Therapeutic Double Balloon Enteroscopy Research Articles

Occult Obscure GI Bleed: Are the Findings and Tolerability of Double-Balloon Enteroscopy Similar in Octogenarians in Comparison With Younger Patients? Analysis of a Large Database

Introduction: Geriatric population is frequently seen in Gastroenterology practice, as does occult obscure GI bleed (OGIB). Our aim was to compare the findings of double balloon enteroscopy (DBE) in octogenarian patients (80 years and older) who underwent therapeutic DBE for occult OGIB, with younger patients. Methods: 1296 patients underwent 1747 double balloon enteroscopies (DBE) between 2/2009 and 9/2013 at a single tertiary center. Of those, 515 patients underwent 757 DBE for occult OGIB. Of the 515 patients, 86 patients were octogenarian (80 years or older) [median age 83 (range 80-91), 46.5%, female], with the remaining 429 patients being younger than 80 years [median age 66 (range 18-79), 53%, female].Figure 1Figure 2Data was abstracted by retrospective chart review. Main outcomes were to identify the yield of DBE and compare the DBE findings amongst cohorts and with VCE Results: Baseline characteristics are shown in table 1. In summary, no statistical significant differences were noticed for gender, prior EGD/ colonoscopy, incidence of prior video capsule endoscopies (VCE) and yield of VCE. Octogenarians had significantly higher rate of angiodysplasias seen on VCE than the younger patients. Table 2 shows DBE details and as expected, octogenarian had a significantly higher rate of angiodysplasias than younger patients (71% vs.52%). Other DBE findings including small bowel tumors among others were not significantly different in the two cohorts. Importantly, no procedure related immediate complications were noticed in both cohorts. Limitations: Single center, retrospective study. Strength: Large database. Conclusion: Octogenarian patients tolerated therapeutic DBE for occult OGIB well, without reported immediate complications. Our results indicate that DBE is safe and has a high diagnostic and therapeutic yield in comparison to VCE in the octogenarian population who presents with occult obscure GI bleed.

Mo1604 Recurrent Overt Obscure GI Bleed - Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde's Syndrome)?

Mo1604 Recurrent Overt Obscure GI Bleed Does Therapeutic Enteroscopy Change the Disease Course of Patients With Acquired Von Willebrand Factor (Vwf) Deficiency (Heyde’s Syndrome)? Bhaumik Brahmbhatt*, Frank Lukens, Joseph L. Blackshear, Carlos R. Simons Linares, Paul T. Kroner, Abhishek Bhurwal, Mark E. Stark, Michael J. Bartel Gastroenterology, Mayo Clinic, Jacksonville, FL; Cardiology, Mayo Clinic, Jacksonville, FL Background: Patients with recurrent overt obscure GI bleed (OGIB) frequently undergo repetitive therapeutic enteroscopies. In this context, acquired vWF deficiency (Heyde’s syndrome) predisposes both AVM formation and hypocoagulability. Patients at risk for acquired vWF deficiency are those with underlying vascular pathology causing turbulent blood flow, especially aortic valve disease and hypertrophic obstructive cardiomyopathy (HOCM), which all result in destruction of vWF polymers. Aim: Investigate our outcome of patients who underwent therapeutic double balloon enteroscopy (DBE) for overt OGIB stratified by the presence or absence of acquired vWF deficiency or risk factors for acquired vWF deficiency. Methods: 1296 patients underwent 1747 double DBE between 2/2009 and 9/2013 at a single tertiary center. Of those, 243 patients underwent DBE for overt OGIB. Of which, 118 patients were tested for vWF polymers and/or underwent transthoracic echocardiogram (TTE). All patients with abnormal vWF level consistent with Heyde’s syndrome and/or very high likelihood for acquired vWF deficiency on TTE (Rmoderate aortic stenosis or regurgitation, Rmoderate mitral regurgitation, HOCM) are in cohort A. All other patients (normal vWF level and no high risk features on TTE) formed cohort B. The main outcome was the rate of recurrent OGIB. Results: 118 patients who met inclusion criteria (mean age 71.7years, SD 10, 44% female), underwent therapeutic DBE for overt OGIB. 8 patients had abnormal vWF level consistent with Heyde’s syndrome and 31 patients had normal vWF level. An additional 40 patients had TTE findings with very high likelihood for acquired vWF deficiency. No significant differences in age, gender, duration of bleed, transfusion requirement, number of transfusion, NSAID use, and anticoagulation were found between both cohorts. Also the DBE intubation depth (upper DBE 201cm vs 192cm; lower DBE 144cm vs 130cm), rate of total enteroscopy (70% vs 67%), DBE procedure time (118min vs 127min) and diagnostic yield (73% vs 73%) did not differ significantly between the cohorts. The findings on DBE did not differ significantly in both cohorts with the majority being AVMs. Median follow up was 180 days (range 1-2120 days, SEM 69). 39.5% of patients re-bled, 46% in cohort A and 38% in cohort B (NS). When considering only patients with a minimal follow up of 30 days, or stratifying by patients with only abnormal TTE or only abnormal vWF level, similar results were achieved. Conclusion: Patients with documented acquired vWF deficiency (Heyde’s syndrome) and patients with very high likelihood for acquired vWF deficiency based on TTE findings have a non-significant higher rebleeding risk following therapeutic DBE for overt OGIB. Based on our results, those patients should be considered for enteroscopy similarly to patients with normal vWF levels.

Su1164 Diagnostic and Therapeutic Double Balloon Enteroscopy in Crohn's Disease Is Safe and Effective

Su1164 Diagnostic and Therapeutic Double Balloon Enteroscopy in Crohn's Disease Is Safe and Effective

Long-Term Outcome of Patients Treated With Double Balloon Enteroscopy for Small Bowel Vascular Lesions

Early rebleeding rate after endoscopic therapy with double balloon enteroscopy (DBE) of hemorrhagic small bowel vascular lesions (SBVL) varies between 10 and 50%. In recent reports, long-term follow-up of patients have been described but rebleeding risk factors are still not well established. The aim of the current study was to identify long-term treatment success rate and rebleeding risk factors after DBE therapy in a large cohort. We conducted a single-center, retrospective cohort study in a large French tertiary-referral center between January 2004 and December 2007. Among 261 patients presenting with obscure gastrointestinal bleeding (OGIB), SBVL was present in 133 patients and was treated successfully in 129 (97%) using mainly argon plasma coagulation. Ninety-eight patients were followed up for a mean period of 22.6±13.9 months (range 1-52). Rebleeding rate was 46% (45/98 patients) at 36 months. On multivariate analysis, the total number of observed lesions (hazard ratio (HR): 1.15, 95% confidence interval (CI): 1.06-1.25, P=0.001) and the presence of a valvular and/or arrhythmic cardiac disease (HR: 2.50, 95% CI: 1.29-4.87, P=0.007) were significantly associated with the risk of rebleeding. Complication rate of therapeutic DBE was 2.3% with no mortality. Endoscopic therapy using DBE for SBVL in patients with recurrent OGIB allows a long-term remission in more than half of the patients. Independent rebleeding risk factors after a first endoscopic therapy are an increased number of SBVL and an associated valvular/arrhythmic heart disease.

Retrograde double balloon enteroscopy: Comparing performance of solely retrograde versus combined same-day anterograde and retrograde procedure

Objective. Retrograde double balloon enteroscopy (DBE) is important for evaluating the distal small bowel, but it is more challenging compared to the oral route. Optimizing small bowel insertion may enhance the diagnostic utility of the examination. We sought to determine if insertion depths achieved with retrograde DBE when performed as an isolated procedure differed significantly from when performed immediately following anterograde DBE. Material and methods. A retrospective analysis was conducted of all retrograde DBE procedures performed at our center with comparisons made between “distal-only” DBE without preceding anterograde DBE and “combined” DBE after a prior same-day anterograde DBE. Results. Two hundred ninety retrograde DBE procedures were performed in 264 patients over 5 years. Success of terminal ileal intubation exceeded 95%. The mean insertion depth into the distal small bowel differed significantly with 112 cm (95% CI 95–129) in the “distal-only” group and 92 cm (95% CI 85–98) in the “combined” group (p = 0.01), with a trend toward a corresponding increased diagnostic yield of 48% versus 37%, respectively (p = 0.15). Multivariate regression analysis identified both insertion route strategy (distal-only > combined; p = 0.01) and type of DBE endoscope (diagnostic > therapeutic; p = 0.02) as significant predictors of retrograde insertion depth. Conclusions. The insertion depth of retrograde DBE is significantly greater when carried out as a separate distal procedure and not in combination with a preceding anterograde DBE, and when performed using a diagnostic as opposed to the therapeutic DBE endoscope. This increased retrograde depth of insertion may be associated with an increased diagnostic yield.

Balloon Enteroscopy: Single- and Double-Balloon Enteroscopy

Balloon enteroscopy is a method that allows endoscopic inspection of the entire small bowel, or large parts of it, while simultaneously making it possible to obtain histologic samples and carry out treatment measures. Studies of double-balloon enteroscopy (DBE) have confirmed the high diagnostic yield of the procedure, with an acceptably low complication rate (approximately 1% for diagnostic DBE and 3% to 4% for therapeutic DBE). The principal indication for the procedure is midgastrointestinal bleeding, that is, when the bleeding source is located in the small bowel. With good patient selection, the diagnostic yield here is 70% to 80%, and this has a substantial influence on subsequent treatment measures. Single-balloon enteroscopy appears to be a simplification of the technique that is easier to handle, but few original studies have been published on the topic to date, and the results of prospective and controlled studies with larger numbers of patients must therefore be awaited. At present, DBE must still be regarded as the standard method for diagnostic and therapeutic endoscopy in the small bowel, avoiding the need for intraoperative enteroscopy or therapeutic laparotomy.

Minimizing procedural cost in diagnosing small bowel bleeding: comparison of a strategy based on initial capsule endoscopy versus initial double-balloon enteroscopy

Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) detect small bowel bleeding with equal diagnostic yield. We aimed to detect factors that influence procedural cost of CE and DBE in diagnosing and treating small bowel bleeding, and to compare them with reimbursement. A cost model analysed procedural cost for diagnostic CE versus diagnostic, unidirectional DBE(scenario 1) and CE plus directed therapeutic DBE(positive findings in CE) versus unidirectional diagnostic plus therapeutic DBE (scenario 2). The frequency of investigations per annum (p.a.) at which cost per procedure is equalized (break-even point) was determined for CE versus DBE. A retrospectively collected cohort of patients was used to validate the cost model and to compare procedural costs with reimbursement (German diagnosis related groups, G-DRG). The break-even point at which cost per procedure is equalized for CE versus DBE was reached at 100 procedures p.a. in scenario 1 and 79 in scenario 2 for a rate of therapeutic enteroscopy of 14%, and 27 for a therapeutic enteroscopy rate of 30%. Personnel cost, procedure time,procedures p.a. and the rate of therapeutic enteroscopy had a major influence on procedural cost. In this patient cohort, the 'CE-first' and the 'DBE-first' strategies produced procedural costs of pound sterling 830 and pound sterling 1,076 per patient to attain a diagnosis, and pound sterling 1,042 versus pound sterling 1,181 to achieve therapeutic enteroscopy, respectively. For this cohort, potential reimbursement was pound sterling 2,320 and pound sterling 3,047 for the 'CE-first' and the 'DBE-first' strategies, respectively (G-DRG). Workflow management of CE versus DBE should consider frequency of investigations p.a. and probability for therapeutic enteroscopy to minimize procedural costs. The cost of DBE increases with less frequent or time-consuming investigations; CE is more robust with regard to these factors. From a third-party payer perspective, a strategy incorporating CE seems to minimize costs in G-DRG.

Therapeutic Double Balloon Enteroscopy Reduces Transfusion Requirements in the Management of Occult or Obscure Gastrointestinal Bleeding

Introduction: Patients with occult or obscure gastrointestinal (GI) bleeding can be challenging to manage. Double Balloon Enteroscopy (DBE) is a novel procedure enabling therapeutic interventions within most of the small bowel. Further research regarding the clinical impact of these interventions is needed. Aim: To evaluate the impact of therapeutic DBE on packed red blood cell transfusion requirements in patients with occult or obscure GI bleeding. Methods: This is a retrospective review of patients who underwent DBE at two tertiary care centers from 5/07 to 10/08 with a focus on patients who had therapeutic endoscopic interventions for occult or obscure GI bleeding. A Student's T-test and Chi square analysis were used for comparison of samples with significance considered if the P value was less than 0.05. Results: There were 77 patients, mean age 64 years (14-89), who underwent DBE in the 18 month period. Of the 77 patients, 70 had occult or obscure GI bleeding. Forty-seven (67%) of the 70 patients had endoscopic findings potentially accounting for the blood loss. These small bowel lesions varied in location from the mid-Jejunum to proximal-mid Ileum and were out of reach via standard small bowel enteroscopy or colonoscopy with Ileoscopy. Forty patients had arterio-venous malformations(AVMs), 4 patients had small bowel ulcerations, 1 patient had celiac disease, 1 patient had a bleeding small bowel (mid-Ileum)polyp and 1 patient had bleeding jejunal diverticula. Forty-two (60%) of the 70 patients had therapeutic DBE interventions including argon plasma coagulation (N=41), hemoclip placement (N=3) and snare polypectomy (N=1). Among the patients with therapeutic interventions, there was a statistically significant per patient decrease in the amount of blood units transfused during the preceding 6 months, [mean 1.8 units (range = 0-20)] compared to the 6 months after the DBE exam, [mean 0.3 units (range = 0-5)]; (P=0.04). There were 3 patients who had post procedure GI bleeding within 30 days after therapeutic DBE; all were managed conservatively. This was not significantly higher compared to the group of patients who did not have a therapeutic intervention (P = 0.17). Conclusions: 1) Therapeutic DBE results in a long-term and clinically significant beneficial outcomes among patients with occult or obscure GI bleeding as noted by a decrease need for red blood cell transfusion requirements. 2) AVMs are the most commonly treated lesion in patients with occult or obscure GI bleeding. 3) Therapeutic DBE is a safe procedure. 4) Gastroenterologists who perform DBE need to be aware of the its potential therapeutic benefits.

Enteroscopy

Until the end of the 20th century, push enteroscopy (PE) was the most commonly used method for the endoscopic investigation of the small bowel. However, PE has been almost completely replaced by double balloon enteroscopy (DBE). Undoubtedly the major endoscopic breakthrough of the last decade, DBE has contributed to the better diagnosis and understanding of diseases of the small bowel, opening-up this obscure part of the gastrointestinal tract to visualisation. Modern diagnostic and therapeutic DBE allows for a deeper and more thorough evaluation of the small bowel than PE, enabling the detection of more pathological lesions. In addition, DBE has for the first time enabled endoscopists to observe the entire small intestine, and has provided endoscopic interventions such as cauterisation of bleeding lesions, polypectomy, placement of small bowel stents, and foreign-body extraction.

Safer endoscopic therapy of small-bowel diseases during double-balloon enteroscopy

We read with interest the article by Mensink et al. [1] on a multicenter survey of complications of double-balloon enteroscopy (DBE). The authors encountered 40 complications in 2362 DBEs (1.7 %), of which 13 occurred after 1728 diagnostic DBEs (0.8 %), and 27 occurred after 634 therapeutic DBEs (4.3 %). The complications consisted of pancreatitis (n = 7), bleeding (n = 19), perforations (n = 6), and others (n = 8). The authors concluded that the complication rate in therapeutic DBE is considerably higher than that associated with therapeutic colonoscopy. We believe that simple techniques can reduce the complication rate.

Complications of double balloon enteroscopy: a multicenter survey

Double balloon enteroscopy (DBE) is a new technique for the visualization of the small bowel. Although the technique is widely used, little is known about the complications. A few complications have been reported in the literature, mainly in case reports. The aim of this study was to establish the complication rate of both diagnostic and therapeutic DBE. A total of 10 centers (nine academic centers and one teaching hospital) across four continents participated in the study. Complications were defined according to the literature. A therapeutic DBE was defined as a DBE with use of argon plasma coagulation, a polypectomy snare, injection of fluids (other than ink for marking), removal of foreign body, or balloon dilation. A total 85 adverse events were reported in 2362 DBE procedures. In all, 40 events fulfilled the definition of a complication, 13 in 1728 diagnostic DBE (0.8 %) and 27 during 634 therapeutic procedures (4.3 %). The complications were rated minor in 21 (0.9 %), moderate in 6 (0.3 %) and severe in 13 procedures (0.6 %). No fatal complications were reported. Seven cases of pancreatitis were reported, six after diagnostic (0.3 %) and one after therapeutic (0.2 %) DBE. Diagnostic DBE is safe with a low complication rate. The complication rate of therapeutic DBE is high compared with therapeutic colonoscopy. The reason for this is unclear. The incidence of pancreatitis after DBE is low (0.3 %), but has to be considered in patients with persistent abdominal complaints after a DBE procedure.

The Comparative Study of the Detection Rate Between Capsule Endoscopy and Double Balloon Enteroscopy in Our Four-Year Experience

Background: There is no consensus on the relative accuracy of capsule endoscopy (CE) versus double balloon enteroscopy (DBE) to detect small bowel lesions. CE is less invasive, but DBE allows for examination of the entire small bowel, tissue sampling and therapeutic intervention. This retrospective study compares the detection rate of CE and DBE in our four-year experience. Adverse events, therapeutic interventions and duration of DBE were evaluated as secondary outcomes. Methods: We reviewed data of patients with obscure gastrointestinal bleeding and/or suspected small bowel lesions who were referred to our unit from December 2002 to November 2006. All patients required bowel preparation for both CE and DBE. After CE were done and reviewed, antegrade or retrograde or combined antegrade and retrograde DBE were performed with or without intervention. The data with a normal distribution were compared with the Student's paired t-test. Categorical data were compared with McNemar's test. Results: Forty five patients with obscure gastrointestinal bleeding [overt bleeding (n = 10), NSIAD use (n = 14), oral anticoagulant use (n = 5), mean Hb ± SD (g/dL):10.4 ± 1.7, number of red blood unit transfusion (median; range): 10; 0-100] and two patients with polyposis syndrome were studied with mean age of 63.9 years (range; 34-83) and 24 females. From forty seven CE and total of fifty five DBE procedures were conducted. CE detected positive findings 87.3% whereas DBE detected positive findings 85.5%, p = 0.5. The positive findings in each type of lesion was compared, angiodysplasia (CE 54.5% and DBE 60%, p = 0.3), erosions or ulcers (CE 14.5% and DBE 16.4%, p = 0.5), bleeding lesions (CE 40% and DBE 16.4%, p = 0.02), small bowel polyps and tumors (CE 80% and DBE 80%, p = 0.75). DBE provided the advantage of therapeutic intervention, argon plasma coagulation (n = 29), clipping (n = 2), both argon plasma coagulation and clipping (n = 2), polypectomies (n = 2), tattooing (n = 48) and biopsies (n = 9) were done. Mean duration of DBE was 179.8 minutes (range; 40-335 minutes) No major complication occurred with either examination. Two patients required resections of small bowel tumors. Conclusion: The overall detection rate of CE and DBE were similar, except in bleeding lesions that CE was superior. Therefore the patients with positive findings on CE should be followed by therapeutic DBE.

Safety and Efficacy of Therapeutic Double Balloon Enteroscopy (TDBE) in Mexican Population

Safety and Efficacy of Therapeutic Double Balloon Enteroscopy (TDBE) in Mexican Population

What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers

Performance parameters for double-balloon enteroscopy (DBE) have not been described. To determine the learning curve for DBE. Prospective cohort study. Six U.S. tertiary centers. A total of 188 subjects undergoing 237 DBE procedures; 130 (69%) with obscure GI bleeding. Performance parameters from each center's initial 10 cases were compared to the subsequent examinations. Exam duration, depth of insertion, and findings on DBE examination. DBE was introduced by mouth in 149 (63%) cases, by rectum in 77 (33%) cases, and through a stoma in 6 (2.5%) patients. The mean (+/-SD) duration was 109.1 +/- 44.6 minutes for the first 10 cases and 92.4 +/- 37.6 minutes for subsequent cases (P = .005) but did not change for rectal DBE procedures. There was no change in mean depth of insertion, but the mean fluoroscopy time declined significantly (P = .025). Diagnostic or therapeutic maneuvers were performed in 64% of cases; DBE led to a diagnosis in 81 (43%) patients. A total of 78% of patients had prior capsule endoscopy (CE) with significant agreement between DBE and CE (kappa = 0.74). One perforation occurred (0.4%). Per-rectal cases failed to reach the small bowel in 24 (31%) cases. All patients did not undergo initial CE. The therapeutic DBE scope was not available for the initial 8 months of the study. There was a significant decline in overall procedural time and fluoroscopy time after the initial 10 DBE cases. There was no improvement in performance parameters when DBE was performed via the rectal approach despite increased, but limited, operator experience.