The spiral enteroscopy training initiative: results of a prospective study evaluating the Discovery SB overtube device during small bowel enteroscopy (with video).

BACKGROUND AND AIM: Indications for small-bowel enteroscopy are increasing, but advancing the endoscope to the ileum remains challenging, especially for less experienced operators. The aim was to evaluate the ease of use, safety, and efficacy of the Discovery SB overtube (Spirus Medical, Stoughton, Massachusetts, USA) during SB enteroscopy by physicians with no experience of the device. PATIENTS AND METHODS: Thirty-three "untrained" endoscopists performed spiral enteroscopy during one of four 2-day training modules. Data were prospectively collected. Patient demographics, depth and time to maximal insertion, total procedure time, and findings were recorded. Trauma was documented during scope withdrawal. Day 1 and day 2 results were compared. RESULTS: Ninety procedures were successfully performed in 95 patients (72.6 % women, age = 48.8 +/- 14.2 years). Endoscopists each performed a mean of five procedures. Mean time to maximal insertion was 20.9 +/- 6.4 minutes. Mean depth achieved was 262.0 +/- 57.4 cm. Total procedure time was 33.6 +/- 8.0 minutes. In 90.3 %, 94.6 %, and 83.9 % of patients, respectively, a trauma score less than 3 was recorded in the esophagus, stomach, and intestine (scale = 0 - 5). There were no perforations, nor significant associations between trauma score and patient age, body mass index, depth of insertion, time to maximal insertion, total procedure time, or day 1 vs. day 2 procedures. Depth of insertion was greater on day 2 than on day 1 (276.9 +/- 53.7 cm vs. 252.0 +/- 58.0 cm, P = 0.043). CONCLUSIONS: Discovery SB provides safe advancement of the enteroscope into the distal small bowel. Maximum depth of insertion appears comparable to that of balloon enteroscopy while taking less time. The device is easy to use and may be effectively operated in as few as five training cases.

Spiral enteroscopy with the new DSB overtube: a novel technique for deep peroral small-bowel intubation.

BACKGROUND AND STUDY AIMS: Spiral enteroscopy is a new technique for deep small-bowel intubation that uses a special overtube (Discovery Small Bowel, DSB) to pleat small bowel. The aims of this prospective study were to evaluate the use of a new-design DSB over new, longer and smaller-diameter enteroscopes, the Fujinon EN-450T5 and the Olympus SIF-Q180. PATIENTS AND METHODS: This is a prospective study of 75 patients at two referral centers. All enteroscopies were performed by two experienced endoscopists. Patients underwent spiral enteroscopy perorally with the DSB and either the Fujinon EN-450T5 or the Olympus SIF-Q180 enteroscope. Procedure time and depth of insertion past the ligament of Treitz were determined for all patients. RESULTS: Peroral spiral enteroscopy with DSB was performed in 50 patients with the Fujinon enteroscope and in 25 patients with the Olympus. Average estimated depth of insertion was 243 cm (range 50 - 380 cm) vs. 256 cm (range 50 - 400 cm) and the average time to reach this depth was 18.7 minutes (range 7 - 52 minutes) vs. 16.2 minutes (range 7 - 33 minutes) in the Fujinon and the Olympus groups respectively. Overall findings were 10 angiodysplasias, 2 small-bowel tumors, 1 Peutz-Jeghers polyp, 1 case of celiac sprue, 2 of small-bowel strongyloidiasis, and 2 small-bowel ulcers. All angiodysplasias were treated with bipolar cauterization. Biopsies were taken from the small-bowel tumors. There were no major complications. CONCLUSIONS: The new DSB is a means of rapid, safe, and effective deep small-bowel intubation. Depth of insertion into the small bowel and total procedure time compare favorably with other deep enteroscopy techniques. The DSB performed equally well with both enteroscopes.

Preoperative nutrition assessment in liver transplantation.

Nutrition assessment and therapy in end-stage liver disease has become increasingly important with the advent of orthotopic liver transplantation. Reduced lean body mass, increased risk of sepsis, and altered metabolism of carbohydrates, protein, and fat are characteristic of patients with liver dysfunction. This study assesses the prevalence of protein-calorie malnutrition and the relative utility of various parameters used to define protein-calorie malnutrition in 104 patients before liver transplantation. Five subgroups were identified for analysis: primary biliary cirrhosis (PBC, n = 21), sclerosing cholangitis (SC, n = 12), chronic active hepatitis (CAH,n = 34), acute hepatitis (AH,n = 11), and other liver diseases (OD,n = 26). Clinical characteristics, anthropometric measurements, secretory protein levels, 24-h urinary creatinine and urea nitrogen, and immunological studies were assessed. Significant differences between groups were noted in age, height, weight, and percentage ideal body weight (IBW), but no differences were noted with respect to triceps skin fold (TSF) and arm muscle circumference (AMC), where uniform depletion of fat and protein stores was found. Overall percentage IBW was significantly elevated (112 +/- 20, mean +/- SD, p < 0.001), whereas TSF and AMC percentage standards were 71 +/- 33 and 89 +/- 11% (respective p < 0.001). With the < 5th percentile of TSF and AMC as markers of malnutrition, 33 and 43% of patients were malnourished, respectively. Hepatic synthetic function was impaired in all groups, with overall albumin 25 +/- 0.6 g/L, transferrin 1.60 +/- 0.66 g/L, and prothrombin 16.8 +/- 6.2 s.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term ethanol consumption alters the hepatic response to the regenerative effects of tumor necrosis factor-alpha.

The pathogenesis of chronic alcoholic liver disease is uncertain, but it may reflect an impaired wound healing response to ethanol-induced liver injury. Cell-to-cell communication such as that mediated by the cytokine tumor necrosis factor is necessary for successful liver regeneration and complete recovery from liver injury. Hence disruption of intercellular regenerative signaling may contribute to the pathogenesis of chronic alcoholic liver disease. To test this hypothesis, the cytokine and regenerative responses triggered by partial hepatectomy were compared in ethanol-fed rats and isocalorically maintained, pair-fed controls. To further clarify the effect of ethanol on tumor necrosis factor-modulated regenerative effects, we evaluated some of the rats in each feeding group after pretreatment with antibodies to tumor necrosis factor. As expected, ethanol inhibited DNA synthesis and liver cell proliferation after partial hepatectomy. Ethanol-associated inhibition of liver regeneration occurred despite apparently similar serum concentrations of the tumor necrosis factor-inducible cytokine interleukin-6. Treatment with antibodies to tumor necrosis factor 1 hr before partial hepatectomy inhibited post-partial hepatectomy induction of interleukin-6 and liver regeneration in ethanol-fed and pair-fed rats. However, serum interleukin-6 was reduced more in ethanol-fed rats than in control rats (93% vs. 66%; p < 0.05). Antibodies to tumor necrosis factor also inhibited hepatic DNA synthesis more in ethanol-fed rats than in controls (85% vs. 50%; p < 0.05). In ethanol-fed rats, the increased effect of tumor necrosis factor antibody on post-partial hepatectomy DNA synthesis suggests heightened sensitivity of hepatocytes to tumor necrosis factor.(ABSTRACT TRUNCATED AT 250 WORDS)