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Initial Experience with a New Double Balloon Colonoscope in Patients with Prior Incomplete Colonoscopy
Abstracts
principles of a regular upper endoscopy, including having the patient in the left lateral decubitus position. Once in the duodenum, reasonable effort was invested into trying to visualize the ampula. The gastroscope was then withdrawn and a transparent cap was attached to the same endoscope. The ampula was again intentionally examined during the second part of the procedure. We considered visualization of the ampula adequate when the orifice was clearly identified. We report the demographic data, indications for the endoscopy, procedure time, visualization of the ampula and complications. Visualization of the ampula was reported as complete, tangential or non-identified. All the data were collected in a previously designed form. Results: We included 20 patients; M/F 13/7 with a mean age of 58 years(range: 20-76 years). Indications for upper endoscopy were upper GI bleeding in 19 patients and familial polyposis syndrome in 1 patient. The mean time for conventional upper endoscopy and the cap-fitted procedure was 8 þ3 min. Conventional upper endoscopy achieved only a tangential view of the ampula in 18 of the 20 patients (90%) and in 2 patients the ampula could not be seen at all. The use of the cap-fitted gastroscope permitted an adequate examination of the ampula and its orifice in all 20 patients (100%). Deattachment of the transparent cap during the procedure occurred in one patient, performing successful endoscopic retrieval of the cap during the same procedure. No other complications occurred. Conclusions: The use of a regular gastroscope equipped with a transparent cap provides an adequate and reliable visualization of the ampula of Vater. Using this technique would potentially allow for a more complete diagnostic examination of the upper gastrointestinal tract without the need for a duodenoscope.
W1470 Diagnosis Yield of New Approaches for Small Bowel Examinations Jean-Francois Rey, Antoine S. Geagea Background: Video Capsule Endoscopy (VCE) and balloon assisted enteroscopy open a new area in small bowel examinations. Both technologies have been combined in order to achieve a better diagnosis yield in patients with suspected small bowel diseases. Aim: The aim of this study was to achieve the clinical benefit of combined approach using VCE for screening and Single Balloon Enteroscopy (SBE) as a final diagnosis tool and treatment. Method: From January 2006 to October 2008, 201 VCE were carried on with Olympus (131) or Given Imaging (70) capsules with or without PEG preparation. SBE (Olympus XSIF 160 DB or XSIF Q160 with NBI) was performed under general anaesthesia for the upper approach and under Propofol sedation for lower route. 194 SBE were performed (131 upper, 75 lower) with only one minor complication (24H abdominal pains after SBE with APC for multiple angiomas). Results: VCE was able to detect: angiomas (74), Crohn’diseases (16), polyps (14), celiac diseases (9) and miscellaneous disorders (21). During this study, we also show the clinical benefit of PEG preparation for VCE examinations, with SBE we perform a complete jejunal examination in 81% of cases and upper ileal examination in 41% in a mean time of 46 minutes. From the anal route a complete exploration of the ileon was possible in 81% with only two cases where we were not able to get through the ileo cecal valve. 12 patients required both route examinations and NBI was particularly useful in Crohn’s disease patients. SBE was able to diagnose lesions missed by the VCE in 17% of cases. It was mainly angiomas (24) and polyps (6) in patients referred after a positive VCE examination. Endoscopic treatment was sometimes limited by the conventional size of biopsy channel (2.8 mm) but becomes easier with a 3.2 mm channel prototype. We should also underline the safety of SBE as we did not observe major complications. The use of only one balloon fixed on the overtube probably explained the reduced time examination with SBE. Progression was also facilitate by the use of home made stiffening wire introduced through the biopsy channel in order to reduce the gastric loop. Therapeutic enteroscopy is still impaired by lack of accessories and limited size of biopsy channel. Conclusion: Although VCE is a major new tool for diagnosis, it is important to confirm and treat patients with SBE. Specialized units able to provide both technologies have to be organised in order to achieve a better diagnosis yield for patients with suspected small bowel diseases.
W1471 Initial Experience with a New Double Balloon Colonoscope in Patients with Prior Incomplete Colonoscopy Kevin C. Ruff, Shabana F. Pasha, Jonathan A. Leighton, G.A. Decker, Michael D. Crowell, M. Edwyn Harrison Background: The success rate of cecal intubation with a standard colonoscope is reported to be 80-95%. Despite using thinner & more flexible endoscopes, incomplete colonoscopy remains a significant problem. Double-balloon colonoscopy (DBC), using a push-and-pull technique with balloons on both the overtube and endoscope, may facilitate completion of the colonic exam after prior incomplete colonoscopy. Recent studies show that retrograde double balloon
AB378 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
enteroscopy can be used for completion of colon examination but the technique is limited by the length of the scope (200 cm) and looping. A new double-balloon colonoscope (Fujinon FC450-B15C) is now available with a shorter length of 152 cm. Aim: To evaluate the procedural characteristics and success rate of DBC in patients with a prior incomplete exam. Methods: A retrospective chart review from January 1, 2008 through November 10, 2008 was performed to identify all patients who had undergone DBC after a prior incomplete colonoscopy using a conventional colonoscope. IRB approval was obtained. Baseline demographic information, procedural information from the initial colonoscopy and repeat DBC, and endoscopic findings during DBC were collected. Successful DBC was defined as cecal intubation. Data are presented as mean SD. Results: Twenty patients with incomplete colonoscopies (70% females, 68.5 13.1 years, BMI 27.9 4.3 kg/m2) were referred for DBC. The extent of initial exam was beyond the splenic flexure in 40% of cases. In 70% looping prevented cecal intubation. With DBC, 95% of procedures were completed beyond the splenic flexure and the cecal intubation rate was 80%. DBC allowed removal of polyps in an additional 9 patients. DBC failed to reach the cecum in 4 cases, 3 due to looping and 1 due to angulation. There was no difference in the quality of colonic preparations between the exams. Average procedure times and medication doses for DBC procedures are presented in Table 1. Conclusions: The new double balloon colonoscope is an effective technique for intubation of the cecum after incomplete colonoscopy with a standard colonoscope. However, incomplete colonoscopy, especially due to looping of the colon is not entirely eliminated with this new technology. Parameters of double balloon colonoscopy
Average Dose of Versed (mg) Average Dose of Demerol (mg) Average time to cecal intubation (min) Average Total Procedure Time (min) Percent cases with general anesthesia
4.9 67.5 26.0 45.7
( 2.0) ( 24.9) ( 17.0) ( 15.8) 20
W1472 Preparations for PillCam Colon Capsule Endoscopy Are As Acceptable and Safe As That for Standard Colonoscopy Cristiano Spada, Maria Elena Riccioni, Lucio Petruzziello, Paola Cesaro, Guido Costamagna Background: PillCam Colon Capsule Endoscopy (PCCE) is an emerging noninvasive method to explore the colon. The preparation (prep) for PCCE lasts longer than that for standard colonoscopy (SC) and requires additional laxatives as it should clean the colon and also facilitate the progression of the capsule. Concerns arise because the large volume of liquids required for PPCE prep may decrease the compliance to the procedure. Aims: Aim of this study was to compare the satisfaction between patients (pts) who received 2 different PCCE regimens with those who received SC regimen. Adverse events occurrence was also compared. Patients and Methods: 40 pts prospectively enrolled in the validation phase of an Italian Multicenter Clinical Trial that evaluates the effect of PCCE prep and procedure on colon cleansing level were compared with a similar group who received prep for SC. Pts were randomized to 2 different PCCE regimens. Regimen I (baseline regimen) included clear liquid diet and 3 liters (L) of PEG on day -1, and 1L PEG in the morning of the procedure day. Additional small doses of NaP boosters were given following capsule ingestion to maintain clean colon and enhance capsule propulsion. Regimen II included low residue diet on days -5 to -2, 4 senna tablets on day -2, clear liquid diet and 3L of PEG on day -1, and PEG instead of NaP boosters on the procedure day. Pts were asked to grade the prep as easy, acceptable, unpleasant, intolerable. They also indicated if they had nausea, vomiting, abdominal pain, headache and vertigo. Pts who received prep for PCCE were compared between the 2 groups and with the group who received prep for SC (low residue diet on days -5 to -1, 4 senna tablets on day -2, 4L of PEG on day -1). Results: No statistical differences were found in term of satisfaction between PCCE regimen I and II, and the SC regimen (Table 1). In addition, no differences were found for adverse events occurrence. Conclusion: PCCE regimens appear as acceptable and as safe as SC regimen. Furthermore, PCCE regimen I (baseline) and regimen II show similar patient’s satisfaction and safety. Table 1. Prep satisfaction
Easy Acceptable Unpleasant Intolerable
PCCE Regimen I (nZ20)
PCCE Regimen II (nZ20)
p
PCCE Regimens (nZ40)
SC Regimen (nZ40)
p
4 11 5 0
4 9 6 1
NS NS NS NS
8 20 11 1
14 14 8 4
NS NS NS NS
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principles of a regular upper endoscopy, including having the patient in the left lateral decubitus position. Once in the duodenum, reasonable effort was invested into trying to visualize the ampula. The gastroscope was then withdrawn and a transparent cap was attached to the same endoscope. The ampula was again intentionally examined during the second part of the procedure. We considered visualization of the ampula adequate when the orifice was clearly identified. We report the demographic data, indications for the endoscopy, procedure time, visualization of the ampula and complications. Visualization of the ampula was reported as complete, tangential or non-identified. All the data were collected in a previously designed form. Results: We included 20 patients; M/F 13/7 with a mean age of 58 years(range: 20-76 years). Indications for upper endoscopy were upper GI bleeding in 19 patients and familial polyposis syndrome in 1 patient. The mean time for conventional upper endoscopy and the cap-fitted procedure was 8 þ3 min. Conventional upper endoscopy achieved only a tangential view of the ampula in 18 of the 20 patients (90%) and in 2 patients the ampula could not be seen at all. The use of the cap-fitted gastroscope permitted an adequate examination of the ampula and its orifice in all 20 patients (100%). Deattachment of the transparent cap during the procedure occurred in one patient, performing successful endoscopic retrieval of the cap during the same procedure. No other complications occurred. Conclusions: The use of a regular gastroscope equipped with a transparent cap provides an adequate and reliable visualization of the ampula of Vater. Using this technique would potentially allow for a more complete diagnostic examination of the upper gastrointestinal tract without the need for a duodenoscope.
W1470 Diagnosis Yield of New Approaches for Small Bowel Examinations Jean-Francois Rey, Antoine S. Geagea Background: Video Capsule Endoscopy (VCE) and balloon assisted enteroscopy open a new area in small bowel examinations. Both technologies have been combined in order to achieve a better diagnosis yield in patients with suspected small bowel diseases. Aim: The aim of this study was to achieve the clinical benefit of combined approach using VCE for screening and Single Balloon Enteroscopy (SBE) as a final diagnosis tool and treatment. Method: From January 2006 to October 2008, 201 VCE were carried on with Olympus (131) or Given Imaging (70) capsules with or without PEG preparation. SBE (Olympus XSIF 160 DB or XSIF Q160 with NBI) was performed under general anaesthesia for the upper approach and under Propofol sedation for lower route. 194 SBE were performed (131 upper, 75 lower) with only one minor complication (24H abdominal pains after SBE with APC for multiple angiomas). Results: VCE was able to detect: angiomas (74), Crohn’diseases (16), polyps (14), celiac diseases (9) and miscellaneous disorders (21). During this study, we also show the clinical benefit of PEG preparation for VCE examinations, with SBE we perform a complete jejunal examination in 81% of cases and upper ileal examination in 41% in a mean time of 46 minutes. From the anal route a complete exploration of the ileon was possible in 81% with only two cases where we were not able to get through the ileo cecal valve. 12 patients required both route examinations and NBI was particularly useful in Crohn’s disease patients. SBE was able to diagnose lesions missed by the VCE in 17% of cases. It was mainly angiomas (24) and polyps (6) in patients referred after a positive VCE examination. Endoscopic treatment was sometimes limited by the conventional size of biopsy channel (2.8 mm) but becomes easier with a 3.2 mm channel prototype. We should also underline the safety of SBE as we did not observe major complications. The use of only one balloon fixed on the overtube probably explained the reduced time examination with SBE. Progression was also facilitate by the use of home made stiffening wire introduced through the biopsy channel in order to reduce the gastric loop. Therapeutic enteroscopy is still impaired by lack of accessories and limited size of biopsy channel. Conclusion: Although VCE is a major new tool for diagnosis, it is important to confirm and treat patients with SBE. Specialized units able to provide both technologies have to be organised in order to achieve a better diagnosis yield for patients with suspected small bowel diseases.
W1471 Initial Experience with a New Double Balloon Colonoscope in Patients with Prior Incomplete Colonoscopy Kevin C. Ruff, Shabana F. Pasha, Jonathan A. Leighton, G.A. Decker, Michael D. Crowell, M. Edwyn Harrison Background: The success rate of cecal intubation with a standard colonoscope is reported to be 80-95%. Despite using thinner & more flexible endoscopes, incomplete colonoscopy remains a significant problem. Double-balloon colonoscopy (DBC), using a push-and-pull technique with balloons on both the overtube and endoscope, may facilitate completion of the colonic exam after prior incomplete colonoscopy. Recent studies show that retrograde double balloon
AB378 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
enteroscopy can be used for completion of colon examination but the technique is limited by the length of the scope (200 cm) and looping. A new double-balloon colonoscope (Fujinon FC450-B15C) is now available with a shorter length of 152 cm. Aim: To evaluate the procedural characteristics and success rate of DBC in patients with a prior incomplete exam. Methods: A retrospective chart review from January 1, 2008 through November 10, 2008 was performed to identify all patients who had undergone DBC after a prior incomplete colonoscopy using a conventional colonoscope. IRB approval was obtained. Baseline demographic information, procedural information from the initial colonoscopy and repeat DBC, and endoscopic findings during DBC were collected. Successful DBC was defined as cecal intubation. Data are presented as mean SD. Results: Twenty patients with incomplete colonoscopies (70% females, 68.5 13.1 years, BMI 27.9 4.3 kg/m2) were referred for DBC. The extent of initial exam was beyond the splenic flexure in 40% of cases. In 70% looping prevented cecal intubation. With DBC, 95% of procedures were completed beyond the splenic flexure and the cecal intubation rate was 80%. DBC allowed removal of polyps in an additional 9 patients. DBC failed to reach the cecum in 4 cases, 3 due to looping and 1 due to angulation. There was no difference in the quality of colonic preparations between the exams. Average procedure times and medication doses for DBC procedures are presented in Table 1. Conclusions: The new double balloon colonoscope is an effective technique for intubation of the cecum after incomplete colonoscopy with a standard colonoscope. However, incomplete colonoscopy, especially due to looping of the colon is not entirely eliminated with this new technology. Parameters of double balloon colonoscopy
Average Dose of Versed (mg) Average Dose of Demerol (mg) Average time to cecal intubation (min) Average Total Procedure Time (min) Percent cases with general anesthesia
4.9 67.5 26.0 45.7
( 2.0) ( 24.9) ( 17.0) ( 15.8) 20
W1472 Preparations for PillCam Colon Capsule Endoscopy Are As Acceptable and Safe As That for Standard Colonoscopy Cristiano Spada, Maria Elena Riccioni, Lucio Petruzziello, Paola Cesaro, Guido Costamagna Background: PillCam Colon Capsule Endoscopy (PCCE) is an emerging noninvasive method to explore the colon. The preparation (prep) for PCCE lasts longer than that for standard colonoscopy (SC) and requires additional laxatives as it should clean the colon and also facilitate the progression of the capsule. Concerns arise because the large volume of liquids required for PPCE prep may decrease the compliance to the procedure. Aims: Aim of this study was to compare the satisfaction between patients (pts) who received 2 different PCCE regimens with those who received SC regimen. Adverse events occurrence was also compared. Patients and Methods: 40 pts prospectively enrolled in the validation phase of an Italian Multicenter Clinical Trial that evaluates the effect of PCCE prep and procedure on colon cleansing level were compared with a similar group who received prep for SC. Pts were randomized to 2 different PCCE regimens. Regimen I (baseline regimen) included clear liquid diet and 3 liters (L) of PEG on day -1, and 1L PEG in the morning of the procedure day. Additional small doses of NaP boosters were given following capsule ingestion to maintain clean colon and enhance capsule propulsion. Regimen II included low residue diet on days -5 to -2, 4 senna tablets on day -2, clear liquid diet and 3L of PEG on day -1, and PEG instead of NaP boosters on the procedure day. Pts were asked to grade the prep as easy, acceptable, unpleasant, intolerable. They also indicated if they had nausea, vomiting, abdominal pain, headache and vertigo. Pts who received prep for PCCE were compared between the 2 groups and with the group who received prep for SC (low residue diet on days -5 to -1, 4 senna tablets on day -2, 4L of PEG on day -1). Results: No statistical differences were found in term of satisfaction between PCCE regimen I and II, and the SC regimen (Table 1). In addition, no differences were found for adverse events occurrence. Conclusion: PCCE regimens appear as acceptable and as safe as SC regimen. Furthermore, PCCE regimen I (baseline) and regimen II show similar patient’s satisfaction and safety. Table 1. Prep satisfaction
Easy Acceptable Unpleasant Intolerable
PCCE Regimen I (nZ20)
PCCE Regimen II (nZ20)
p
PCCE Regimens (nZ40)
SC Regimen (nZ40)
p
4 11 5 0
4 9 6 1
NS NS NS NS
8 20 11 1
14 14 8 4
NS NS NS NS
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