- Email: [email protected]
Clinical Diagnosis of Small Bowel Metastasis in Malignant Melanoma
Abstracts
from pylorus to lesion by the SB transit time. In those with O1 lesion on CE, most proximal was measured in patients undergoing antegrade and most distal lesion was measured in patients undergoing retrograde DBE. Comparison between means was performed by Student’s t test. Results: Mean age of patients was 62 years. 19 (56%) were women and 15 (44%) were men. Indications for CE included GI bleeding (32,92%), diarrhea (1,3%) and screening for polyps in a patient with Peutz Jeghers Syndrome (3%). DBE was indicated for biopsy of mass and/or ulcer in 17 (50%), to diagnose the cause of active bleeding in 12 (35%), for treatment of non bleeding AVMs in 4 (11%) and for treatment of friable anastomosis in a patient with underlying Crohn’s disease (3%). Overall,DBE identified the abnormal finding in 18 (53%) patients. Major findings on DBE included AVMs (10, 29%), polyps (6, 18%), SB enteritis (1,3%) and nodularity (1,3%). Interventions done included APC (11, 61%), biopsy (5,28%), snare cautery (1,6%) and polypectomy (1,6%). 26 patients had initial antegrade DBE and abnormal findings were identified in 14 (54%). Patients with positive antegrade DBE had an average LI of 0.16 þ/ 0.12 compared to 0.43 þ/ 0.25 in patients with negative antegrade DBE [p ! 0.05]. DBE identified the abnormal finding in 14/20 (70%) patients when LI was !0.5. None of the patients with a LI O0.5 had abnormal finding detected on DBE [p ! 0.005]. 8 patients had an initial retrograde DBE and abnormal finding was identified in 4 (50%). Average LI was 0.92 þ/ 0.08 and 0.85 þ/ 0.12 in patients with positive and negative retrograde DBE respectively [p Z 0.44]. Conclusion: 1) A CE derived LI predicts the success and initial route of insertion of DBE. 2) As LI increases diagnostic yield of antegrade DBE decreases. No lesions were identified on antegrade DBE when LI was O0.5.3) Lesions located within mid to distal small bowel are difficult to reach with DBE.
T1625 A Pilot Study of Spiral Enteroscopy Using a New Design 48F Discovery SB Overtube and the Fujinon 200 cm 3 9.4 mm Enteroscope Paul A. Akerman, Daniel Cantero, Jose Avila, Jesus Pangtay Introduction: Intraoperative enteroscopy, double balloon enteroscopy (DBE) and single balloon enteroscopy all use small bowel (sb) pleating techniques to visualize lengths of sb greater than the length of the enteroscope. Our prior studies have shown proof of concept for pleating sb using a spiral overtube on a pediatric colonoscope. Here we present our results using the newly designed 48F Discovery SB overtube with the Fujinon 200 cm, 9.4 mm enteroscope (Fuji ENT). The new Discovery SB has a smaller diameter (48F) and improved spiral and shaft characteristics. The Fuji ENT has increased endoscope length for deeper sb insertion. Aims & Methods: This is a sb enteroscopy pilot study using the newly designed Discovery SB with the Fuji ENT. The Discovery SB overtube is 48F outer diameter, 118 cm long with a 5 mm raised spiral at the distal end. The Fujinon enteroscope (EN-450TS) is 200 cm long, 9.4 mm diameter with a 2.8 mm working channel. 50 consecutive patients with obscure bleeding were enrolled. The distal balloon on the Fuji ENT was not used. MAC sedation was performed with Propofol, Versed and Fentanyl. All patients were outpatients. Advancement through the sb was accomplished with spiral pleating, push advancement or combination technique. Withdrawal was accomplished with counter-clockwise rotation. Results: 24 males and 26 females were enrolled. Ave. age 46 yrs (19-78). Ave. height 164 cm and weight 72 kg. Average total procedure time was 29.0 min. Ave. time to maximal depth of insertion was 18.7 min. Ave. estimated insertion depth past the Ligament of Treitz was 243 cm (range 50-380 cm) Findings were 8 AVM’s, 1 tumor, 2 strongyloides. Complications were 8 sore throats that all resolved in 72 hours and one intussusception recognized and reduced during procedure. Mild mucosal trauma was seen in 5 pts and moderate mucosa trauma in 1 patient. All pts were discharged the same day of procedure. Ave anesthesia use was 75 mg Propofol, 4.3 mg midazolam, and 84 mcg fentanyl. On a visual analog scale, ease of rotation was good to excellent on all pts and controlled withdrawal was very good to excellent. Conclusion: The newly developed 48F Discovery SB overtube with the Fujinon 200 cm enteroscope is rapid and safe for advancement through the small bowel. Depth of insertion into the small bowel compares favorably with published DBE data and procedure times are superior. Controlled withdrawal was achieved in all pts. Overall, the Discovery SB/Fuji ENT combination may offer advantages compared to Double Balloon Enteroscopy. Future comparative studies are needed.
T1626 A New in Vitro Porcine Model for Spiral Enteroscopy Training: The Akerman Enteroscopy Trainer Paul A. Akerman, Daniel Cantero, William H. Bookwalter, Robert Ailinger Benchtop model training for enteroscopy is critical to teach techniques and concepts. The most common in vitro model for enteroscopy consists of the esophagus/stomach and 100-200 cm of small bowel (sb) with mesentery removed. This model attempts to reproduce the mesentery of the sb to better mimic the in vivo pleating and unpleating seen in spiral enteroscopy. Methods and Model: The Akerman Enteroscopy Trainer consists of 2 major components. The upper component corresponds to the esophagus, stomach and doudenum. The lower component corresponds to the freely mobile small bowel past the LOT. An artificial mesentery is formed with clips hanging from a curving metal rod that attaches to the mesenteric side of the small bowel along its entire length. Clips are attached every 3 cm along the length of the small bowel and at the terminal end of the small bowel an
AB264 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
elastic band is attached and gives mild resistance to pleating. Findings: In one setting 24 trainees used the device over the course of 4 hours. The small bowel length was 130 cm. SE pleating techniques for advancement and controlled withdrawal were demonstrated. The endoscopic appearance with SE exactly mimics that seen in vivo. The model showed no appreciable dimunition of function or performance after 4 hours of continous use. Conclusion: This new porcine in vitro benchtop model is very useful to demonstrate spiral advancement and pleating techniques along with counterclockwise withdrawal. The model exactly mimics the endoscopic images seen with spiral pleating enteroscopy in vivo. The model is a durable and rapid way to demonstrate SE. The model may be very useful to demonstrate other enteroscopy techniques including single and double balloon enteroscopy.
The Akerman Enteroscopy Trainer
T1627 A Pilot Study of Spiral Enteroscopy Using a New Design 48F Discovery SB Overtube and the Olympus 200 cm 3 9.2 mm Enteroscope Paul A. Akerman, Daniel Cantero, Jose Avila, Jesus Pangtay Introduction: Intraoperative enteroscopy, double balloon enteroscopy (DBE) and single balloon enteroscopy all use small bowel (sb) pleating techniques to visualize lengths of sb greater than the length of the enteroscope. Our prior studies have shown proof of concept for pleating sb using a spiral overtube on a pediatric colonoscope. Here we present our results using the newly designed Discovery SB overtube with the Olympus 200 cm, 9.2 mm enteroscope (Oly ENT). The new Discovery SB has a smaller diameter (48F) and improved spiral and shaft characteristics. The Oly ENT has a longer length to improve insertion depths. Aims & Methods: This is a pilot study presenting initial results of the newly designed Discovery SB with the Oly ENT. The Discovery SB overtube is 48F outer diameter, 118 cm long with a 5 mm raised spiral at the distal end. The Olympus enteroscope (GIF) is 200 cm long, 9.2 mm diameter with a 2.8 mm working channel. 25 consecutive patients with obscure bleeding were enrolled. MAC sedation with Propofol, Versed and Fentanyl was used. All patients were outpatients. Advancement through the small bowel was accomplished with spiral pleating, push advancement or combination technique. Withdrawal was accomplished with counter-clockwise rotation. Results: 15 males and 10 females were enrolled. Ave. age 45 yrs (25-68). Ave. height 166 cm and weight 69 kg. Average total procedure time was 26.1 min. Ave. time to maximal depth of insertion was 16.2 min. Ave. estimated insertion depth past the Ligament of Treitz was 256 cm (range 50-400 cm) Findings were 7 AVM’s, 1 tumor, 1 strongyloides. Complications were 7 sore throats that all resolved in 72 hours and one intussusception recognized and reduced during procedure. Mild mucosal trauma was seen in 5pts and moderate mucosa trauma in 2 patients. All pts were discharged the same day of procedure. Ave anesthesia use was 70 mg Propofol, 4.1 mg midazolam, and 81 mcg fentanyl. On a visual analog scale, ease of rotation was good to excellent on all pts and controlled withdrawal was very good to excellent. Conclusion: The newly developed 48F Discovery SB overtube with the Olympus 200 cm 9.2 mm enteroscope is rapid and safe for spiral advancement through the small bowel. Depth of insertion into the small bowel compares favorably with published single balloon enteroscopy data and procedure times are superior. Controlled withdrawal was achieved in all pts. Overall, the Discovery SB/Olympus ENT combination may offer advantages compared to single balloon enteroscopy. Future studies are needed.
T1628 Clinical Diagnosis of Small Bowel Metastasis in Malignant Melanoma Joerg G. Albert, Peter Helmbold, Martin Fechner, Eckhard Fiedler, Winfried A. Voderholzer, Wolfgang C. Marsch, Herbert Lochs, Wolfram Sterry, Sonja Vay, Wolfgang Stremmel, Matthias M. Dollinger Introduction: Intestinal metastases are found in up to 60% of melanoma patients at postmortem examination, mostly located in the small bowel. However, there are no
www.giejournal.org
Abstracts
clinical data based on a prospective study. Methods: In this prospective, multicenter study, we screened patients with established diagnosis of malignant melanoma for positive fecal occult blood test (FOBT). With a positive FOBT patients were offered endoscopic investigations (esophago-gastro-duodenoscopy, colonoscopy, and capsule endoscopy; group A). In patients with American Joint Committee on Cancer (AJCC) stage IV (metastasized) melanoma, small bowel endoscopy was offered independently of the screening test (group B). Results: 362 patients were included, 310 (85.6%) in group A and 52 (14.4%) in group B (figure 1). In 13 of 37 (35.1%) patients with AJCC stage IV (group B), small bowel metastases were detected. Metastases were resected in three (23.1%). In 18 patients with AJCC I to III melanoma (group A) and with a positive FOBT, 4 (22.2%) were found to have small bowel metastases. Resection was done in 3, but was not performed in one patient for rapidly progressive disease. Resection confirmed clinically suspected metastases in all cases. Stepwise logistic regression analysis (forward selection; SPSS Inc., Chicago, USA) identified low hematocrit as significant predictive factor (p Z 0.02) for occurrence of small bowel metastases. Conclusion: Melanoma metastases are found by small bowel endoscopy in about 1/5 of AJCC I-III, and in 1/3 of AJCC IV patients. Resection is carried out if it seems feasible to completely remove the metastatic disease or if palliative resection may avoid life-threatening complications.
T1629 Reduction of the Capture Rate in the Stomach Can Increase Complete Examination Rate of Capsule Endoscopy: A Prospective Randomized Controlled Trial Zhuan Liao, Feng Li, Zhao-Shen Li Background and Objective: Capsule endoscope failed to reach the cecum in approximately 20% of cases, with delayed gastric emptying being the most common cause. We hypothesized that reduction of the capture rate in the stomach saves the battery life, and thus allows capsule endoscope to capture more images in the small intestine. The aim of this study was to determine whether reduction of the capture rate of capsule endoscope in the stomach can increase complete examination rate (CER). Patients and Methods: A total of 50 patients were prospectively randomized into two groups, modified capture (MCR, n Z 25) and control (n Z 25) groups. The OMOM capsule endoscopy system (Jianshan Science & Technology (Group) Co., Ltd, Chongqing, China), which has the functions of real-time viewing images and modifying the capture rate during the examination, was used. In patients of MCR group, the capture rate of the capsule endoscope was initially set at 0.5 frames per second (fps), and then modified to 2 fps once the capsule endoscope passed the pylorus, whereas in patients of the control group, the capture rate of capsule endoscope was set and kept at 2 fps during the entire recording. The CER, gastric transit time (GTT), small bowel images and total work time were recorded and analyzed. Results: There was no significant difference in the genders, mean age, number of hospitalized patients, and indications between the two groups. No patients used the narcotics, prokinetics, and no patient with diabetic gastroparesis was included. The CER was significantly higher in MCR group than in the control group (100% vs. 72.0% p Z 0.014). The total work time was much longer in the MCR group than in the control group (649.9 144.8 min vs. 445.2 56.2 min, p ! 0.001). Small bowel images in the MCR group was significantly more than in the control group (45740 [9720w62400] frames vs. 40320 [7920w49320] frames, p Z 0.042). There were no significant differences in GTT between the two groups. Conclusions: Reduction of the capture rate of capsule endoscope in the stomach can increase the complete small bowel examination rate by reducing battery consumption in the stomach and prolonging the total work time of OMOM capsule.
T1630 Clinical Application of OMOM Capsule Endoscopy in China: A Review of 1,068 Cases Zhuan Liao, Feng Li, Zhao-Shen Li Background and Objective: A new capsule endoscope (CE), OMOM CE, developed by Jianshan Science & Technology (Group) Co., Ltd, Chongqing, China, has been widely used in China and in some areas of Asian and European countries. About 53,000 OMOM capsules have been ingested since 2004. However, there are few published studies that summarize OMOM CE experience with large sample. Methods: A database was retrieved from the OMOM CE Database. The patient’s age, gender, indications, diagnostic results were analyzed. Results: 1,068 patients aged 10w90 (mean, 49), of whom 608 were males (59.6%), underwent OMOM CE. 478 (44.8%) were referred with obscure gastrointestinal bleeding (OGIB), 316 (29.6%)
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with abdominal pain, and 102 (9.6%) with diarrhea. The others indications included health examination (71, 6.6%), suspected Crohn’s disease (52, 4.9%), obscure weight loss (22, 2.1%), suspected tumors (20, 1.9%). The overall diagnostic yield was 47.2% (504/1068). The diagnostic yield of OMOM CE in OGIB subgroup was much higher than in the non-OGIB subgroup (71.1% vs. 27.8%, p ! 0.001). The most common findings in Chinese patients with OGIB were vascular abnormality (24.4%), tumor (17.6%), inflammation (15.2%), active bleeding (14.6%), and polyps (14.4%). Conclusions: The OMOM capsule endoscopy is a valuable tool for small bowel evaluation with good overall diagnostic yield. The yield in OGIB subgroup was much higher than in the non-OGIB subgroup. Vascular abnormality and tumor of small intestine were the most common causes in Chinese patients with OGIB.
The OMOM capsule endoscopy system. A. OMOM image workstation, B. OMOM capsule endoscope, C. Image recorder, D. Portable monitor. T1631 Complications, Complete Examination Rate and Gastrointestinal Transit Time of OMOM Capsule Endoscopy: An Analysis with 1,068 Cases Zhuan Liao, Feng Li, Zhao-Shen Li Background and Objective: A new wireless OMOM capsule endoscope (OMOM CE), developed by Jianshan Science & Technology (Group) Co., Ltd, Chongqing, China, has been widely used in China and in some areas of Southeast Asian and European countries. About 53,000 OMOM capsules have been ingested since 2004. However, there are few published studies that summarize OMOM capsule endoscopy on complications, complete examination small bowel rate (CER), gastric transit time (GTT), and small bowel transit time (SBTT) with large sample. Methods: A database was retrieved from the Jianshan Science & Technology Ltd. OMOM CE Database. The 1,068 cases were from 17 endoscopy centers that used the OMOM CE system in Mainland China. The complications, complete small bowel examination rate (CER), gastric transit time (GTT), small bowel transit time (SBTT), and total work time were recorded and analyzed. Results: The major complication of OMOM CE was capsule retention, which were seen in 23 patients (esophageal 4, gastric 9, afferent loop 1, small bowel retention 9). The overall retention rate was 2.15%. Four capsules retained in the small bowel were surgically removed, and the remainders were successfully removed by gastroscopy or double balloon enteroscopy. The overall CER of OMOM CE was 82.68%. In the 185 patients with uncompleted examination, the delayed gastric emptying was the major cause (68 patients’ GTT O120 min, 36.8%). The CER was not related to the gender or age. The decrease in CER was positively related to the increase in GTT, and inversely related to the increase in total work time (TWT) of OMOM CE (Both p ! 0.001). The CER in the non-OGIB group was greater than OGIB group (78.5% vs. 86.5% p ! 0.001). The mean GTT, SBTT and TWT were 68 min (rang 1w543 min), 261 min (rang 27w690 min), and 468 min (rang 168w911 min), respectively. Conclusions: This is the first large report on OMOM capsule endoscopy, and the capsule retention rate is very low and comparable with that of Given PillCam capsule system. The complete small bowel examination rate was 82.6%, which was related to gastric transit time and total work time of OMOM capsule, but not related to gender and age.
T1632 Right Lateral Position Improves Complete Examination Rate of Capsule Endoscope: A Prospective Randomized, Controlled Trial Zhuan Liao, Feng Li, Zhao-Shen Li Background and Aim: It has been reported that capsule endoscopes (CE) fail to reach the cecum in 20% of patients within the 8-hour battery life. The delayed gastric transit is the most common causes of incomplete small bowel
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB265
from pylorus to lesion by the SB transit time. In those with O1 lesion on CE, most proximal was measured in patients undergoing antegrade and most distal lesion was measured in patients undergoing retrograde DBE. Comparison between means was performed by Student’s t test. Results: Mean age of patients was 62 years. 19 (56%) were women and 15 (44%) were men. Indications for CE included GI bleeding (32,92%), diarrhea (1,3%) and screening for polyps in a patient with Peutz Jeghers Syndrome (3%). DBE was indicated for biopsy of mass and/or ulcer in 17 (50%), to diagnose the cause of active bleeding in 12 (35%), for treatment of non bleeding AVMs in 4 (11%) and for treatment of friable anastomosis in a patient with underlying Crohn’s disease (3%). Overall,DBE identified the abnormal finding in 18 (53%) patients. Major findings on DBE included AVMs (10, 29%), polyps (6, 18%), SB enteritis (1,3%) and nodularity (1,3%). Interventions done included APC (11, 61%), biopsy (5,28%), snare cautery (1,6%) and polypectomy (1,6%). 26 patients had initial antegrade DBE and abnormal findings were identified in 14 (54%). Patients with positive antegrade DBE had an average LI of 0.16 þ/ 0.12 compared to 0.43 þ/ 0.25 in patients with negative antegrade DBE [p ! 0.05]. DBE identified the abnormal finding in 14/20 (70%) patients when LI was !0.5. None of the patients with a LI O0.5 had abnormal finding detected on DBE [p ! 0.005]. 8 patients had an initial retrograde DBE and abnormal finding was identified in 4 (50%). Average LI was 0.92 þ/ 0.08 and 0.85 þ/ 0.12 in patients with positive and negative retrograde DBE respectively [p Z 0.44]. Conclusion: 1) A CE derived LI predicts the success and initial route of insertion of DBE. 2) As LI increases diagnostic yield of antegrade DBE decreases. No lesions were identified on antegrade DBE when LI was O0.5.3) Lesions located within mid to distal small bowel are difficult to reach with DBE.
T1625 A Pilot Study of Spiral Enteroscopy Using a New Design 48F Discovery SB Overtube and the Fujinon 200 cm 3 9.4 mm Enteroscope Paul A. Akerman, Daniel Cantero, Jose Avila, Jesus Pangtay Introduction: Intraoperative enteroscopy, double balloon enteroscopy (DBE) and single balloon enteroscopy all use small bowel (sb) pleating techniques to visualize lengths of sb greater than the length of the enteroscope. Our prior studies have shown proof of concept for pleating sb using a spiral overtube on a pediatric colonoscope. Here we present our results using the newly designed 48F Discovery SB overtube with the Fujinon 200 cm, 9.4 mm enteroscope (Fuji ENT). The new Discovery SB has a smaller diameter (48F) and improved spiral and shaft characteristics. The Fuji ENT has increased endoscope length for deeper sb insertion. Aims & Methods: This is a sb enteroscopy pilot study using the newly designed Discovery SB with the Fuji ENT. The Discovery SB overtube is 48F outer diameter, 118 cm long with a 5 mm raised spiral at the distal end. The Fujinon enteroscope (EN-450TS) is 200 cm long, 9.4 mm diameter with a 2.8 mm working channel. 50 consecutive patients with obscure bleeding were enrolled. The distal balloon on the Fuji ENT was not used. MAC sedation was performed with Propofol, Versed and Fentanyl. All patients were outpatients. Advancement through the sb was accomplished with spiral pleating, push advancement or combination technique. Withdrawal was accomplished with counter-clockwise rotation. Results: 24 males and 26 females were enrolled. Ave. age 46 yrs (19-78). Ave. height 164 cm and weight 72 kg. Average total procedure time was 29.0 min. Ave. time to maximal depth of insertion was 18.7 min. Ave. estimated insertion depth past the Ligament of Treitz was 243 cm (range 50-380 cm) Findings were 8 AVM’s, 1 tumor, 2 strongyloides. Complications were 8 sore throats that all resolved in 72 hours and one intussusception recognized and reduced during procedure. Mild mucosal trauma was seen in 5 pts and moderate mucosa trauma in 1 patient. All pts were discharged the same day of procedure. Ave anesthesia use was 75 mg Propofol, 4.3 mg midazolam, and 84 mcg fentanyl. On a visual analog scale, ease of rotation was good to excellent on all pts and controlled withdrawal was very good to excellent. Conclusion: The newly developed 48F Discovery SB overtube with the Fujinon 200 cm enteroscope is rapid and safe for advancement through the small bowel. Depth of insertion into the small bowel compares favorably with published DBE data and procedure times are superior. Controlled withdrawal was achieved in all pts. Overall, the Discovery SB/Fuji ENT combination may offer advantages compared to Double Balloon Enteroscopy. Future comparative studies are needed.
T1626 A New in Vitro Porcine Model for Spiral Enteroscopy Training: The Akerman Enteroscopy Trainer Paul A. Akerman, Daniel Cantero, William H. Bookwalter, Robert Ailinger Benchtop model training for enteroscopy is critical to teach techniques and concepts. The most common in vitro model for enteroscopy consists of the esophagus/stomach and 100-200 cm of small bowel (sb) with mesentery removed. This model attempts to reproduce the mesentery of the sb to better mimic the in vivo pleating and unpleating seen in spiral enteroscopy. Methods and Model: The Akerman Enteroscopy Trainer consists of 2 major components. The upper component corresponds to the esophagus, stomach and doudenum. The lower component corresponds to the freely mobile small bowel past the LOT. An artificial mesentery is formed with clips hanging from a curving metal rod that attaches to the mesenteric side of the small bowel along its entire length. Clips are attached every 3 cm along the length of the small bowel and at the terminal end of the small bowel an
AB264 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
elastic band is attached and gives mild resistance to pleating. Findings: In one setting 24 trainees used the device over the course of 4 hours. The small bowel length was 130 cm. SE pleating techniques for advancement and controlled withdrawal were demonstrated. The endoscopic appearance with SE exactly mimics that seen in vivo. The model showed no appreciable dimunition of function or performance after 4 hours of continous use. Conclusion: This new porcine in vitro benchtop model is very useful to demonstrate spiral advancement and pleating techniques along with counterclockwise withdrawal. The model exactly mimics the endoscopic images seen with spiral pleating enteroscopy in vivo. The model is a durable and rapid way to demonstrate SE. The model may be very useful to demonstrate other enteroscopy techniques including single and double balloon enteroscopy.
The Akerman Enteroscopy Trainer
T1627 A Pilot Study of Spiral Enteroscopy Using a New Design 48F Discovery SB Overtube and the Olympus 200 cm 3 9.2 mm Enteroscope Paul A. Akerman, Daniel Cantero, Jose Avila, Jesus Pangtay Introduction: Intraoperative enteroscopy, double balloon enteroscopy (DBE) and single balloon enteroscopy all use small bowel (sb) pleating techniques to visualize lengths of sb greater than the length of the enteroscope. Our prior studies have shown proof of concept for pleating sb using a spiral overtube on a pediatric colonoscope. Here we present our results using the newly designed Discovery SB overtube with the Olympus 200 cm, 9.2 mm enteroscope (Oly ENT). The new Discovery SB has a smaller diameter (48F) and improved spiral and shaft characteristics. The Oly ENT has a longer length to improve insertion depths. Aims & Methods: This is a pilot study presenting initial results of the newly designed Discovery SB with the Oly ENT. The Discovery SB overtube is 48F outer diameter, 118 cm long with a 5 mm raised spiral at the distal end. The Olympus enteroscope (GIF) is 200 cm long, 9.2 mm diameter with a 2.8 mm working channel. 25 consecutive patients with obscure bleeding were enrolled. MAC sedation with Propofol, Versed and Fentanyl was used. All patients were outpatients. Advancement through the small bowel was accomplished with spiral pleating, push advancement or combination technique. Withdrawal was accomplished with counter-clockwise rotation. Results: 15 males and 10 females were enrolled. Ave. age 45 yrs (25-68). Ave. height 166 cm and weight 69 kg. Average total procedure time was 26.1 min. Ave. time to maximal depth of insertion was 16.2 min. Ave. estimated insertion depth past the Ligament of Treitz was 256 cm (range 50-400 cm) Findings were 7 AVM’s, 1 tumor, 1 strongyloides. Complications were 7 sore throats that all resolved in 72 hours and one intussusception recognized and reduced during procedure. Mild mucosal trauma was seen in 5pts and moderate mucosa trauma in 2 patients. All pts were discharged the same day of procedure. Ave anesthesia use was 70 mg Propofol, 4.1 mg midazolam, and 81 mcg fentanyl. On a visual analog scale, ease of rotation was good to excellent on all pts and controlled withdrawal was very good to excellent. Conclusion: The newly developed 48F Discovery SB overtube with the Olympus 200 cm 9.2 mm enteroscope is rapid and safe for spiral advancement through the small bowel. Depth of insertion into the small bowel compares favorably with published single balloon enteroscopy data and procedure times are superior. Controlled withdrawal was achieved in all pts. Overall, the Discovery SB/Olympus ENT combination may offer advantages compared to single balloon enteroscopy. Future studies are needed.
T1628 Clinical Diagnosis of Small Bowel Metastasis in Malignant Melanoma Joerg G. Albert, Peter Helmbold, Martin Fechner, Eckhard Fiedler, Winfried A. Voderholzer, Wolfgang C. Marsch, Herbert Lochs, Wolfram Sterry, Sonja Vay, Wolfgang Stremmel, Matthias M. Dollinger Introduction: Intestinal metastases are found in up to 60% of melanoma patients at postmortem examination, mostly located in the small bowel. However, there are no
www.giejournal.org
Abstracts
clinical data based on a prospective study. Methods: In this prospective, multicenter study, we screened patients with established diagnosis of malignant melanoma for positive fecal occult blood test (FOBT). With a positive FOBT patients were offered endoscopic investigations (esophago-gastro-duodenoscopy, colonoscopy, and capsule endoscopy; group A). In patients with American Joint Committee on Cancer (AJCC) stage IV (metastasized) melanoma, small bowel endoscopy was offered independently of the screening test (group B). Results: 362 patients were included, 310 (85.6%) in group A and 52 (14.4%) in group B (figure 1). In 13 of 37 (35.1%) patients with AJCC stage IV (group B), small bowel metastases were detected. Metastases were resected in three (23.1%). In 18 patients with AJCC I to III melanoma (group A) and with a positive FOBT, 4 (22.2%) were found to have small bowel metastases. Resection was done in 3, but was not performed in one patient for rapidly progressive disease. Resection confirmed clinically suspected metastases in all cases. Stepwise logistic regression analysis (forward selection; SPSS Inc., Chicago, USA) identified low hematocrit as significant predictive factor (p Z 0.02) for occurrence of small bowel metastases. Conclusion: Melanoma metastases are found by small bowel endoscopy in about 1/5 of AJCC I-III, and in 1/3 of AJCC IV patients. Resection is carried out if it seems feasible to completely remove the metastatic disease or if palliative resection may avoid life-threatening complications.
T1629 Reduction of the Capture Rate in the Stomach Can Increase Complete Examination Rate of Capsule Endoscopy: A Prospective Randomized Controlled Trial Zhuan Liao, Feng Li, Zhao-Shen Li Background and Objective: Capsule endoscope failed to reach the cecum in approximately 20% of cases, with delayed gastric emptying being the most common cause. We hypothesized that reduction of the capture rate in the stomach saves the battery life, and thus allows capsule endoscope to capture more images in the small intestine. The aim of this study was to determine whether reduction of the capture rate of capsule endoscope in the stomach can increase complete examination rate (CER). Patients and Methods: A total of 50 patients were prospectively randomized into two groups, modified capture (MCR, n Z 25) and control (n Z 25) groups. The OMOM capsule endoscopy system (Jianshan Science & Technology (Group) Co., Ltd, Chongqing, China), which has the functions of real-time viewing images and modifying the capture rate during the examination, was used. In patients of MCR group, the capture rate of the capsule endoscope was initially set at 0.5 frames per second (fps), and then modified to 2 fps once the capsule endoscope passed the pylorus, whereas in patients of the control group, the capture rate of capsule endoscope was set and kept at 2 fps during the entire recording. The CER, gastric transit time (GTT), small bowel images and total work time were recorded and analyzed. Results: There was no significant difference in the genders, mean age, number of hospitalized patients, and indications between the two groups. No patients used the narcotics, prokinetics, and no patient with diabetic gastroparesis was included. The CER was significantly higher in MCR group than in the control group (100% vs. 72.0% p Z 0.014). The total work time was much longer in the MCR group than in the control group (649.9 144.8 min vs. 445.2 56.2 min, p ! 0.001). Small bowel images in the MCR group was significantly more than in the control group (45740 [9720w62400] frames vs. 40320 [7920w49320] frames, p Z 0.042). There were no significant differences in GTT between the two groups. Conclusions: Reduction of the capture rate of capsule endoscope in the stomach can increase the complete small bowel examination rate by reducing battery consumption in the stomach and prolonging the total work time of OMOM capsule.
T1630 Clinical Application of OMOM Capsule Endoscopy in China: A Review of 1,068 Cases Zhuan Liao, Feng Li, Zhao-Shen Li Background and Objective: A new capsule endoscope (CE), OMOM CE, developed by Jianshan Science & Technology (Group) Co., Ltd, Chongqing, China, has been widely used in China and in some areas of Asian and European countries. About 53,000 OMOM capsules have been ingested since 2004. However, there are few published studies that summarize OMOM CE experience with large sample. Methods: A database was retrieved from the OMOM CE Database. The patient’s age, gender, indications, diagnostic results were analyzed. Results: 1,068 patients aged 10w90 (mean, 49), of whom 608 were males (59.6%), underwent OMOM CE. 478 (44.8%) were referred with obscure gastrointestinal bleeding (OGIB), 316 (29.6%)
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with abdominal pain, and 102 (9.6%) with diarrhea. The others indications included health examination (71, 6.6%), suspected Crohn’s disease (52, 4.9%), obscure weight loss (22, 2.1%), suspected tumors (20, 1.9%). The overall diagnostic yield was 47.2% (504/1068). The diagnostic yield of OMOM CE in OGIB subgroup was much higher than in the non-OGIB subgroup (71.1% vs. 27.8%, p ! 0.001). The most common findings in Chinese patients with OGIB were vascular abnormality (24.4%), tumor (17.6%), inflammation (15.2%), active bleeding (14.6%), and polyps (14.4%). Conclusions: The OMOM capsule endoscopy is a valuable tool for small bowel evaluation with good overall diagnostic yield. The yield in OGIB subgroup was much higher than in the non-OGIB subgroup. Vascular abnormality and tumor of small intestine were the most common causes in Chinese patients with OGIB.
The OMOM capsule endoscopy system. A. OMOM image workstation, B. OMOM capsule endoscope, C. Image recorder, D. Portable monitor. T1631 Complications, Complete Examination Rate and Gastrointestinal Transit Time of OMOM Capsule Endoscopy: An Analysis with 1,068 Cases Zhuan Liao, Feng Li, Zhao-Shen Li Background and Objective: A new wireless OMOM capsule endoscope (OMOM CE), developed by Jianshan Science & Technology (Group) Co., Ltd, Chongqing, China, has been widely used in China and in some areas of Southeast Asian and European countries. About 53,000 OMOM capsules have been ingested since 2004. However, there are few published studies that summarize OMOM capsule endoscopy on complications, complete examination small bowel rate (CER), gastric transit time (GTT), and small bowel transit time (SBTT) with large sample. Methods: A database was retrieved from the Jianshan Science & Technology Ltd. OMOM CE Database. The 1,068 cases were from 17 endoscopy centers that used the OMOM CE system in Mainland China. The complications, complete small bowel examination rate (CER), gastric transit time (GTT), small bowel transit time (SBTT), and total work time were recorded and analyzed. Results: The major complication of OMOM CE was capsule retention, which were seen in 23 patients (esophageal 4, gastric 9, afferent loop 1, small bowel retention 9). The overall retention rate was 2.15%. Four capsules retained in the small bowel were surgically removed, and the remainders were successfully removed by gastroscopy or double balloon enteroscopy. The overall CER of OMOM CE was 82.68%. In the 185 patients with uncompleted examination, the delayed gastric emptying was the major cause (68 patients’ GTT O120 min, 36.8%). The CER was not related to the gender or age. The decrease in CER was positively related to the increase in GTT, and inversely related to the increase in total work time (TWT) of OMOM CE (Both p ! 0.001). The CER in the non-OGIB group was greater than OGIB group (78.5% vs. 86.5% p ! 0.001). The mean GTT, SBTT and TWT were 68 min (rang 1w543 min), 261 min (rang 27w690 min), and 468 min (rang 168w911 min), respectively. Conclusions: This is the first large report on OMOM capsule endoscopy, and the capsule retention rate is very low and comparable with that of Given PillCam capsule system. The complete small bowel examination rate was 82.6%, which was related to gastric transit time and total work time of OMOM capsule, but not related to gender and age.
T1632 Right Lateral Position Improves Complete Examination Rate of Capsule Endoscope: A Prospective Randomized, Controlled Trial Zhuan Liao, Feng Li, Zhao-Shen Li Background and Aim: It has been reported that capsule endoscopes (CE) fail to reach the cecum in 20% of patients within the 8-hour battery life. The delayed gastric transit is the most common causes of incomplete small bowel
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