⁎4747 Diagnostic yield of push-enterostomy in nonbleeding intestinal disorders.

*4745 CLINICAL IMPACT OF PUSH-ENTEROSCOPY:PROSPECTIVE STUDY. Emmanuel Cuillerier, Bruno Landi, Christelle Flobert, Alexis Bezet, Philippe Marteau, Jean-Philippe Barbier, Christophe Cellier, Laennec Hosp, Paris, France. Despite increased use of push-enteroscopy (PE), there are little data regarding the clinical impact of PE. The aim of this study was to evaluate the impact of PE on diagnostic and therapeutic patient management. Methods: Sixty-eight patients (41M, 27F, mean age 52 y) referred for PE were included in this ongoing prospective study between May 1998 and August 1999. Indications for PE were: overt GI bledding (n=32,47%)and isolated iron deficiency anemia (n=14, 21%) of unkown origin, small bowel radiological abnormalities (n=8, 12%), malabsorption and/or chronic diarrhea (n=9, 13%), other indications (n=5, 7%). Before the procedure, the requesting physicians were asked to fill out a questionnaire listing the theoretical patient management plans (diagnostic procedures and/or treatment) as PE would have not been available. One month after PE, the same physicians were asked about: 1) the diagnostic procedures performed after PE, 2) the final diagnostic, 3) the impact of PE regarding changes in diagnostic and therapeutic management. Results: Responses to the 2 questionnaires were obtained for 97% of patients. The diagnostic yield of PE was 35% (n=24). PE modified the diagnostic management in 40% (n=27) of patients and therapeutic management in 32% (n=22)(medical treatment 10 pts, endoscopic treatment 8 pts, surgery 4 pts). As a whole, PE had clinical implications (changes in the diagnostic and/or therapeutic management) in 54% (n=37) of patients. The clinical impact of PE was greater in case of overt intestinal bleeding (56% of patients) than in isolated iron deficiency anemia (36% of patients). Updated data will be presented at the meeting. Conclusion: PE is perceived as useful by requesting physicians. Changes in management plan occurred in more than half of the patients explored by PE when diagnostic yield was 35%. *4746 A NEW METHOD OF ENTEROSCOPY. Hironori Yamamoto, Yukihiro Sato, Yutaka Sekine, Toshihiko Higashizawa, Kenichi Ido, Kentaro Sugano, Jichi Med Sch, Tochigi, Japan. Purpose The most popular insertion method of enteroscopy is the pushing method. However, deep insertion of an enteroscope is difficult with this method because pushing power is lost by the tortuous small intestine. Moreover, it causes a tremendous discomfort to the patient. Other methods such as the sonde method and the ropeway method are too cumbersome for practical use. We developed a new method of enteroscopy namely a double balloon method to improve the accessibility to the small intestine. Methods The new method uses a balloon that is attached to the tip of the scope and a sliding overtube with another balloon at its distal end. The tube is placed over the scope before insertion. The insertion is started with both balloons deflated. When the both balloons reach the duodenum, the balloon on the tube is inflated to fix the tube to the intestine. After redundant loops of the scope are taken by gentle withdrawal of the scope shaft and the tube, the scope is inserted deeper while holding the overtube in place. When the tip of the scope is inserted as deep as possible, the balloon on the scope tip is inflated. Then, the balloon on the tube is deflated and the tube is inserted along the scope. When the distal end of the tube reaches the scope end, the balloon on the tube is inflated to make the second fix point to the intestine. The scope is advanced deeper by just repeating the similar procedure. We tried this method in three cases between June 29 and October 8 of 1999. We used the Olympus XP-240 with a working length of 103 cm and a hand-made overtube of vinyl chloride with an outer diameter of 12 mm and 75 cm in length. Results Despite the short length of the scope, it was successfully inserted as deep as 30 to 50 cm beyond the Treiz ligament in all three cases. Bleeding points were successfully identified in the first two cases and a stricture of the intestine was observed in the last case. The scope was unable to advance deeper because the entire length of the scope was used already. Conclusions A deep insertion of an enteroscope is difficult because of the tortuous loop formation of the small intestine. A splinting tube was used to keep the intestine straight. However, we found that the real reason of the difficulty is the stretchable nature of the looped intestine. We developed a new method of enteroscopy using a soft overtube with a balloon for holding the intestine to prevent stretching. With this new method, an excessive stretch of the intestine is prevented; hence the patient’s discomfort is minimized. This is thought to be a promising method, which might give us free endoscopic access to the small intestine.

AB220

GASTROINTESTINAL ENDOSCOPY

*4747 DIAGNOSTIC YIELD OF PUSH-ENTEROSTOMY IN NONBLEEDING INTESTINAL DISORDERS. Andre Van Gossum, Alain Schmit, Robert Jagodzinski, Michael Adler, Jacques Deviere, Mahmoud Ghandour, Erasme Hosp, Brussels, Belgium. The main indication for push-enteroscopy is obscure digestive bleeding. However, endoscopic investigation of the small bowel is also used in other intestinal disorders. Aim of the study : to define the indications and the diagnostic yield of push-enteroscopy in patients with non-bleeding intestinal disorders. Methods : all the enteroscopies, that were performed in our institution from January 1995 to October 1999 were reviewed. The Olympus push-enteroscopes (SIF-100 or 140) were used, on sedation (93%) or general anesthesia. Indications were divided in 4 groups : unexplained malabsorption (I), undefined radiologic lesions (II), unexplained abdominal pain (III) and follow-up of chronic diseases (i.e. coeliac diseases, lymphoma, familial polyposis, Crohn’s disease) (IV). These results were considered to be positive, allowing a definitive diagnosis ; helpfull, permitting to rule out some diseases ; or negative. Results : 64 out of 445 (14%) of push-enteroscopies were performed in 59 patients (29 m/30 f ; mean age 47 y). In conclusion : in non-bleeding disorders, the diagnostic yield of pushenteroscopy was positive in 39%, helpfull in 32% and negative in 29%, respectively. In these indications, push-enteroscopy must be used in well selected patients. The highest positive yield was observed in the follow-up of patients with chronic intestinal disorders.

Groups

I

II

III

IV

n positive helpful negative

25 9 11 5

14 6 2 6

4 0 0 4

16 8 6 2

*4748 DIAGNOSTIC EFFICACY OF PUSH - ENTEROSCOPY IN OCCULTED OR OVERTED RECCURENT BLEEDING OF GASTROINTESTINAL TRACT. Vassilios C. Delis, Vassilios E. Balatsos, Vassilios C. Vamvakousis, Panagiotis P. Kassapidis, Anastasios C. Konstantinidis, Athanassios S. Hatzinicolaou, Philip P. Georgopoulos, Nikolaos P. Skandalis, Gen Athens Hosp G Gennimatas, Athens, Greece. Background: Push type enteroscopy is a recent method of investigating the small intestine. It has the advantage of direct visualization of the lumen, permits biopsy and in some cases treatment. Aim of this study was to evaluate the efficacy of push - enteroscopy in cases of occulted or overted recurrent bleeding of Gastrointestinal tract. Method: We studied 111 patients, 61 men and 50 women aged 14 - 80 years. 47 of them presented with overt bleeding and 64 with occulted bleeding of GI tract. All had already undergone UGI endoscopy, colonoscopy, and small bowel enteroclysis. All of the patients underwent enteroscopy with the PENTAX VSB 2900 push enteroscope. Midazolam 2-5 mgr iv were usually given as sedation during the examination and in some cases Pethidine 25 50 mgr and Glucagon 1 mgr. The enteroscope was introduced 30 150 mgr beyond the ligament of Treitz. The enteroscopic findings are shown in the table 1. In 43 / 111 (38.7%) enteroscopy was normal. None of the patients presented any adverse symptom during enteroscopy. Conclusions: Push enteroscopy is an easy and safe new diagnostic modality of Gastrointestinal tract, permitting diagnosis in 61.5% of the patients. So it should become the method of choice for patients with occulted or overted recurrent bleeding of GI tract with negative upper and lower GI endoscopy.

Table 1 N Angiodysplasia 27 Coeliac sprue 5 Crohn’s disease 4 Esophagitis 1 Esophageal Hernia 2

24.4% 4.5% 3.5% 0.9% 1.8%

N Benign tumors Malignant tumor Peptic ulcer Water melon stomach Congestive gastropathy

10 1 14 2 2

9.1% 0.9% 12.6% 1.8% 1.8%

VOLUME 51, NO. 4, PART 2, 2000