Prospective evaluation of the long-term outcomes after deep small-bowel spiral enteroscopy in patients with obscure GI bleeding.

BACKGROUND: Spiral enteroscopy can be safe and effective in the short term for evaluation of obscure GI bleeding, but long-term data are lacking. OBJECTIVE: To assess the long-term clinical outcomes after deep small-bowel spiral enteroscopy performed for obscure GI bleeding. DESIGN: Prospective cohort study. SETTING: Academic referral center. PATIENTS: This study included 78 patients who underwent antegrade spiral enteroscopy for evaluation of obscure GI bleeding. INTERVENTION: Diagnostic spiral enteroscopy with hemostatic therapeutic maneuvers applied as indicated. MAIN OUTCOME MEASUREMENTS: Postprocedure evidence of recurrent overt GI bleeding, blood transfusion requirements, need for iron supplementation, serum hemoglobin values, and the need for additional therapeutic procedures. RESULTS: Long-term follow-up data (mean [± standard deviation] 25.3 ± 7.5 months; range 12.9-38.8 months) were obtained in 61 patients (78%). Among those with long-term follow-up data, overt bleeding before spiral enteroscopy was present in 62%, compared with 26% in the follow-up period (P < .0001). The mean (± SD) hemoglobin value increased from 10.6 ± 1.8 to 12.6 ± 1.9 g/dL (P < .0001). Blood transfusion requirements decreased by a mean of 4.19 units per patient (P = .0002), and the need for iron supplementation (P = .0487) and additional procedures (P < .0001) decreased in the follow-up period. There were 8 adverse events (9%) (7 mild, 1 moderate). LIMITATIONS: Single-center study, intervention bias. CONCLUSION: In patients with obscure GI bleeding, deep small-bowel spiral enteroscopy is safe and effective in reducing the incidence of overt bleeding. An increase in hemoglobin values along with a decrease in blood transfusion requirement, need for iron supplementation, and need for additional therapeutic procedures were found over long-term follow-up. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT00861263.).

Diagnostic yield of spiral enteroscopy when performed for the evaluation of abnormal capsule endoscopy findings.

BACKGROUND: Spiral enteroscopy (SE) has emerged as a new alternative for deep intubation of the small intestine. SE is most often used to evaluate abnormal findings on capsule endoscopy (CE). OBJECTIVE: Investigate the ability of SE to reproduce abnormal findings detected on preceding CE. DESIGN: Prospective study. SETTING: Two academic tertiary care centers. PATIENTS: Consecutive patients undergoing SE to investigate a clinically significant finding on CE. MAIN OUTCOME MEASUREMENT: Ability of SE to identify findings on CE. RESULTS: Total of 56 anterograde SE procedures were performed. CE findings included arteriovenous malformations (AVMs) (n=26), masses (n=8), ulcers (n=4), polyps (n=4), abnormal mucosa (n=6), fresh blood (n=6), and stricture (n=1). Majority of the patients had CE findings located in the jejunum (41 of 56 or 73.2%). Mean depth of enteroscope insertion was 224.6±68.7 cm. SE detected relevant small bowel pathology in 32 of 56 (57.1%) patients. Findings on CE were reproduced in 30 of 56 (53.6%) cases. Reproducibility was independent of patient body mass index (P=0.38), CE indication (P=0.24), CE lesion location (P=0.29), days between CE and SE (P=0.30), and depth of insertion (P=0.81). Type of CE findings (particularly AVMs) significantly affected SE reproducibility (P=0.015). SE procedure time was inversely related to SE reproducibility (odds ratio=0.94, 95% confidence interval=0.88-0.99, P=0.02). LIMITATIONS: Small sample size and potential for false-positive CE study. CONCLUSIONS: SE seems to be moderately effective (57.1%) in terms of its ability to locate pathology within the small intestine. The type of small bowel pathology targeted by SE may affect its clinical utility. AVMs observed on CE can be seen at the time of SE in the majority of cases (60%).

Spiral enteroscopy is safe and effective for an elderly United States population of patients with numerous comorbidities.

BACKGROUND & AIMS: Preliminary studies performed outside of the United States demonstrated that spiral enteroscopy is safe and effective when performed in young, healthy patients. However, spiral enteroscopy has not been evaluated in a US population of patients with numerous comorbidities. We evaluated the feasibility, efficacy, and safety of spiral enteroscopy in a US population of older patients with multiple comorbidities and a high prevalence of pathologic findings. METHODS: We performed a prospective case series of 61 patients with clinical indications for deep enteroscopy conducted at 2 US academic tertiary referral centers. Patients underwent deep enteroscopy with the spiral Endo-Ease Discovery SB overtube. Insertion depth, procedure time, diagnostic findings, therapeutic maneuvers, sedation type, and complications were recorded. RESULTS: Spiral enteroscopy was attempted in 61 patients (mean age, 65.4 +/- 12.4 years); 52% were rated by American Society of Anesthesiologists guidelines as class 3 (n = 30) or 4 (n = 2). The procedure was successfully completed in 56 of 61 patients (92%). Average insertion depth was 217.4 +/- 79 cm beyond the ligament of Treitz. The total mean procedure time was 41 +/- 15 minutes (diagnostic time, 36 +/- 12 minutes; therapy time, 5 +/- 9 minutes). Positive findings were noted in 36 cases (59%), with therapeutic maneuvers performed in 30 cases (49%). A total of 41 cases (67%) were performed under conscious sedation; fluoroscopy was not used in any case. Four mild complications occurred, and there were no perforations. CONCLUSIONS: Spiral enteroscopy is technically feasible and safe in an elderly US population of patients with numerous comorbidities.

Intraductal biliary and pancreatic endoscopy: an expanding scope of possibility.

Intraductal endoscopy describes the use of an endoscope to directly visualize the biliary and pancreatic ducts. For many years, technological challenges have made performing these procedures difficult. The "mother-baby" system and other various miniscopes have been developed, but routine use has been hampered due to complex setup, scope fragility and the time consuming, technically demanding nature of the procedure. Recently, the SpyGlass peroral cholangiopancreatoscopy system has shown early success at providing diagnostic information and therapeutic options. The clinical utility of intraductal endoscopy is broad. It allows better differentiation between benign and malignant processes by allowing direct visualization and targeted sampling of tissue. Therapeutic interventions, such as electrohydraulic lithotripsy (EHL), laser lithotripsy, photodynamic therapy, and argon plasma coagulation (APC), may also be performed as part of intraductal endoscopy. Intraductal endoscopy significantly increases the diagnostic and therapeutic yield of standard endoscopic retrograde cholangiography (ERCP), and as technology progresses, it is likely that its utilization will only increase. In this review of intraductal endoscopy, we describe in detail the various endoscopic platforms and their diagnostic and clinical applications.

Endoscopic therapy of benign biliary strictures.

Benign biliary strictures are being increasingly treated with endoscopic techniques. The benign nature of the stricture should be first confirmed in order to ensure appropriate therapy. Surgery has been the traditional treatment, but there is increasing desire for minimally invasive endoscopic therapy. At present, endoscopy has become the first line approach for the therapy of post-liver transplant anastomotic strictures and distal (Bismuth I and II) post-operative strictures. Strictures related to chronic pancreatitis have proven more difficult to treat, and endoscopic therapy is reserved for patients who are not surgical candidates. The preferred endoscopic approach is aggressive treatment with gradual dilation of the stricture and insertion of multiple plastic stents. The use of uncovered self expandable metal stents should be discouraged due to poor long-term results. Treatment with covered metal stents or bioabsorbable stents warrants further evaluation. This area of therapeutic endoscopy provides an ongoing opportunity for fresh research and innovation.