease the need for transfusions and allow for an early diagnosis of GIB in VAD recipients.

A multicenter, U.S. experience of single-balloon, double-balloon, and rotational overtube–assisted enteroscopy ERCP in patients with surgically altered pancreaticobiliary anatomy (with video)

Data on overtube-assisted enteroscopy to facilitate ERCP in patients with surgically altered pancreaticobiliary anatomy, or long-limb surgical bypass, is limited. To evaluate and compare ERCP success by using single-balloon (SBE), double-balloon (DBE), or rotational overtube enteroscopy. Consecutive patients identified retrospectively. Eight U.S. referral centers. Long-limb surgical bypass patients with suspected pancreaticobiliary diseases. Overtube-assisted enteroscopy ERCP. Enteroscopy success: visualizing the pancreaticobiliary-enteric anastomosis or papilla. ERCP success: completing the intended pancreaticobiliary intervention. Clinical success: greater than 50% reduction in abdominal pain or level of hepatic enzyme elevations or resolution of jaundice. From January 2008 through October 2009, 129 patients had 180 enteroscopy-ERCPs. Anatomy was Roux-en-Y: gastric bypass (n = 63), hepaticojejunostomy (n = 45), postgastrectomy (n = 6), Whipple procedure (n = 10), and other (n = 5). ERCP success was 81 of 129 (63%). Enteroscopy success: 92 of 129 (71%), of whom 81 of 92 (88%) achieved ERCP success. Reasons for ERCP failure (n = 48): afferent limb entered but pancreaticobiliary anastomosis and/or papilla not reached (n = 23), cannulation failure (n = 11), afferent limb angulation (n = 8), and jejunojejunostomy not identified (n = 6). Select interventions: anastomotic stricturoplasty (cautery ± dilation, n = 16), stone removal (n = 21), stent (n = 25), and direct cholangioscopy (n = 11). ERCP success rates were similar between Roux-en-Y gastric bypass and other long-limb surgical bypass and among SBE, DBE, and rotational overtube enteroscopy. Complications were 16 of 129, 12.4%. Retrospective study. (1) ERCP is successful in nearly two-thirds of long-limb surgical bypass patients and in 88% when the papilla or pancreaticobiliary-enteric anastomosis is reached. (2) Enteroscopy success in long-limb surgical bypass is similar among SBE, DBE, and rotational overtube enteroscopy methods. (3) Referral of long-limb surgical bypass patients who require ERCP to high-volume institutions may be considered before more invasive percutaneous or surgical alternatives.

Single-Step Direct Cholangioscopy by Freehand Intubation Using Standard Endoscopes for Diagnosis and Therapy of Biliary Diseases

Commercially available 10F cholangioscope systems have limitations in examination of the biliary tree. Further, they are not readily available in all endoscopy units. Direct cholangioscopy (DC) using slim and ultraslim gastroscopes have been utilized to detect and treat bile duct (BD) diseases. It often requires initial duodenoscope introduction, followed by over-the-wire exchange to a gastroscope for BD intubation. We report a novel single-step DC technique using forward-viewing endoscopes without requiring tandem-scope exchange. In patients with native papilla, a "J" maneuver, accomplished by retroflexing the endoscope in the second portion of the duodenum and withdrawing the retroflexed scope into the BD, was used to achieve free intubation. A variety of readily available standard endoscopes were used. For biliary-enteric anastomoses, balloon dilation, if necessary followed by enteroscope advancement, was utilized for BD visualization. A total of 18 patients underwent 22 DC procedures (8 male, 10 female, mean age 69 years). Direct intubation was successful in all procedures. Indications included BD stone (n=10), BD stricture or tumor (n=8). A native papilla was present in 13 patients and biliary-enteric anastomoses in 5; 8 patients had altered gastrointestinal anatomy. Sphincterotomy was required in 12/13 native papilla patients to facilitate DC. Free intubation of the BD was accomplished in 19 of 22 exams, and 3 facilitated by guidewire (over-the-wire in 2 and alongside a guidewire in 1). Overtube-assisted enteroscopy was used to reach the BD in four patients. The findings were stones (n=6), strictures or tumors (n=7), abnormal mucosa (n=5), a dilated duct confirming stone clearance without stricture (n=3), and retained stent (n=1). Interventions were biopsy (n=8), stone extraction (n=5), electrohydraulic lithotripsy (n=3), chromoendoscopy (n=2), narrow-band imaging (n=2), through the scope stricture dilation (n=2), and argon-plasma coagulation of biliary tumor (n=1). Complications were cholangitis managed with intavenous antibiotics (n=1). Single-step DC can be achieved without using tandem-scope exchange, and may be clinically useful for diagnostic and therapeutic purposes in managing select biliary tract diseases.

Mo1320 Overtube-Assisted Enteroscopy ERCP vs. Percutaneous Transhepatic Biliary Drains for Treatment of Biliary-Enteric Anastomotic Strictures in Patients With Long Limb Surgical Biliary Bypass

Patients with long limb surgical biliary bypass (LLSBB) may develop biliary-enteric anastomotic strictures (AS). Percutaneous transhepatic biliary drains (PTBD) and surgical revision may be required. Preliminary experience with overtube assisted ERCP (OA-ERCP)stricturoplasty to treat AS is promising. AIM: Compare and evaluate technical success, complications, and duration of treatment for OA-ERCP vs. PTBD to achieve resolution of AS in patients with LLSBB.

Small bowel enteroscopy.

Over the past decade, the advent of capsule endoscopy and balloon-assisted enteroscopy has revolutionized the approach to small intestinal diseases. The small bowel is no longer out of reach, and has fallen within the diagnostic and therapeutic realm of the gastrointestinal endoscopist. Double-balloon enteroscopy was the first type of balloon-assisted endoscopy and is the method for which there are the most data. Single-balloon enteroscopy has since been introduced as an alternative balloon-assisted method, followed more recently by the development of spiral overtube-assisted enteroscopy. The purpose of the present article is to review these methods of small bowel enteroscopy and to discuss the latest developments. While the investigation of small bowel diseases cannot be addressed without considering the central role of capsule endoscopy, a detailed assessment is beyond the scope of the present article, and capsule endoscopy will only be discussed as it pertains to enteroscopy.

Mo1461 Biliary-Enteric Anastomotic Stricturoplasty Using Overtube-Assisted Enteroscopy ERCP in Patients With Long Limb Surgical Biliary Bypass

Limited data exists on ERCP in long limb surgical biliary bypass (LLSBB) patients. A subset of Roux-Y liver transplant and other LLSBB develop benign biliary-enteric anastomotic strictures (AS). Conventionally, patients undergo PTC and multiple drain exchanges. Surgical revision may be required. Only case reports exist on ERCP techniques to treat AS in patients with LLSBB.

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.

Initial Experience with Retrograde Overtube-Assisted Enteroscopy Using a Spiral Tip Overtube

Overtube-assisted enteroscopy has expanded therapeutic options for the small bowel, but the effectiveness of spiral tip overtube-assisted endoscopy for retrograde small bowel evaluation is not known. This retrospective study reviewed the results of retrograde enteroscopy procedures among six consecutive patients. In these patients, cecal retroflexion was necessary to enter the terminal ileum when using an enteroscope, and 40 to 130 cm of the distal small bowel was intubated. The average procedure time was 52 minutes. The procedure was diagnostic in four patients, and successful endoscopic therapy was performed in three patients, including completion of a polypectomy at the ileocecal valve, resolution of a distal intestinal obstruction in a patient with cystic fibrosis, and a small bowel anastomotic stricture release. There were no procedure-related complications. Overtube-assisted enteroscopy with the spiral tip overtube allows for antegrade or retrograde evaluation of the small bowel. Panenteroscopy may become possible as the technique and equipment improve. The advantages of the different forms of overtube-assisted enteroscopy (spiral, single, and double balloon) need to be determined.

Techniques, Tricks, and Complications of Enteroscopy

Small bowel endoscopy has made tremendous advances over the last 8 years. The introduction of capsule endoscopy, double-balloon enteroscopy, single-balloon enteroscopy and spiral overtube-assisted enteroscopy have completely removed the mystery in investigating the small intestine. These new procedures are challenging and timeconsuming to perform. A brief overview on the technical issues and complications related to these small bowel endoscopy procedures is presented.