Predictive value of patency capsule and magnetic resonance enterography for capsule endoscopy retention in patients with established Crohn's disease.

INTRODUCTION: retention is the most common adverse event of the small bowel capsule endoscopy procedure. Patency capsule (Medtronic, Dublin, Ireland) and magnetic resonance enterography are two diagnostic methods that can prevent small bowel capsule endoscopy retention. The aim of this study was to evaluate the predictive value of these two diagnostic methods. MATERIAL AND METHODS: a prospective, comparative and observational study was performed in patients with established Crohn's disease. All patients had undergone magnetic resonance enterography and patency capsule procedures. If the patency capsule was not retained, the patient underwent a small bowel capsule endoscopy; otherwise, double balloon enteroscopy was performed to locate the stenosis. Magnetic resonance enterography predictive criteria for retention were analyzed in all cases. Sensitivity, specificity, positive predictive value and negative predictive value of the patency capsule and magnetic resonance enterography compared to small bowel capsule endoscopy or double balloon enteroscopy were calculated. RESULTS: forty patients were included (24 female, 55 ± 13 years old). Retention criteria with capsule endoscopy or double balloon enteroscopy were found in six patients, agreeing in five cases with patency capsule and in three cases with magnetic resonance enterography. Sensitivity, specificity, positive predictive value, negative predictive value and Kappa coefficient for predicting retention with the patency capsule were 83 %, 100 %, 100 % and 97 %, respectively, and 50 %, 91 %, 50 % and 91 %, respectively, with magnetic resonance enterography. CONCLUSIONS: patency capsule has a higher sensitivity and positive predictive value than magnetic resonance enterography for preventing small bowel capsule endoscopy retention in Crohn's disease patients.

Predictive value of patency capsule and magnetic resonance enterography for capsule endoscopy retention in patients with established Crohn’s disease

Introduction: retention is the most common adverse event of the small bowel capsule endoscopy procedure. Patency capsule (Medtronic, Dublin, Ireland) and magnetic resonance enterography are two diagnostic methods that can prevent small bowel capsule endoscopy retention. The aim of this study was to evaluate the predictive value of these two diagnostic methods. Material and methods: a prospective, comparative and observational study was performed in patients with established Crohn’s disease. All patients had undergone magnetic resonance enterography and patency capsule procedures. If the patency capsule was not retained, the patient underwent a small bowel capsule endoscopy; otherwise, double balloon enteroscopy was performed to locate the stenosis. Magnetic resonance enterography predictive criteria for retention were analyzed in all cases. Sensitivity, specificity, positive predictive value and negative predictive value of the patency capsule and magnetic resonance enterography compared to small bowel capsule endoscopy or double balloon enteroscopy were calculated. Results: forty patients were included (24 female, 55 ± 13 years old). Retention criteria with capsule endoscopy or double balloon enteroscopy were found in six patients, agreeing in five cases with patency capsule and in three cases with magnetic resonance enterography. Sensitivity, specificity, positive predictive value, negative predictive value and Kappa coefficient for predicting retention with the patency capsule were 83 %, 100 %, 100 % and 97 %, respectively, and 50 %, 91 %, 50 % and 91 %, respectively, with magnetic resonance enterography. Conclusions: patency capsule has a higher sensitivity and positive predictive value than magnetic resonance enterography for preventing small bowel capsule endoscopy retention in Crohn’s disease patients (AU)

Assessment of the Role of a Second Evaluation of Capsule Endoscopy Recordings to Improve Diagnostic Yield and Patient Management.

Introduction: The diagnostic yield (DY) of small-bowel capsule endoscopy (SBCE) varies considerably according to its indication. Some strategies have been used to increase DY with varying results. The intention of this study was to identify whether evaluation of the SBCE recordings by a second reviewer can increase DY and change patient management. Methods: One hundred SBCEs with different indications, already read by an endoscopist were read by a second blinded endoscopist. When the results of the 2 readings were different, the images were discussed by the endoscopists; if no consensus was reached, they took the opinion of a third endoscopist into account. All the participating endoscopists had experience in reading SBCEs (i.e., >50 per year). The SBCE findings were divided into positive (vascular lesions, ulcers, and tumors), equivocal (erosions or red spots), and negative. The interobserver agreement and the increase in DY were assessed as well as the percentage of false-negatives (FNs) in the first evaluation. Results: The indications for SBCE were small-bowel bleeding (SBB) in 48 cases, Crohn's disease (CD) in 30, and other causes (iron-deficiency anemia, small-bowel tumors, and diarrhea) in 22. There was substantial interobserver agreement between evaluations (κ = 0.79). The findings in the first evaluation were positive in 60%, equivocal in 20% and, negative in 20%. In the second evaluation, 66% were positive, 18% were equivocal, and 16% were negative. The increase in DY with the second reading was 6% (p = 0.380), i.e., 6.3% for SBB, 4.4% for CD and 9.2% for other indications, resulting in a change in management of 4% of the patients. FNs in the first SBCE reading were found in 4% of the SBCEs. Discussion: A second evaluation of the SBCE recordings identified significant pathology that the first evaluation had missed, resulting in a nonsignificant 6% increase in DY and a change in the management of 4% of the patients.

Introdução: O rendimento diagnóstico (DY) da enteroscopia por cápsula (SBCE) varia consideravelmente de acordo com as suas indicações. Foram estudadas algumas estratégias para melhorar o DY, com resultados variados. O objetivo deste estudo é avaliar se uma segunda leitura de registos de enteroscopia por cápsula por um segundo endoscopista pode melhorar o DY e alterar o manejo dos doentes. Métodos: 100 SBCE realizadas por indicações variadas, previamente avaliadas por um endoscopista, foram reavaliadas por um segundo endoscopista cego para a primeira leitura. Na presença de resultados discordantes nas 2 leituras, as imagens foram discutidas pelos 2 endoscopistas, e por um terceiro na ausência de consenso entre os 2 primeiros. Todos os endoscopistas são experientes na leitura de SBCE (>50 SBCE/ano). Os achados foram categorizados em positivos (lesões vasculares, úlceras e tumores), equívocos (erosões e pontos vermelhos) e negativos. Foi avaliada a concordância inter-observador e o aumento do DY, bem como a percentagem de falsos negativos da primeira avaliação. Resultados: As indicações para SBCE foram hemorragia do intestino delgado (SBB) em 48 casos, doença de Crohn (CD) em 30 e outras causas (anemia por défice de ferro, pesquisa de tumores do intestino delgado e diarreia) em 22. A concordância inter-observador foi substancial (k = 0.79). Os achados da primeira avaliação foram positivos em 60%, equívocos em 20% e negativos em 20%, enquanto na segunda avaliação foram positivos em 66%, equívocos em 18% e negativos em 16%. O aumento de DY foi de 6% com a segunda leitura (p = 0.38), sendo 6.3% para SBB, 4.4% para CD e 9.2% para outras indicações, resultando numa alteração no manejo de 4% dos doentes. Foram identificados falsos negativos na primeira avaliação em 4% das SBCE. Conclusão: A segunda avaliação dos registos de SBCE identificou patologia significativa previamente não identificada, resultando num aumento não significativo de 6% do DY e numa alteração no manejo de 4% dos doentes.

Feasibility of using an led-probe in third-space endoscopy: a clinical study.

BACKGROUND: Third-space endoscopy is a novel, safe, and effective method for treating different gastrointestinal conditions. However, several failed endoscopic procedures are attributed to incomplete myotomy. Lighting devices are used to prevent organic injuries. We aimed to investigate the feasibility of using a hand-made LED-probe (LP) in third-space procedures. METHODS: This prospective study was conducted in a tertiary-care center in Mexico between December 2016 and January 2019. We included peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy(G-POEM) procedures. Pseudoachalasia, peptic ulcer, normal gastric emptying scintigraphy (GES) and prepyloric tumors were excluded. LP was used to guide or confirm procedures. Clinical and procedural characteristics were recorded and analyzed. RESULTS: Seventy third-space procedures were included (42POEM,28G-POEM), with an average patient age of 46.7 ± 14.3 and 43.7 ± 10.1 years, respectively. For the POEM and G-POEM groups, respectively, 18/42(42.9%) and 13/28(46.7%) patients were males; median procedure times were 50 (interquartile range [IQR]: 38-71) and 60(IQR: 48-77) min, median LP placement times were 5(IQR: 4-6) and 6(IQR: 5-7) min, mild adverse events occurred in 4(9.4%) and 4(14.2%) of cases, and clinical success at 6 months occurred in 100 and 85.7% of cases. Integrated relaxation pressure (IRP) improved from 27.3 ± 10.8 to 9.5 ± 4.1 mmHg (p < 0.001); retention percentage at 4 h also improved. LP was successfully placed and adequate myotomy confirmed including 14.2 and 17.8% of POEM and G-POEM difficult patients. CONCLUSIONS: Using an LP is promising and allows guiding during third-space procedures either for submucosal tunnel creation or myotomy confirmation, with excellent safety and efficacy in clinical practice.

Conventional clips vs over-the-scope-clips for the closure of the entry site in POEM and G-POEM procedures

BACKGROUND: new alternatives for entry site closure (ESC) in per-oral endoscopy myotomy (POEM) and gastric peroral endoscopy myotomy (G-POEM) have appeared. OBJECTIVE: to compare the over-the-scope-clip (OTSC®) and conventional clips (CC) for ESC in POEM and G-POEM. MATERIAL AND METHODS: a retrospective review of a prospective POEM and G-POEM database was performed between January 2015 and August 2019. A description was made of outcomes, using either OTSC® or CC for submucosal tunnel closure. RESULTS: forty-six POEM and 26 G-POEM were included in the study (23/13 per group [CC/OTSC®]). There were no clinical or procedure differences. ESC was performed with 1 OTSC® vs 5 CC and 1 vs 6 (p = 0.01) for POEM and G-POEM, respectively. Adverse events associated with clips were 21.7% vs 13% (p = 0.01) and 7.7% vs 0% (p = 0.02) for CC and OTSC® in POEM and G-POEM, respectively. CONCLUSION: OTSC® represents a safe and effective alternative for entry site closure in POEM and G-POEM cases. Further studies are needed to recommend OTSC® as the first option for submucosal tunnel closure in these procedures

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Clinical feasibility of a new antireflux ablation therapy on gastroesophageal reflux disease (with video).

BACKGROUNDS AND AIMS: New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT) for control of GERD in patients without hiatal hernia. METHODS: Patients with proton pump inhibitor (PPI)-refractory GERD without hiatal hernia underwent ARAT between January 2016 and October 2019. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL), upper endoscopy, 24-hour pH monitoring, and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT. RESULTS: One hundred eight patients were included (61 men [56.5%]; median age, 36.5 years; range, 18-78 years). ARAT was performed on all patients. At the 36-month evaluation, 84 patients had completed the protocol. Median ARAT time was 35.5 minutes (range, 22-51 minutes), and median circumference ablation was 300° (range, 270°-320°). No major adverse events occurred, and 14 of 108 patients (12.9%) presented with stenosis that was responsive to balloon dilation (<5 sessions). At the 3-month evaluation, the acid exposure time (AET), DeMeester score, and GERD-HRQL score had decreased from 18.8% to 2.8% (P = .001), 42.5 to 9.1 (P = .001), and 36.5 to 10 (P = .02), respectively, and these values were maintained up to 36 months. Success (AET <4%) was achieved in 89% and 72.2% at 3 and 36 months, respectively. Related factors at 36 months were as follows: pre-ARAT Hill type II (odds ratio [OR], 3.212; 95% confidence interval [CI], 1.431-5.951; P = .033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P = .042), and AET <4% at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P = .021). CONCLUSIONS: ARAT is a feasible, safe, and effective therapy for early and mid-term treatment of GERD in patients without a sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role. (Clinical trial registration number: NCT03548298.).

Predictores para identificar lesiones en intestino delgado por enteroscopia posterior a una cápsula endoscópica positiva / No disponible

INTRODUCCIÓN Y OBJETIVO: estudios han evaluado la concordancia entre la cápsula endoscópica y la enteroscopia doble-balón con resultados diversos. El objetivo de este estudio es identificar factores que predicen la visualización de las lesiones en el intestino delgado por enteroscopia doble-balón después de una cápsula endoscópica positiva. MÉTODOS: estudio retrospectivo, observacional y comparativo que evaluó a pacientes con enteroscopia doble balón después de un cápsula endoscópica positiva entre enero de 2017 y agosto de 2019. Los datos estudiados fueron demográficos, indicaciones, comorbilidades y resultados de cápsula endoscópica y enteroscopia doble-balón. Se evaluaron mediante una regresión logística múltiple. RESULTADOS: se incluyeron 91 pacientes (edad 58 ± 16,5 años, 53 mujeres). Sesenta y dos enteroscopia doble-balón (68,1 %) encontraron las mismas lesiones que la cápsula endoscópica. Los factores predictivos para enteroscopia doble-balón positiva fueron lesiones múltiples (OR 8,10, 1,50-43,78; p = 0,015) y < 15 días ambos estudios (OR 5,31, 1,19-23,66; p = 0,029). En el subgrupo de pacientes con hemorragia de intestino delgado (70 pacientes), 46 enteroscopia doble-balón (65,7 %) coincidieron con la cápsula endoscópica. Los factores predictivos en este grupo fueron lesiones múltiples (OR 10,42, 1,37-79,30; p = 0,024), < 15 días entre ambos estudios (OR 13,51, 1,78-102,22; p = 0,012), > 60 años (OR 7,45, 1,51-36,75; p = 0,014) y úlceras (OR 4,67, 1,08-20,22; p = 0,039). CONCLUSIONES: los factores predictivos para enteroscopia doble-balón positiva después de cápsula endoscópica positiva son lesiones múltiples y < 15 días entre ambos procedimientos. En pacientes con hemorragia de intestino delgado, edad mayor a 60 años y presencia de úlceras también son

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Predictors for finding lesions in the small bowel by enteroscopy after a positive capsule endoscopy.

INTRODUCTION: studies have examined the agreement between capsule endoscopy and double-balloon enteroscopy, with varying results. The aim of this study was to identify factors that predict the visualization of lesions in the small bowel by double-balloon enteroscopy after a positive capsule endoscopy. METHODS: a retrospective, observational and comparative study was performed that evaluated patients that underwent double-balloon enteroscopy after a positive capsule endoscopy, between January 2017 and August 2019. The data studied included demographics, indications, comorbidities and the results of capsule endoscopy and double-balloon enteroscopy, which were evaluated by multiple logistic regression. RESULTS: 91 patients were included (age 58 ± 16.5 years, 53 female). Sixty-two double-balloon enteroscopy (68.1 %) found the same lesions as capsule endoscopy. Predictive factors for a positive double-balloon enteroscopy were multiple lesions (OR 8.10, 1.50-43.78; p = 0.015) and < 15 days between both studies (OR 5.31, 1.19-23.66; p=0.029). In the subgroup of patients with small bowel bleeding (70 patients), the results of 46 double-balloon enteroscopies (65.7 %) agreed with the capsule endoscopy. Predictive factors in this group were multiple lesions (OR 13.51, 1.78-102.22; p = 0.012), < 15 days between both studies (OR 13.51, 1.78-102.22; p = 0.012), > 60 years of age (OR 7.45, 1.51-36.75; p = 0.014) and ulcers (OR 4.67, 1.08-20.22; p = 0.039). CONCLUSIONS: predictive factors for a positive double-balloon enteroscopy after a positive capsule endoscopy were multiple lesions and < 15 days between both procedures. In patients with small bowel bleeding, age over 60 years and the presence of ulcers were also predictive factors.

Conventional clips vs over-the-scope-clips for the closure of the entry site in POEM and G-POEM procedures.

BACKGROUND: new alternatives for entry site closure (ESC) in per-oral endoscopy myotomy (POEM) and gastric peroral endoscopy myotomy (G-POEM) have appeared. OBJECTIVE: to compare the over-the-scope-clip (OTSC®) and conventional clips (CC) for ESC in POEM and G-POEM. MATERIAL AND METHODS: a retrospective review of a prospective POEM and G-POEM database was performed between January 2015 and August 2019. A description was made of outcomes, using either OTSC® or CC for submucosal tunnel closure. RESULTS: forty-six POEM and 26 G-POEM were included in the study (23/13 per group [CC/OTSC®]). There were no clinical or procedure differences. ESC was performed with 1 OTSC® vs 5 CC and 1 vs 6 (p = 0.01) for POEM and G-POEM, respectively. Adverse events associated with clips were 21.7% vs 13% (p = 0.01) and 7.7% vs 0% (p = 0.02) for CC and OTSC® in POEM and G-POEM, respectively. CONCLUSION: OTSC® represents a safe and effective alternative for entry site closure in POEM and G-POEM cases. Further studies are needed to recommend OTSC® as the first option for submucosal tunnel closure in these procedures.