Diagnostic and therapeutic yield is not influenced by the timing of small-bowel enteroscopy: morning versus afternoon.

BACKGROUND: Small-bowel enteroscopies (BEs) are tedious and prolonged, and their efficacy may be affected by the timing of procedures. OBJECTIVE: We aimed to evaluate the differences in diagnostic yield, insertion depth, procedure duration, therapeutic yield, and adverse events (AEs) of enteroscopies performed in the morning versus the afternoon. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Patients who underwent BE for suspected small-bowel disease at a single institution between January 2008 and August 2009. MAIN OUTCOME MEASUREMENT: Differences in diagnostic yield, insertion depth, procedure duration, therapeutic yield, and AEs between morning (started before noon) and afternoon (after noon) procedures. RESULTS: A total of 250 enteroscopies were performed on 250 patients, of which 125 patients (50%) underwent a procedure in the morning and 125 patients (50%) underwent the procedure in the afternoon. The diagnostic yield with anterograde enteroscopy was the same in both the morning and afternoon (63.7% and 63.7%, respectively; P = .99). The procedure durations were also similar (42.4 ± 21.5 minutes vs 46.2 ± 22.4 minutes, respectively; P = .25). Similarly the diagnostic yield with retrograde enteroscopy was similar in morning and afternoon (44.1% and 35.3%, respectively; P = .46). However, the procedure durations of retrograde BE were significantly shorter in the morning compared with the afternoon (51.3 ± 21.3 minutes vs 66.6 ± 32.9 minutes, respectively; P = .03). Therapeutic yield and AEs were similar. LIMITATIONS: Retrospective study. CONCLUSIONS: The timing of procedure, morning versus afternoon, did not affect the diagnostic and therapeutic efficacy of BE in patients with suspected small-bowel disease.

Multiple pancreatic pseudocysts treated with endoscopic transpapillary drainage.

Management of a solitary pancreatic pseudocyst with endoscopic transpapillary stent drainage is a well recognized treatment modality. Endoscopic options are however limited in the presence of multiple pancreatic pseudocysts. Conventionally surgery has been the mainstay of treatment in this situation. In this case report, we present a patient with multiple pancreatic pseudocysts who was successfully treated via transpapillary placement of pancreatic duct stent.

Spiral enteroscopy: prospective U.S. multicenter study in patients with small-bowel disorders.

BACKGROUND: The performance characteristics of spiral enteroscopy have not been well-described. OBJECTIVE: To determine the technical performance, diagnostic and therapeutic yields, and safety of oral spiral enteroscopy in patients with suspected or established small-bowel pathology. DESIGN: Prospective, multicenter, cohort study, with centralized database. SETTING: Ten U.S. tertiary-care medical centers. PATIENTS: This study involved 148 participants, of whom 101 were referred for obscure bleeding. All participants referred for antegrade deep enteroscopy were considered eligible. INTERVENTION: Spiral enteroscopy. MAIN OUTCOME MEASUREMENTS: Examination duration, depth of insertion, spiral enteroscopy findings, mucosal assessment upon withdrawal, and patient symptom assessment (day 1 and day 7 after the procedure). RESULTS: Spiral enteroscopy was successful in 93% of patients, with a median depth of insertion beyond the angle of Treitz of 250 cm (range 10-600 cm). The mean (± standard deviation) total procedure time was 45.0 ± 16.2 minutes for all procedures, and 35.4 minutes for diagnostic procedures. The diagnostic yield was 65%, of which 48% revealed more than one abnormality. The most common findings were angiectasias (61.5%), inflammation (7.5%), and neoplasia (6.8%). Argon plasma coagulation ablation accounted for 64% of therapeutic interventions. LIMITATIONS: This was not a randomized, controlled trial of deep enteroscopy modalities. CONCLUSION: Spiral enteroscopy appears to be safe and effective for evaluation of the small bowel. The procedure duration, depth of insertion, and diagnostic and therapeutic yields compare favorably with previously published data on other deep enteroscopy techniques such as single-balloon and double-balloon enteroscopy. Comparative studies are warranted.

The clinical utility of single-balloon enteroscopy: a single-center experience of 172 procedures.

BACKGROUND: Single-balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small-bowel disease. Although there is substantial literature addressing double-balloon enteroscopy and its impact on the diagnosis and management of small-bowel disease, there are limited data available on the clinical utility of SBE. OBJECTIVES: To evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center. DESIGN: Single-center, retrospective study. SETTING: Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio. PATIENTS: A total of 161 patients were referred for SBE from January 2006 to August 2008. MAIN OUTCOME MEASUREMENTS: Demographic, clinical, procedural, and outcome data were collected and analyzed. RESULTS: A total of 161 patients underwent a total of 172 procedures. Antegrade and retrograde approaches were used in 83% and 17% of subjects, respectively. The average insertion depth using the antegrade approach was 132 cm beyond the ligament of Treitz (range 20-400 cm). The average insertion depth using the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). The average procedure time was 40 minutes overall, 38 minutes (range 12-90) antegrade and 48 minutes (range 28-89) retrograde. Fluoroscopy was used in 20 cases (12%). Diagnostic yield was 58% (99/172); 42% (72/172) were therapeutic cases. There were no significant complications. LIMITATIONS: Single-center, retrospective study. CONCLUSIONS: SBE demonstrated a high diagnostic yield and frequently provided useful therapeutic intervention. It seems to be a safe and effective method for performing deep enteroscopy.

Capsule endoscopy in examination of esophagus for lesions after radiofrequency catheter ablation: a potential tool to select patients with increased risk of complications.

BACKGROUND: Esophageal injury can result from left atrial radiofrequency ablation (RFA) therapy, with added concern because of its possible relationship to the development of atrial-esophageal (A-E) fistulas. OBJECTIVE: Evaluate utility of esophageal capsule endoscopy to detect esophageal lesions as a complication of RFA therapy in the treatment of atrial fibrillation (AF). METHODS: Consecutive patients with AF who underwent left atrial RFA therapy and received capsule endoscopy within 48 hours postablation. Video was reviewed by a single gastroenterologist. The medical records were also reviewed for symptoms immediately postablation and at the 3-month follow-up. RESULTS: A total of 93 consecutive patients were included and 88 completed the study and were analyzed. The prevalence of esophageal lesions was 17% (15/88 patients). Nine percent (8/88) of these patients had lesions anatomically consistent with the location of the ablation catheter. Six patients with positive capsule findings had symptoms of chest pain (3/6, 50%), throat pain (2/6, 33%), nausea (1/6, 17%), and abdominal pain (1/6, 17%). An additional 24 patients were symptomatic postablation, but with normal capsule findings. All patients with identified lesions by capsule endoscopy received oral proton pump inhibitor therapy, and were instructed to contact the Cleveland Clinic in the event of worsening symptoms. No delayed complications were reported at the 3-month follow-up. CONCLUSION: This study supports the use of capsule endoscopy as a tool for the detection of esophageal injury post-RFA therapy. PillCam ESO is well tolerated and provides satisfactory images of the areas of interest in the esophagus without potential risk related to insufflation with regular esophagogastroduodenoscopy.

Single-balloon enteroscopy.

Single-balloon enteroscopy has emerged as a viable alternative to double-balloon enteroscopy in the management of small bowel disease. Technically, it is easier to perform, may be more efficient, and in the limited literature available, seems to provide similar diagnostic and therapeutic yield when compared with double-balloon enteroscopy. This review provides up-to-date views on this emerging technology and its application.

Small bowel enteroscopy.

For the examination of the small bowel in patients with suspected small bowel bleeding, endoscopic tools to perform deep enteroscopy have become essential. Double balloon enteroscopy has gained worldwide acceptance as an endoscopic technique that can be used safely and effectively to provide complete examination of the small bowel, offer therapeutic intervention, and favorably affect clinical outcomes. Single balloon enteroscopy seems to have utility similar to that of the double balloon system. Preliminary experience with a novel overtube device using either the single or double balloon enteroscope has suggested that this may be a very viable approach to deep enteroscopy. Collectively, these are remarkable innovations that allow access to portions of the small bowel that were previously only available by intraoperative enteroscopy or laparotomy. On the basis of the available data, each of these procedures seems to have unique merits, is generally safe and well tolerated, and is highly likely to be clinically beneficial.