Retrospective analysis of endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy / 中华消化内镜杂志

Objective:To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) after pancreaticoduodenectomy and endoscopic selection strategies.Methods:Clinical data of 34 patients treated with ERCP after pancreaticoduodenectomy at the Endoscopic Center of the First Affiliated Hospital of Air Force Medical University from January 2013 to December 2021 were retrospectively analyzed. The success rates of endoscopic insertion, diagnosis, treatment and ERCP, and the incidence of adverse events were analyzed.Results:Fifty ERCP treatments were performed in 34 patients. The success rates of endoscopic insertion, diagnosis, treatment, and ERCP after pancreaticoduodenectomy were 92.0% (46/50), 93.5% (43/46), 88.4% (38/43) and 76.0% (38/50), respectively. The success rates of ERCP assisted with colonoscope and balloon-assisted enterosocpe were 76.0% (19/25) and 75.0% (18/24), respectively. There were 3 adverse events, including 1 case of anastomotic mucosa tear during surgery, 1 case of cardiopulmonary arrest and 1 case of postoperative cholangitis.Conclusion:ERCP is effective and safe after pancreaticoduodenectomy in general. ERCP assisted with colonoscope and balloon-assisted colonoscope shows similar success rate after pancreaticoduodenectomy.

Clinical value of endoscopic stricturotomy under balloon-assisted enteroscopy in the treatment of benign jejuno-ileal stenosis / 中华消化杂志

Objective:To evaluate the efficacy and safety of endoscopic stricturotomy (EST) under balloon-assisted enteroscopy (BAE) in treatment of benign jejuno-ileal stenosis.Methods:From December 2015 to August 2021, at the Air Force Medical Center, 41 patients who were diagnosed with benign jejuno-ileal stenosis underwent BAE deep small bowel EST and/or surgery due to ineffective or ineffective drug treatment were retrospectively analyzed. Twenty-one patients were treated with EST (EST group) and 20 patients were treated with surgery (surgery group). The etiology and follow-up time were analyzed, the general conditions (male proportion and age), the immediate technical success rate (the percentage of the stenosis that the enteroscope could pass through after EST in the total number of treated stenoses), the incidence of complications (including perforation, bleeding, etc.), the symptom remission rates at 3-month, 6-month, and 1-year after treatment (the percentage of patients with complete or partial remission in the total number of patients), cumulative symptom-free survival rate (no obstruction-related symptoms after EST or surgery till the last follow-up) and cumulative surgery-free survival rate of two groups were compared. Chi-square test, independent t-test, Fisher′s exact probability method and Kaplan-Meier analysis were used for statistical analysis. Results:The main etiology of stricture of EST group and surgery group was Crohn′s disease (71.4%, 15/21 and 60.0%, 12/20, respectively), and the median follow-up time was 12 months (6 to 46 months) and 45 months (14 to 73 months), respectively. There were no significant differences in male proportion, age, immediate technical success rate and incidence of complication between EST group and surgery group (57.1%, 12/21 vs. 65.0%, 13/20; (45.2±17.4) years old vs. (43.1±20.3) years old; 95.3%, 41/43 vs. 100.0%, 30/30; 26.9%, 7/26 vs. 10.0%, 2/20, all P>0.05). In the EST group, 9.5% (2/21) of the patients received surgery because of perforation during EST, 76.2% (16/21) of the patients did not need surgery after EST, and the median symptom-free survival time of patients without symptoms in EST group was 13.3 months. There was no significant difference in the symptom remission rate at 3-month after treatment between EST group and the surgery group (17/19 vs. 100.0%, 20/20, P>0.05). The symptom remission rate at 6-month and 1-year of EST group were lower than those of the surgery group (15/19 vs. 100.0%, 20/20; 8/11 vs. 100.0%, 20/20), and the differences were statistically significant (both were Fisher′s exact probability method, P=0.047 and 0.037). The cumulative symptom-free survival rates at 3-month, 6-month and 1-year of EST group and surgery group were 66.0% vs. 90.0%, 61.0% vs. 85.0% and 54.0% vs. 80.0%, respectively.The results of Kaplan-Meier analysis indicated that there was no significant difference in the symptom-free survival curve between two groups ( P>0.05). The 3-month, 6-month and 1-year cumulative surgery-free survival rates after treatment in EST group were 90.0%, 81.0% and 73.0%, respectively. The 3-month, 6-month and 1-year cumulative surgery-free survival rates after treatment in surgery group were all 100.0%. Conclusion:EST under BAE is technically feasible, and safe in the treatment of benign jejuno-ileal stenosis, and can effectively relieve clinical obstruction symptoms and avoid or delay surgery in the short term.

Endoscopic features of gastrointestinal stromal tumor in the small intestine

BACKGROUND/AIMS: Gastrointestinal stromal tumor (GIST) is one of the most common types of submucosal tumors (SMTs). Because of GIST's malignant potential, it is crucial to differentiate it from other SMTs. The present study aimed to identify characteristic endoscopic findings of GISTs in the small intestine. METHODS: We reviewed the clinicopathological and endoscopic findings of 38 patients with endoscopically or surgically resected SMTs in the small intestine. SMTs were classified into GIST and non-GIST groups, and clinicopathological and endoscopic findings were compared between the 2 groups. RESULTS: Fifteen patients had GIST and 23 patients had other types of SMTs in the small intestine. Comparison of the endoscopic findings between the 2 groups revealed that dilated vessels in the surrounding mucosa were significantly more in number in the GIST group than in the non-GIST group (P<0.05). However, there were no other differences in endoscopic findings between the 2 groups. Among patients with GISTs, the presence of dilated vessels in the surrounding mucosa was not associated with bleeding risk, tumor size, or metastasis rate at diagnosis. CONCLUSIONS: Dilated vessels in the surrounding mucosa, identified during balloon-assisted endoscopy, may be a diagnostic indicator for GIST in the small intestine. However, its clinical significance should be further analyzed.

Magnified single-balloon enteroscopy in the diagnosis of intestinal follicular lymphoma: a case series

The objective of this study was to evaluate the magnified endoscopic findings in the diagnosis of follicular lymphoma in the small intestine in comparison with those of intestinal follicular lymphoma and lymphangiectasia. Four patients with follicular lymphoma and 3 with lymphangiectasia in the small intestine were retrospectively analyzed. A prototype magnifying singleballoon enteroscope was used. The findings of the intestinal follicular lymphoma and lymphangiectasia were retrospectively analyzed to determine the magnified endoscopic findings of follicular lymphoma in the small intestine. Opaque white granules were observed in 3 of the 4 patients with follicular lymphoma. Magnified narrow-band imaging (NBI) of the opaque white granules showed stretched microvessels, which had a diminutive tree-like appearance. The remaining patient had no opaque white granules and only displayed whitish villi. Magnified NBI observation of the whitish villi revealed the absence of marginal villus epithelium, which was confirmed by histology. The magnified NBI enteroscopy revealed the diminutive tree-like appearance on the opaque white granules and the absence of marginal villus epithelium of the whitish villi in intestinal follicular lymphoma. These findings may be useful in diagnosing follicular lymphoma.

Steroid-refractory extensive enteritis complicated by ulcerative colitis successfully treated with adalimumab

Extracolonic involvement of the gastrointestinal tract is extremely uncommon in ulcerative colitis (UC) and rarely found in the upper gastrointestinal tract or in postoperative cases since it typically responds to steroids. Here we report a case of UC complicated by extensive ileal inflammation that was refractory to steroids. A 20-year-old man was diagnosed with UC of typical pancolitis without ileal involvement and started treatment with pH-dependent mesalazine and oral prednisolone. Although his symptoms transiently resolved, the condition flared when the steroid dose was tapered down. Computed tomography revealed marked thickening of the ileal wall, and capsule endoscopy and balloon-assisted enteroscopy found diffuse mucosal inflammation with ulcers in the ileum. On the contrary, the inflammation in the colon and rectum was improving. Since the response to the second steroid course was inadequate, treatment with adalimumab and 6-mercaptopurine was initiated and finally achieved clinical and endoscopic remission. The investigation of small intestinal lesions is necessary in patients with UC whose clinical deterioration cannot be explained by colonic lesions.

Balloon-Assisted Enteroscopy and Capsule Endoscopy in Suspected Small Bowel Crohn's Disease

Inflammatory bowel diseases are idiopathic inflammatory diseases of two main types, Crohn's disease and ulcerative colitis. Crohn's disease can affect the entire gastrointestinal tract, and the distal ileum is involved in up to 70% of patients. Moreover, Crohn's disease in one-quarter to one-third of patients involves isolation of the small bowel. Due to the nonspecific symptoms and anatomical location of the disease, small bowel Crohn's disease is a phenotype that is particularly difficult to manage. Since the introduction of capsule endoscopy in 2000 and balloon-assisted enteroscopy in the 21st century, it is now possible to directly inspect for small bowel Crohn's disease. However, the new modalities still have limitations, such as capsule retention and invasiveness of balloon-assisted enteroscopy. The diagnostic yields of both capsule endoscopy and balloon-assisted enteroscopy are high for patients with suspected small bowel Crohn's disease. Therefore, earlier use of capsule endoscopy or balloon-assisted enteroscopy can help with the diagnosis and earlier treatment of these patients to avert possible disastrous outcomes.

Comparison of the Efficacy and Safety of Single- versus Double-Balloon Enteroscopy Performed by Endoscopist Experts in Single-Balloon Enteroscopy: A Single-Center Experience and Meta-Analysis

BACKGROUND/AIMS: Studies concerning the efficacy and safety of single-balloon enteroscopy (SBE) compared with that of double-balloon enteroscopy (DBE) often appear to be conflicting. However, previous studies were performed by endoscopists who were less experienced in SBE compared with DBE. METHODS: We performed a retrospective analysis of SBE and DBE data performed by a single enteroscopist, with expertise in SBE, using a prospective balloon-assisted enteroscopy registry from 2013 to 2015. Furthermore, we performed a comprehensive literature search and meta-analysis of available studies, including the current study, to clarify the efficacy and safety of SBE versus DBE. RESULTS: A total of 65 procedures in 44 patients with SBE and 74 procedures in 69 patients with DBE were analyzed. There were no significant differences in diagnostic yield (61.1% vs 77.3%, respectively, p=0.397), therapeutic yield (39.1% vs 31.8%, respectively, p=0.548), and complication rate (4.4% vs 2.3%, p=1.000). In the meta-analysis, which included four randomized controlled trials and three observational studies, there were no significant differences in the pooled relative risk and odds ratio for diagnostic and therapeutic yield and complications of SBE compared with those of DBE. CONCLUSIONS: The performance of SBE appears to be similar to that of DBE in terms of diagnostic and therapeutic yield and complications.

The role of small bowel endoscopy in small bowel Crohn's disease: when and how?

Endoscopy has a crucial role in the diagnosis, management, and surveillance of inflammatory bowel disease (IBD). It contributes in supporting the diagnosis of IBD with the clinical history, physical examination, laboratory findings, and targeted biopsies. Furthermore, endoscopy has a significant role in assessing disease activity and distribution in treatment efficacy evaluation, post-surgical recurrence risk, and cancer surveillance in patients with long-lasting illness. Endoscopy also provides therapeutic potential for the treatment of IBD, especially with stricture dilatation and treatment of bleeding. Small bowel (SB) endoscopy (capsule endoscopy and device-assisted enteroscopy) and cross-sectional radiologic imaging (computed tomography enterography and magnetic resonance enterography) have become important diagnostic options to diagnose and treat patients with SB Crohn's disease. We reviewed the present role of SB endoscopy in patients with SB Crohn's disease.

Magnetic resonance enterography for the evaluation of the deep small intestine in Crohn's disease

For the control of Crohn's disease (CD) a thorough assessment of the small intestine is essential; several modalities may be utilized, with cross-sectional imaging being important. Magnetic resonance (MR) enterography, i.e., MRE is recommended as a modality with the highest accuracy for CD lesions. MRE and MR enteroclysis are the two methods performed following distension of the small intestine. MRE has sensitivity and specificity comparable to computed tomography enterography (CTE); although images obtained using MRE are less clear compared with CTE, MRE does not expose the patient to radiation and is superior for soft-tissue contrast. Furthermore, it can assess not only static but also dynamic and functional imaging and reveals signs of CD, such as abscess, comb sign, fat edema, fistula, lymph node enhancement, less motility, mucosal lesions, stricture, and wall enhancement. Several indices of inflammatory changes and intestinal damage have been proposed for objective evaluation. Recently, diffusion-weighted imaging has been proposed, which does not need bowel preparation and contrast enhancement. Comprehension of the characteristics of MRE and other modalities is important for better management of CD.

Value of the use of balloon-assisted enteroscopy in diagnosis and treatment of small bowel tumor / 解放军医学杂志

Objective To study the value of the use of balloon-assisted enteroscopy (BAE) in the diagnosis and treatment of small bowel tumor. Methods From May 2007 to September 2014, a total of 126 patients with suspected small bowel tumor were enrolled. BAE was performed in all the patients. Of them, abdominal CT scan were performed in 80 patients, gastrointestinal barium radiography in 22, and capsule endoscopy in 24. The positive detection rate, sensitivity, specificity, and the rates of missed diagnosis and misdiagnosis of different examinations were compared. Balloon-assisted endoscopic treatment was conducted in some patients, and its safety and feasibility were assessed. Results The positive rate, sensitivity, and specificity of BAE for suspected small bowel tumor were significantly higher than that of abdominal CT scan, gastrointestinal barium radiography and CE (The positive rates of balloon-assisted enteroscopy, abdominal CT, gastrointestinal barium, capsule endoscopy were 92.9%, 47.5%, 68.2%, 91.7% respectively; their sensitivity 100%,71.1%, 66.7%, 100%, and specificity 100%, 82.9%, 28.6%, 22.2%), respectively (P<0.01), while the rates of diagnostic failure and misdiagnosis were remarkably lowered (The rates of diagnostic failure of balloon assisted enteroscopy, abdominal CT, gastrointestinal barium, capsule endoscopy were 0%, 28.9%, 33.3%, 0%, and the rates of misdiagnosis from these 0%, 17.1%, 71.4%, 77.8% respectively) (P<0.0l). In a certain number patients with intestinal neoplasm, removal of the tumor could be performed with the aid of BAE. Conclusion With the aid of BAE, the rate of positive diagnostic rate of small bowel tumor is significantly elevated, and it is safe and reliable for endoscopic removal for some small bowel tumors, thus it is valuable in clinical application.

Small Bowel Stent-in-Stent Placement for Malignant Small Bowel Obstruction Using a Balloon-Assisted Overtube Technique

Self-expanding metal stents are a useful therapy to palliate malignant and benign luminal gastrointestinal obstruction. Self-expanding metal stents has been widely reported for colonic, esophageal, and gastric obstruction. However, endoscopic delivery and placement to the small bowel is more challenging and difficult. This case illustrates the usefulness and technical advantages of the balloon-overtube and enteroscopy technique for the palliative treatment of neoplastic stenosis affecting the small intestine.

Capsula endoscópica y enteroscopia asistida por balones en pacientes con sospecha de enfermedad de intestino delgado métodos complementarios / Capsule endoscopy and balloon enteroscopy in patients with suspected small bowel disease complementary methods

El desarrollo reciente de la cápsula endoscópica (CE) y la enteroscopia asistida por balones (EAPB) ha cambiado el algoritmo diagnóstico de la patología del intestino delgado. La combinación de ambos métodos parece ser una herramienta útil. Mostrar la experiencia con el uso combinado de CE y EAPB en pacientes con sospecha de enfermedades del intestino delgado. 34 pacientes a quienes se les realizó CE y EAPB. El endoscopista conocía el resultado de la CE. Equipos: CE M2A, PillCam SB (Given Imaging), videoenteroscopios doble balón Fujinon EN-450P5, EN-450T5, enteroscopio balón único Olympus SIG Q-180. Se registraron datos demográficos, indicaciones, segmentos evaluados, hallazgos y complicaciones. 34 pacientes (19 mujeres, 15 hombres), edad promedio: 57,67 años. Principales indicaciones: sangrado digestivo oscuro evidente 67,64 %, anemia 11,76%, enfermedad de Crohn 5,88%. La EAPB se realizó por vía anterógrada en 25 pacientes, retrógrada en 4 y combinada en 5. Se detectaron lesiones con CE en 85,29% pacientes, con EAEAPB en 67,64% y con ambos métodos en 52,9%. En 11 pacientes se detectaron lesiones por CE y la EAPB fue normal. En 2 pacientes hubo hallazgos en la EAPB no vistos por la cápsula. Hallazgos mas frecuentes: CE: angioectasias 11, tumor subepitelial ulcerado 2, presencia de sangre 4, úlceras 3. EAPB: angioectasias 9, tumor subepitelial ulcerado 1, ulceras 3, divertículo de Meckel, 1. Terapéutica endoscópica en 13 pacientes y cirugía en 4 con sangrado digestivo. CE y EBU combinadas permiten mejorar el diagnóstico y orientar la conducta terapéutica en pacientes con sospecha de patología del intestino delgado...

The recent development of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) has changed the diagnostic algorithm of small bowel pathology. The combination of both methods seems to be a useful tool. To show the experience with the combined use of CE and BAE in patients with suspected small bowel diseases. 34 patients who underwent CE and BAE. The endoscopist knew the outcome of the CE. We used the CE M2A, Pillcam (Given Imaging), double balloon videoenteroscopy Fujinon EN-450P5, EN-450T5, single balloon enteroscopy GIS Olympus Q-180. Demographic data, indications, segments evaluated, findings and complications were recorded. 34 patients (19 women, 15 men), average age: 57.67 years. Main indications: evident obscure gastrointestinal bleeding 67.64%, anemia 11, 76%, Crohn’s disease 5.88%. Anterograde BAE was performed in 25 patients, retrograde in 4 and combined in 5 patients. CE lesions were detected in 85.29% patients with BAE in 67.64% and 52.9% in both methods. In 11 patients lesions were detected by CE and the BAE was normal. In 2 patients there were findings in the BAE, not seen by the capsule. Most common finding: CE: 11 angiodysplasia, 2 subepithelial ulcerated tumor, 4 blood presence, 3 ulcers. BAE: 9 angiodysplasia, 1 subepithelial ulcerated tumor, 3 ulcers, 1 Meckel diverticulum. Therapeutic endoscopy was performed in 13 patients and surgery in 4 patients with digestive bleeding. Combined CE and BAE allow improving the diagnostic and orientate the therapeutic behavior in patients with suspected small bowel pathology...