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Double-Balloon Enteroscopy: An Initial North American Experience
Abstracts
M1385 The Efficacy of Endoscopic Coagulation for Gastric Vascular Ectasia Fumie Rai, Yukinori Imai, Sayaka Nakashima, Shin Arai, Shinichi Ota, Kenji Fujiwara Background and Aim: In recent years there have been many reports that endoscopic thermal ablation, such as argon plasma coagulation (APC), is effective in controlling bleeding from gastric vascular ectasia (VE). However, the long-term efficacy of this treatment is not yet confirmed. The aim of this study is to assess the short-term and long-term effects of endoscopic coagulation for gastric VE. Subjects and Methods: The subjects were 26 cases with gastric VE that received endoscopic coagulation between 1997 and 2003. Single VE in 8 cases, several VEs in 4 cases, watermelon stomach in 4 cases, DAVE in 10 cases. Bleeding from the VE were confirmed during endoscopic observation in 12 patients. Other cases had also the episodes of GI bleeding. Thirteen cases were treated by heater probe unit (HPU; power 10-15 J) and 13 cases by APC (argon gas flow 1.0-1,2 L/min; power 60 W). We repeated endoscopic coagulation until the bleeding stopped and the VE disappeared. We observed the recurrent bleeding or recurrence of VE during follow-up. Results: In all cases of confirmed bleeding, hemostasis and the eradication of VE could be achieved in any cases. The mean follow up was 34 months. Among 12 cases with single or several VE, rebleeding occurred in 1 case with single VE. In 6 of 14 (43%) cases with multiple VEs, rebleeding occurred during follow up. In 5 of these 6 cases, the patients were complicated with chronic renal failure under gone hemodialysis. There was no difference in the results of HPU and APC treatment. Serious complication did not occur in any cases. Conclusion: The short-term results of endoscopic coagulation for gastric VE were good in any types. However, in cases of multiple VEs, especially complicated with chronic renal failure, the long-term efficacy of this therapy was not satisfactory.
M1387 Capsule Endoscopic Diagnosis of Extra-Intestinal Bleeding Samir K. Nath, Gottumukkala S. Raju Introduction & Aims: Unlike cable endoscopy, which requires sedation and distension of the lumen for visualization, CE provides imaging of the gut without disturbing its physiological state. It is unclear whether CE, designed primarily for small intestinal imaging, will be useful in the diagnosis of bleeding lesions in the stomach or colon that were not apparent to the cable endoscopy. We report the role of CE in 50 patients (pts) with obscure GI bleeding in the diagnosis of extraintestinal bleeding. Methods: CE reports & hospital charts of pts with obscure GI bleeding (2002-04) were reviewed to establish site of bleeding, etiology of bleeding, & CE indicators of bleeding & the outcome of these pts. Results: CE images of 50 pts (mean age: 67; range 39-90 years, M/F: 23/27) who underwent CE for diagnosis of obscure GI bleeding (overt n Z 20; occult with Hb ! 8 g/dl: n Z 3, Hb 8-11 g/dl: n Z 27) were reviewed. I. Bleeding Source was diagnosed in 15 of the 50 pts. In 4 pts the source of bleeding was present outside the small intestine: stomach (n Z 3) & colon (n Z 1). II. Etiology of Extra-intestinal Bleeding: a) Stomach: GAVE (n Z 1), Dielaufoy’s lesion (DL) (n Z 2) c) Colon: Cecal AVM (n Z 1). III. CE Findings Suspicious for Extra-intestinal Bleeding: Flecks of heme or blood clots in the stomach (n Z 2), fresh blood in the duodenum with normal stomach (n Z 1), blood in the cecum without any blood in the small intestine provided clues for extra-intestinal source of bleeding. IV. Specific Diagnosis: i. GAVE: At EGD, it was initially misdiagnosed as hemorrhagic gastritis. Capillary blanching & refilling along with active bleeding from the pylorus as the CE exited the stomach confirmed the diagnosis of GAVE. ii. Gastric DL: Of the two pts, in one CE identified the lesion. In the other, presence of old blood in the duodenum lead to suspicion of a gastric source of bleeding on repeat endoscopy actively bleeding DL was identified. iii. Cecal AVMs: Bleeding from the cecum was identified on a 3rd CE; cecal AVMs were identified at colonoscopy (narcotics were avoided for sedation) after injection of nalaxone. V. Outcome: Endoscopic therapy controlled bleeding and there was no recurrence of bleeding during a follow-up of 6-12 moths. Conclusions: Capsule endoscopy is useful in the diagnosis of extraintestinal bleeding and search for lesions should not be limited to the small intestine alone during capsule endoscopic review.
M1386 Capsule Endoscopic Imaging of the Colon Is Not Ready for Prime Time: Lookout for a Better Prep Aaron M. Harvey, Samir K. Nath, Gottumukkala S. Raju Introduction: While capsule endoscopy (CE) is being embraced as the imaging of choice for evaluation of small intestine, developmental work is being undertaken to expand it’s role in imaging the esophagus and colon. Although drinking Golytely provides excellent imaging at colonoscopy, it is unclear whether this preparation would be adequate for CE, since the CE, unlike the cable endoscopy, lacks the ability to clear any debris by suction. Aim: To evaluate the quality of CE imaging after one gallon of Golytely prep. Methods: This is a retrospective review of 50 CE of patients that drank 1 gallon of Golytely the night before CE. Five minute CE video segments from the stomach, duodenum, terminal ileum, and 3 segments in between the duodenum and terminal ileum, and colon were evaluated for the quality of imaging in a randomly assigned fashion by a single observer. Interobserver agreement was determined by 2 experienced endoscopists who both independently reviewed 96 random segments - good (k .622; k .528; k .534). Statistics: Standard Z-tests were used to compare the proportion of satisfactory preparations in the colon to the segments of the SI. Results: Quality of CE imaging of the colon was unsatisfactory in the majority of patients (96%). Although the quality of imaging of the SI was satisfactory after Golytely preparation, there was a trend for an increase in unsatisfactory examinations towards the distal SI. The proportion of satisfactory preparations in the colon was significantly less compared to the segments of the gastrointestinal tract visualized proximal to it (p ! .0001). Conclusion: CE imaging of the colon is poor after cleaning it with a gallon of Golytely the evening before the procedure. Further work is needed to improve the quality of imaging either by the use of better agents to clean the colon or by the incorporation of mechanisms in the capsule to clear the debris.
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M1388 Double-Balloon Enteroscopy: An Initial North American Experience Matthew Remedios, Gregory Monkewich, Nancy Basset, Gabor Kandel, Paul Kortan, Gary May, Hironori Yamamoto, Norman Marcon Unlike conventional (push) enteroscopy, double-balloon enteroscopy (DBE) offers the potential for complete small bowel (SB) examination and treatment of previously inaccessible lesions. Reports on the utility and safety of this emerging technique are largely limited to the Japanese experience. Aim: To assess the technical and clinical outcomes of patients undergoing DBE in a North American setting. Methods: The charts of twenty patients (mean age 57 y [range 34-81]; 10 males) who underwent a total of 28 DBE (Fujinon EN 450P 5/20, EN 450T5) procedures were retrospectively reviewed. Enteroscopic approaches were antegrade in 17 and retrograde in 11 (two via ileostomy). Six patients had combined approaches (2 of them had an additional DBE). Indications for DBE were suspected/known SB bleeding lesions (18 pts), abnormal SB x-ray (1 pt) and polyposis syndrome (1 pt). Capsule endoscopy had previously been performed in 17 patients. Results: In all DBE cases, endoscope insertion into the SB was judged to be significantly deeper than with standard techniques, including push enteroscopy. Complete enteroscopy was achieved in one of the six patients who underwent a combined approach. The mean duration of a procedure was 3 h (range 1.2-4.9 h). Factors predictive of technical difficultly included previous laparotomy and obesity. DBE for SB pathologies was diagnostic in 15/20 patients (75%), which included small bowel tumors/polyp (3 pts), vascular ectasias (5 pts), ulcers (4 pts), Dieulafoy lesion (1 pt), radiation enteritis (1 pt) and celiac disease (1 pt). DBE identified all abnormal capsule findings. An ileal carcinoid tumor, missed by capsule, was easily visualized at DBE. Endoscopic therapy was performed in 8/20 patients (40%) including coagulation (6 pts), hemoclip placement (1 pt) and polypectomy (1 pt). Tattooing of neoplastic lesions in 2 patients during DBE facilitated their localization at subsequent surgery. There were no major procedure-related complications. In the 18 patients with gastrointestinal bleeding, transfusion requirements were a mean of 20 units (range 2-100) in the 12 months prior to DBE. After DBE, only 3 patients required ongoing transfusions. Conclusions: DBE is a useful tool for the diagnosis and/or management of small bowel lesions beyond the reach of conventional endoscopes, or following a positive capsule endoscopy.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB179
M1385 The Efficacy of Endoscopic Coagulation for Gastric Vascular Ectasia Fumie Rai, Yukinori Imai, Sayaka Nakashima, Shin Arai, Shinichi Ota, Kenji Fujiwara Background and Aim: In recent years there have been many reports that endoscopic thermal ablation, such as argon plasma coagulation (APC), is effective in controlling bleeding from gastric vascular ectasia (VE). However, the long-term efficacy of this treatment is not yet confirmed. The aim of this study is to assess the short-term and long-term effects of endoscopic coagulation for gastric VE. Subjects and Methods: The subjects were 26 cases with gastric VE that received endoscopic coagulation between 1997 and 2003. Single VE in 8 cases, several VEs in 4 cases, watermelon stomach in 4 cases, DAVE in 10 cases. Bleeding from the VE were confirmed during endoscopic observation in 12 patients. Other cases had also the episodes of GI bleeding. Thirteen cases were treated by heater probe unit (HPU; power 10-15 J) and 13 cases by APC (argon gas flow 1.0-1,2 L/min; power 60 W). We repeated endoscopic coagulation until the bleeding stopped and the VE disappeared. We observed the recurrent bleeding or recurrence of VE during follow-up. Results: In all cases of confirmed bleeding, hemostasis and the eradication of VE could be achieved in any cases. The mean follow up was 34 months. Among 12 cases with single or several VE, rebleeding occurred in 1 case with single VE. In 6 of 14 (43%) cases with multiple VEs, rebleeding occurred during follow up. In 5 of these 6 cases, the patients were complicated with chronic renal failure under gone hemodialysis. There was no difference in the results of HPU and APC treatment. Serious complication did not occur in any cases. Conclusion: The short-term results of endoscopic coagulation for gastric VE were good in any types. However, in cases of multiple VEs, especially complicated with chronic renal failure, the long-term efficacy of this therapy was not satisfactory.
M1387 Capsule Endoscopic Diagnosis of Extra-Intestinal Bleeding Samir K. Nath, Gottumukkala S. Raju Introduction & Aims: Unlike cable endoscopy, which requires sedation and distension of the lumen for visualization, CE provides imaging of the gut without disturbing its physiological state. It is unclear whether CE, designed primarily for small intestinal imaging, will be useful in the diagnosis of bleeding lesions in the stomach or colon that were not apparent to the cable endoscopy. We report the role of CE in 50 patients (pts) with obscure GI bleeding in the diagnosis of extraintestinal bleeding. Methods: CE reports & hospital charts of pts with obscure GI bleeding (2002-04) were reviewed to establish site of bleeding, etiology of bleeding, & CE indicators of bleeding & the outcome of these pts. Results: CE images of 50 pts (mean age: 67; range 39-90 years, M/F: 23/27) who underwent CE for diagnosis of obscure GI bleeding (overt n Z 20; occult with Hb ! 8 g/dl: n Z 3, Hb 8-11 g/dl: n Z 27) were reviewed. I. Bleeding Source was diagnosed in 15 of the 50 pts. In 4 pts the source of bleeding was present outside the small intestine: stomach (n Z 3) & colon (n Z 1). II. Etiology of Extra-intestinal Bleeding: a) Stomach: GAVE (n Z 1), Dielaufoy’s lesion (DL) (n Z 2) c) Colon: Cecal AVM (n Z 1). III. CE Findings Suspicious for Extra-intestinal Bleeding: Flecks of heme or blood clots in the stomach (n Z 2), fresh blood in the duodenum with normal stomach (n Z 1), blood in the cecum without any blood in the small intestine provided clues for extra-intestinal source of bleeding. IV. Specific Diagnosis: i. GAVE: At EGD, it was initially misdiagnosed as hemorrhagic gastritis. Capillary blanching & refilling along with active bleeding from the pylorus as the CE exited the stomach confirmed the diagnosis of GAVE. ii. Gastric DL: Of the two pts, in one CE identified the lesion. In the other, presence of old blood in the duodenum lead to suspicion of a gastric source of bleeding on repeat endoscopy actively bleeding DL was identified. iii. Cecal AVMs: Bleeding from the cecum was identified on a 3rd CE; cecal AVMs were identified at colonoscopy (narcotics were avoided for sedation) after injection of nalaxone. V. Outcome: Endoscopic therapy controlled bleeding and there was no recurrence of bleeding during a follow-up of 6-12 moths. Conclusions: Capsule endoscopy is useful in the diagnosis of extraintestinal bleeding and search for lesions should not be limited to the small intestine alone during capsule endoscopic review.
M1386 Capsule Endoscopic Imaging of the Colon Is Not Ready for Prime Time: Lookout for a Better Prep Aaron M. Harvey, Samir K. Nath, Gottumukkala S. Raju Introduction: While capsule endoscopy (CE) is being embraced as the imaging of choice for evaluation of small intestine, developmental work is being undertaken to expand it’s role in imaging the esophagus and colon. Although drinking Golytely provides excellent imaging at colonoscopy, it is unclear whether this preparation would be adequate for CE, since the CE, unlike the cable endoscopy, lacks the ability to clear any debris by suction. Aim: To evaluate the quality of CE imaging after one gallon of Golytely prep. Methods: This is a retrospective review of 50 CE of patients that drank 1 gallon of Golytely the night before CE. Five minute CE video segments from the stomach, duodenum, terminal ileum, and 3 segments in between the duodenum and terminal ileum, and colon were evaluated for the quality of imaging in a randomly assigned fashion by a single observer. Interobserver agreement was determined by 2 experienced endoscopists who both independently reviewed 96 random segments - good (k .622; k .528; k .534). Statistics: Standard Z-tests were used to compare the proportion of satisfactory preparations in the colon to the segments of the SI. Results: Quality of CE imaging of the colon was unsatisfactory in the majority of patients (96%). Although the quality of imaging of the SI was satisfactory after Golytely preparation, there was a trend for an increase in unsatisfactory examinations towards the distal SI. The proportion of satisfactory preparations in the colon was significantly less compared to the segments of the gastrointestinal tract visualized proximal to it (p ! .0001). Conclusion: CE imaging of the colon is poor after cleaning it with a gallon of Golytely the evening before the procedure. Further work is needed to improve the quality of imaging either by the use of better agents to clean the colon or by the incorporation of mechanisms in the capsule to clear the debris.
www.mosby.com/gie
M1388 Double-Balloon Enteroscopy: An Initial North American Experience Matthew Remedios, Gregory Monkewich, Nancy Basset, Gabor Kandel, Paul Kortan, Gary May, Hironori Yamamoto, Norman Marcon Unlike conventional (push) enteroscopy, double-balloon enteroscopy (DBE) offers the potential for complete small bowel (SB) examination and treatment of previously inaccessible lesions. Reports on the utility and safety of this emerging technique are largely limited to the Japanese experience. Aim: To assess the technical and clinical outcomes of patients undergoing DBE in a North American setting. Methods: The charts of twenty patients (mean age 57 y [range 34-81]; 10 males) who underwent a total of 28 DBE (Fujinon EN 450P 5/20, EN 450T5) procedures were retrospectively reviewed. Enteroscopic approaches were antegrade in 17 and retrograde in 11 (two via ileostomy). Six patients had combined approaches (2 of them had an additional DBE). Indications for DBE were suspected/known SB bleeding lesions (18 pts), abnormal SB x-ray (1 pt) and polyposis syndrome (1 pt). Capsule endoscopy had previously been performed in 17 patients. Results: In all DBE cases, endoscope insertion into the SB was judged to be significantly deeper than with standard techniques, including push enteroscopy. Complete enteroscopy was achieved in one of the six patients who underwent a combined approach. The mean duration of a procedure was 3 h (range 1.2-4.9 h). Factors predictive of technical difficultly included previous laparotomy and obesity. DBE for SB pathologies was diagnostic in 15/20 patients (75%), which included small bowel tumors/polyp (3 pts), vascular ectasias (5 pts), ulcers (4 pts), Dieulafoy lesion (1 pt), radiation enteritis (1 pt) and celiac disease (1 pt). DBE identified all abnormal capsule findings. An ileal carcinoid tumor, missed by capsule, was easily visualized at DBE. Endoscopic therapy was performed in 8/20 patients (40%) including coagulation (6 pts), hemoclip placement (1 pt) and polypectomy (1 pt). Tattooing of neoplastic lesions in 2 patients during DBE facilitated their localization at subsequent surgery. There were no major procedure-related complications. In the 18 patients with gastrointestinal bleeding, transfusion requirements were a mean of 20 units (range 2-100) in the 12 months prior to DBE. After DBE, only 3 patients required ongoing transfusions. Conclusions: DBE is a useful tool for the diagnosis and/or management of small bowel lesions beyond the reach of conventional endoscopes, or following a positive capsule endoscopy.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB179