Outcomes in Patients with Left Ventricular Assist Devices, Pacemakers, and Implantable Cardioverter Defibrillators Undergoing Single Balloon Enteroscopy.

OBJECTIVES: Obscure overt gastrointestinal bleeding can be challenging to evaluate in patients with electronic cardiac devices such as continuous flow left ventricular assist devices (LVADs), pacemakers (PPMs), and implantable cardioverter defibrillators (ICDs). Limited data exist on the utility and safety of single balloon enteroscopy (SBE) in patients with cardiac devices. We aimed to evaluate the safety, efficacy, diagnostic, and therapeutic outcomes of the aforementioned devices in patients undergoing SBE. METHODS: A retrospective study was performed using the medical records of 57 patients undergoing SBE at our institution from 2010 to 2014. Patients were divided into two groups: those with cardiac devices and those without. Data on comorbidities, complications, findings, diagnostic, and therapeutic yield were compared. t Test and logistic regression assessed the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and standard deviation. For dichotomous data, the results were summarized as odds ratio and 95% confidence intervals. RESULTS: The overall age in patients with cardiac devices was 67.89 ± 6.96 versus 66.03 ± 11.95 years in the control. The cardiac device group was composed of 42.1% women; the control comprised 21.1% women. There were 19 patients with cardiac devices; 8 (LVAD + ICD), 1 (LVAD + PPM + ICD), 2 (PPM + ICD), 6 (PPM), 2 (ICD); 38 patients were in the control group. Patients with cardiac devices were hospitalized more often than patients without devices; this finding was not statistically significant (odds ratio 1.826, 95% confidence interval 0.544-6.128, P = 0.389). Procedure times were longer in the cardiac device group, 65.16 ± 49.92 minutes, when compared with the control, 57.40 ± 20.42, but it also did not reach statistical significance (mean difference 7.758, 95% confidence interval -11.360 to 26.876, P = 0.049). There was no statistically significant difference in major or minor events between patients with cardiac devices and the control group. Diagnostic and therapeutic yield and rebleeding rates were similar across both groups. CONCLUSIONS: Patients in the cardiac device group did not appear to be at any more significant risk than those without cardiac devices. Furthermore, diagnostic and therapeutic yield and rebleeding rates appear to be similar across both groups. Clinicians may perform SBE in these patients safely and effectively, with good overall outcomes.

Timing of single balloon enteroscopy: significant or not?

BACKGROUND: The development of balloon assisted enteroscopy (BAE) has revolutionized diagnostic and therapeutic modalities for small-bowel disorders. Although the role of emergent esophagogastroduodenoscopy and colonoscopy for upper and lower gastrointestinal bleeding is well defined, there is scarce data with regard to emergent BAE for gastrointestinal bleeding. STUDY: We performed a retrospective cohort study including 110 hospitalized patients with obscure gastrointestinal bleeding who underwent single balloon enteroscopy (SBE) between January 2010 and August 2013. Patients were divided into two groups based on procedures performed emergently (within 24 hours) versus non-emergently (greater than 24 hours). Data on patient demographics, hemodynamic characteristics, type of obscure bleed, lesions identified, location of lesions, endoscopic intervention performed, need for further surgical or radiological intervention, diagnostic and therapeutic yield, and adverse events were compared between groups. Independent samples t test and Fisher's exact test were used to assess the association between dependent and independent variables. For continuous data, the results were summarized as mean difference and 95 % confidence intervals (CI), and for binary as odds ratio and 95 %CI. RESULTS: Although patients in the group where enteroscopy was performed within 24 hours had a significantly higher incidence of radiological intervention (10.0 % vs. 0.0 %, P = 0.019), the diagnostic and therapeutic yields between the two groups were not significantly different. Additionally, there were no statistically significant differences between the groups for overt and occult bleeding, transfusion requirements, type and location of lesions, endoscopic intervention performed, or adverse events. Hospital stay was shorter in the patients who had SBE within 24 hours of admission (6.2 vs. 11.3 days, P < 0.001). CONCLUSIONS: Although the diagnostic and therapeutic yields of SBE were not significantly different between patients having the procedure within 24 hours and those having it later, the early SBE group required more interventional radiology procedures. While endoscopists may not necessarily have to perform emergent assessment within 24 hours in patients with obscure gastrointestinal bleeding (OGIB) for greater diagnostic or therapeutic yield, early intervention may allow for earlier stabilization and thus shorter hospital stays. Prospective studies further evaluating these findings are indicated.

The safety and efficacy of single balloon enteroscopy in the elderly.

BACKGROUND: Single balloon enteroscopy (SBE) is an important tool in the management of small bowel disease with limited data available on its performance in the elderly. We aimed to evaluate the safety, efficacy, diagnostic and therapeutic outcomes of SBE in the elderly. METHODS: A retrospective review was performed on 366 patients undergoing 428 SBEs from 2010 to 2014. Patients were divided into different age groups: control <55, 55-64, 65-74 and ⩾75 years. Data on comorbidities, complications, findings, diagnostic and therapeutic yield were compared between groups. RESULTS: Anterograde and retrograde SBE were performed in 340 and 49 patients, respectively, with 63 patients requiring more than 1 procedure. Diagnostic yield was significantly higher for age ⩾75 years compared with <55, 66.3% versus 50%, odds ratio (OR) 1.97 [95% confidence interval (CI) 1.14-3.41]. Therapeutic yield was significantly higher in all three older age groups compared with <55 years, 20.3%: 55-64 years, 44.4%, OR 3.13(95% CI 1.7-5.78); 65-74 years, 42%, OR 2.84 (95% CI 1.59-5.06); and >75 years, 47.5%, OR 3.55 (95% CI 1.96-6.43). No significant difference was seen between age groups in complications or failures. Our overall complication rate was 2.3% with 5 minor and 5 major complications. There was a higher yield of angioectasias in the elderly. Argon plasma coagulation (APC) and multipolar electrocoagulation were used more often in older age groups. CONCLUSION: SBE is safe in elderly patients and delivers higher diagnostic and therapeutic yields compared to younger patients. The elderly are more likely to have angioectasias and undergo APC and electrocoagulation.

Capsule Studies Performed in a Tertiary Care Center Versus Community Referrals Prior to Single-Balloon Enteroscopy: Does It Matter?

BACKGROUND AND AIMS: Within the community, patients with positive capsule endoscopy (CE) are often referred to centers performing balloon-assisted enteroscopy. There is limited data evaluating the concordance and diagnostic/therapeutic yield of CE performed in the community versus CE conducted at institutions experienced with enteroscopy. The primary aim of this retrospective study was to evaluate the concordance between CE and SBE after CE was performed either in the community or at our tertiary care center. METHODS: A total of 141 patients were analyzed after selecting patients undergoing evaluation of obscure GI bleeding from January 2010 to May 2014. Forty-seven CE were performed inside and the remaining 94 CE were performed at outside institutions prior to single-balloon enteroscopy at our institution. Agreement beyond chance was evaluated using kappa coefficient. A p value <5% was considered significant. RESULTS: The most frequent findings on CE were vascular lesions in 39 patients (41.5%) within the referral group and 23 within inside patients (48.9%), followed by active bleeding/clots in 23 patients (24.5%) and in 14 patients (29.8%) respectively. There was a fair degree of concordance in the referral group for vascular lesions 0.23 (0.03-0.42) compared to a good degree in the inside group 0.65 (0.44-0.87). Fair agreement was found looking at ulcers within the referral group 0.29 (0.06-0.65) compared to a moderate agreement in the inside group 0.55 (0.17-0.94). CONCLUSIONS: Degree of concordance for vascular lesions and ulcers was significantly higher for patients undergoing CE at our institution compared to those referred from the community. Patients referred to tertiary care centers for balloon-assisted enteroscopy may benefit from advanced endoscopists re-reading the capsule findings or even potentially repeating CE in hemodynamically stable patients if the study is not available.

Biliary fascioliasis mimicking sphincter of Oddi dysfunction.

Fasciola hepatica, a liver fluke of livestock, rarely presents as chronic biliary tract infection in humans. We report a 38-year-old woman from Ethiopia who presented with right upper quadrant pain and a dilated common bile duct on ultrasound and magnetic resonance cholangiopancreatography (MRCP) without other abnormalities. She was suspected to have type II sphincter of Oddi dysfunction. She underwent endoscopic retrograde cholangiopancreatography (ERCP) and had a fluke, diagnosed as Fasciola hepatica, in the common hepatic duct. This report confirms the diagnostic and therapeutic role of ERCP in the management of biliary fascioliasis, and highlights the need to include fascioliasis in the differential diagnosis of biliary pain in patients emigrating from areas where this infection is endemic.

ERCP in pregnancy: is it safe?

BACKGROUND: Although rare, pancreaticobiliary disease during pregnancy can pose a serious risk to both the mother and fetus. Data regarding the relative safety of endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy are sparse. METHODS: We performed a retrospective review of 17 ERCP procedures performed at a single tertiary care referral center between January 2005 and April 2009. Records were reviewed for ERCP indication, endoscopic interventions, use and extent of fluoroscopy, postprocedure complications, and pregnancy outcomes including Apgar scores. RESULTS: All procedures were performed without any maternal adverse events immediately or on follow-up. There were no signs of fetal distress during any of these cases, and there were no fetal complications noted upon delivery or at 30-day follow-up per chart review. CONCLUSION: Therapeutic ERCP during pregnancy appears to be safe when performed in experienced hands and with judicious use of fluoroscopy.

Biliary leaks after laparoscopic cholecystectomy: time to stent or time to drain.

BACKGROUND: Endoscopic retrograde cholangiopan-creatography (ERCP) with placement of a biliary stent or nasobiliary (NB) drain is the procedure of choice for treatment of post-cholecystectomy bile duct leaks. The aim of this study was to compare the effect of NB drainage versus internal biliary stenting on rates of leak closure, time elapsed until drain or stent removal, length of hospital stay and number of required endoscopic procedures. METHODS: Charts were reviewed on 20 patients who underwent laparoscopic cholecystectomy complicated by Luschka or cystic duct leak. Ten patients were treated with NB drains connected to low intermittent suction and repeat NB cholangiograms were performed until leak closure was observed. Ten patients were treated with internal biliary stents. Biliary sphincterotomies were performed for stone extraction or a presumed papillary stenosis. Large bilomas were drained percutaneously prior to stenting. RESULTS: In all 20 patients, a cholangiogram and successful placement of a NB drain or internal stent was achieved. Four patients (20%) were found to have bile duct stones, which were extracted following a sphincterotomy. Sixteen patients required percutaneous drains to evacuate large bilomas prior to biliary instrumentation. Fifteen cystic duct leaks and 5 Luschka duct leaks were reviewed. There were no complications related to ERCP. Closure of the leak was documented within 2 to 11 days (mean 4.7+/-0.9 days) in patients receiving a NB drain. The drains were removed non-endoscopically following leak closure. The internal stent group required stenting for 14 to 53 days (mean 29.1+/-4.4 days). The stent was then removed endoscopically after documentation of leak closure. Bile leaks following laparoscopic cholecystectomy closed rapidly after NB drainage and did not require repeat endoscopy for removal of the NB drain, resulting in fewer ERCPs required for treatment of biliary leaks. Internal biliary stents were in place longer owing to the nature of this intermittent endoscopic approach but an accurate comparison of time to leak closure could not be determined. Leak closure resulted once the bile flow was re-established, regardless of the technique, but removal of the NB drains was performed earlier than removal of the biliary stents. The number of ERCPs required per patient was 1.0+/-0 in the NB group and 2.2+/-0.1 (range 2-3) in the internal stent group. The length of hospitalization was 8.7+/-3.3 days for the NB group and 7.5+/-2.3 days for the internal stent group. Biliary stent placement resulted in an insignificant decrease in hospitalization at the expense of generating twice as many endoscopic procedures. CONCLUSIONS: Our data suggest that NB drainage may be advantageous in patients requiring a prolonged hospital admission or in patients in whom repeat endoscopy is undesirable. Internal biliary stenting appears preferable when early discharge is anticipated or when expertise in placement and management of NB drains is lacking.

Safety of conventional and wireless capsule endoscopy in patients supported with nonpulsatile axial flow Heart-Mate II left ventricular assist device.

BACKGROUND: Left ventricular assist devices (LVADs) are increasingly being used as a bridge for cardiac transplantation in patients with decompensated cardiac function. A known complication of these devices is severe and sometimes life-threatening GI bleeding, usually related to the presence of angioectasias. Endoscopy has been generally accepted as safe in patients with cardiac disease and implanted cardiac devices, when it is performed with appropriate monitoring. However, the literature is sparse regarding the safety of endoscopy in patients with LVADs. OBJECTIVE: Given the potential risks for GI bleeding in this subgroup of patients, our aim was to shed light on the potential safety of endoscopy in these patients. DESIGN: We present our experience with endoscopic intervention for varied sources of GI bleeding in a group of patients with the HeartMate II implantable LVAD. SETTING: A tertiary care university-based hospital setting, Tampa General Hospital at the University of South Florida, Tampa, Florida. PATIENTS: Patients with severe cardiomyopathy requiring cardiac support with the HeartMate II implantable LVAD. INTERVENTIONS: Patients received upper and lower GI endoscopy as dictated by their clinical presentations. One patient received capsule endoscopy as well. CONCLUSIONS: We observed that endoscopy, including capsule endoscopy, may be safely performed in these patients with appropriate monitoring.