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Double Balloon Enteroscopy (DBE) in the Elderly: Indications, Findings, and Agreement with Video Capsule Endoscopy
Abstracts
S1536 A Single Center Retrospective Review of Spiral Enteroscopy Sophie W. Esmail, Elizabeth Odstrcil, Damien Mallat, Daniel Demarco Background: Spiral enteroscopy (SE) is a relatively new method of small bowel visualization. Its safety and efficacy has been reported in the training setting. Our aim is to present a series of SE procedures performed by two operators at a single tertiary care referral center. Methods: A total of 57 patients between April and November 2008, 24 males and 33 females, mean age 60 (range 26-88 years), underwent SE. Indications included abnormal capsule endoscopy (40%), anemia (17%), obscure GI bleeding (14%), abdominal pain (10%), melena (8%), and abnormal imaging (3%). Less common indications were unexplained weight loss, chronic diarrhea, and recurrent small bowel obstruction. 25% of patients had altered anatomy, including Roux-en-Y gastric bypass (RYGB), small bowel resection, choledochojejunostomy, and a Whipple procedure. One procedure was performed as an ERCP in a patient with a known biliary stricture and stent. The device employed was the Discovery SB (Spirus Medical, Stoughton, MA), an overtube with a raised 5mm spiral on its distal end. The Discovery SB was used with either the Fujinon (EN-450T5) or the Olympus (SIF-Q180) enteroscopes. 77% of patients underwent deep sedation with propofol, and the remainder required general endotracheal anesthesia. Results: 54 procedures were successfully performed in 57 patients. Two procedures were unsuccessful due to sharp angulation in the stomach; one procedure was aborted due to respiratory instability. A mean estimated depth of 246 74 cm distal to the pylorus was achieved, corresponding to the proximal ileum. The excluded stomach was reached in 5 of the 7 patients with RYGB. Average total procedure time was 28 minutes. 16 distinct abnormalities of the small bowel were identified in 51% of the cases. Findings included: arteriovenous malformations (23%), lymphangectasia (5%), mucosal changes (3.5%), diverticuli (3.5%), an ileal and a biliary stricture, dilated jejunum, submucosal mass, polyps, afferent limb syndrome, excluded stomach gastritis, and adhesions. Interventions included 14 argon plasma coagulations, 8 biopsies, 8 India ink tattoos, 2 stricture dilations, and a biliary stent removal with stricture dilation. The overall complication rate was 7%. Two patients with a history of radiation enteritis had suspected perforation at the time of SE. Both patients underwent surgery and no perforations were identified. Conclusion: SE is emerging as a valuable tool not only in large academic centers, but also in tertiary care referral centers. Our data provides the first example that demonstrates the utility of SE in a community-based hospital setting. Caution is advised with a history of radiation enteritis.
S1537 Double Balloon Enteroscopy (DBE) in the Elderly: Indications, Findings, and Agreement with Video Capsule Endoscopy Sanjay R. Hegde, Kevan Iffrig, Sharon Downey, Stephen J. Heller, Jeffrey L. Tokar, Oleh Haluszka Introduction: DBE is useful in the diagnostic evaluation and treatment of obscure GI bleeding and small bowel pathology. Limited data are available on indications, findings and agreement between DBE and video capsule endoscopy (CE) in older patients. Aim: To evaluate the distribution of indications, findings and overall agreement of DBE with CE in patients according to age (! or O 75 years). Methods: Retrospective review of DBE procedures at our center between August 2007 and August 2008 in patients divided by age (! and O 75 years). Results: A total of 216 DBE procedures in 170 patients (87 male, 144 White) were reviewed. The mean age of patients studied was 66 þ/- 16.4 yrs. (range 20-95 yrs.). Within this group, 60 patients (79 procedures) were O age 75. The most common indications for DBE in patients O age 75 were obscure GI bleeding (96%) and abnormal CE (70.9%). The most common indications for DBE in patients ! age 75 were obscure GI bleeding (79.6%), abnormal CE (66.4%), and abnormal SBFT/CT/MRI (14.6%). A higher percentage of patients O age 75 were on anti-platelet medications (42% vs. 33.6%) and anti-coagulation therapy (26.7% vs. 11.8%) compared to patients ! age 75. The most common DBE findings in patients O age 75 were angioectasia (39%), erosion/ulcer (10.1%), and polyp/mass (9%). The most common DBE findings in patients ! age 75 were angioectasia (23%), polyp/mass (14%), and erosion/ulcer (11.5%). In patients O age 75 there was agreement between DBE findings and CE findings in 19/43 patients (44.1%). In patients ! age 75 there was agreement between DBE findings and CE findings in 23/72 patients (31.9%). Endoscopic therapy was indicated in 38/79 (48.1%) procedures for patients O age 75 and 45/137 (32.8%) procedures for patients ! age 75. Endoscopic therapy was successful in 32/38 (84.2%) cases for patients O age 75 and 34/45 (75.6%) for patients ! age 75. Conclusions: A greater percentage of patients O age 75 have angioectasias, and are more likely to require endoscopic therapy than younger patients, while patients ! age 75 have a higher percentage of polyps/mass lesions found on DBE. The agreement between findings on DBE and prior abnormal CE are relatively low in both age groups. In patients O 75 the greater likelihood of finding angioectasias requiring therapy suggests that an earlier role for DBE in elderly patients may be appropriate.
www.giejournal.org
S1538 Intra-Abnominal Air Recognized By Computed Tomography After Endoscopic Submucosal Dissection with Gastric Lesions Fumito Onogi, Hiroshi Araki, Takashi Ibuka, Kenji Yamazaki, Shinji Nishiwaki, Tomohiro Kato, Hisataka Moriwaki Introduction: Endoscopic submicosal dissection (ESD) has been established as a new treatment for gastrointesitinal lesions. However, it also has disadvantaged such as higher technical difficulty and risk of perforation or bleeding. We experienced the finding of small and focal air close to the stomach by computrd tomography (CT) after ESD, and defined it as ‘‘intra-abdominal microperforation’’. Aims and Methods: Two hundred and thirty consecutive cases with gastric lesion resected by ESD, between January, 2006 and July, 2008 in our constitution. They received CT scan and blood test shortly after ESD. The lesions were 193 early gastric cancers, 32 adenomas, 2 carcinoids and 2 hyperplastic polyps. Male to female ratio was 169: 61. The mean age was 71 years old (range 29-91). Lesion locations were U: 41/M: 86/L: 100/remaining stomach: 3 cases (Lesion location was categorized into upper third of stomach (‘‘U’’), middle third (‘‘M’’), and lower third (‘‘L’’), based on the Japanese classification of gastric carcinoma). We compared the outcome and clinical significance of intra-abnominal microperforation with gastric lesion. Results: Visible perforation during ESD occurred in two cases (0.9%) and delayed perforation occurred in one case (0.4%). Twenty nine cases had intra-abdominal microperforation (12.6%). We compared the group of intra-abdominal microperforation with the negative group. There was significant differences in the size of resected specimen, the duration of operation and the incidence of pyrexia(above 37.5 degrees after ESD), while there was no significant difference in the age, hospitalization, leukocyte count and C-reactive protein within 3 days postoperatively. No serious complication was observed in the case of perforation and intra-abdominal microperforation, respectively. The positive-cases could be classified into two types; those with microperforation completely distant from stomach (TypeA, 8 cases) and those with microperforation confined in the wall of the stomach under serosa (TypeB, 19 cases). In comparision between 2 types, there was no significant difference in either parameter (the age, the size of resected specimen, the duration of operation, hospitalization, pyrexia, the endoscopic findings at the end of ESD procedure, leukocyte count and C-reactive protein within 3 days postoperatively). Conclusion: We considers that pyrexia with longer time of treatment and larger size of resected specimen are predictors of intraabdominal microperforation but it is difficult to predict intra-abdominal microperforation after ESD with endoscopic findings. The cases with microperforation did not develop serious complications.
S1539 Single Balloon Enteroscopy: Low Incidence of Procedure Related Hyperamylasemia and Complications Huseyin Aktas, Peter Mensink, Jelle Haringsma, Ernst J. Kuipers Background: Single balloon enteroscopy (SBE) is relatively new technique for endoscopic visualization of the small bowel. Double balloon enteroscopy (DBE) has shown a complication rate of 0.8% and 4.3% for diagnostic and therapeutic procedures, respectively. The main concern after diagnostic DBE is acute pancreatitis, reported in 0.3% of cases. A relation with hyperamylasemia is suggested, and recent studies have shown a high prevalence after proximal DBE procedures. It is hypothesized that the DBE method increases intraluminal pressure and local friction of the ‘push-and-pull’ technique, both promoting pancreatic juice activation. About the complication rate of SBE little is known. The aim of this study was to evaluate the complication rate and occurrence of hyperamylasemia after SBE. Methods: Prospectively, consecutive patients undergoing a proximal SBE (Olympus XSIF-Q260Y) were evaluated. Serum amylase activity and CRP were assessed immediately before and 2-3 hours after SBE. Hyperamylasemia was defined as a serum amylase O99 U/l. Abdominal pain and complications were assessed directly and 30 days afterwards. Results In 15 months, 53 SBE procedures were performed: male 26, mean age 53 (17-79) years. In 31 (58%) patients only a proximal SBE procedure was performed and 22 (42%) patients had a combined procedure. The indications for the SBE were: anemia (nZ31), Crohn’s disease (nZ12), abdominal complaints (nZ2) and Peutz-Jeghers syndrome (nZ1). The mean proximal and distal insertion depth was 230 (60-330) and 100 (5-200) cm, respectively. In 30 patients abnormalities were found (11 angiodysplasia, 15 ulcerative lesions, 2 polyps, and 2 tumors). Therapy was performed in 11 SBE: 9 APC and 1 polypectomy. No major complications were noted. Complete serum measurements were performed in 46 patients. Eight (17%) patients had post-SBE hyperamylasemia. The mean serum amylase levels were: basal 63 U/l (SD 25,9) and post-SBE 84 U/l (SD 57,0; pZ0,02). Two (3%) patients reported abdominal pain after the procedure clinically suggestive for mild pancreatitis, both resolved on conservative treatment. Factors like sex, indication, duration, number of passes, route of SBE, findings and / or treatment showed no significant correlation with the presence of hyperamylasemia. The serum CRP level remained stable before and after SBE, within normal ranges. Conclusion SBE seems a safe endoscopic procedure with a low complication rate. The incidence of hyperamylasemia after proximal SBE procedures seems lower as compared to proximal DBE procedures (17% versus 46-51% as presented in literature). This lower incidence suggests less irritation of the pancreas by the SBE technique.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB197
S1536 A Single Center Retrospective Review of Spiral Enteroscopy Sophie W. Esmail, Elizabeth Odstrcil, Damien Mallat, Daniel Demarco Background: Spiral enteroscopy (SE) is a relatively new method of small bowel visualization. Its safety and efficacy has been reported in the training setting. Our aim is to present a series of SE procedures performed by two operators at a single tertiary care referral center. Methods: A total of 57 patients between April and November 2008, 24 males and 33 females, mean age 60 (range 26-88 years), underwent SE. Indications included abnormal capsule endoscopy (40%), anemia (17%), obscure GI bleeding (14%), abdominal pain (10%), melena (8%), and abnormal imaging (3%). Less common indications were unexplained weight loss, chronic diarrhea, and recurrent small bowel obstruction. 25% of patients had altered anatomy, including Roux-en-Y gastric bypass (RYGB), small bowel resection, choledochojejunostomy, and a Whipple procedure. One procedure was performed as an ERCP in a patient with a known biliary stricture and stent. The device employed was the Discovery SB (Spirus Medical, Stoughton, MA), an overtube with a raised 5mm spiral on its distal end. The Discovery SB was used with either the Fujinon (EN-450T5) or the Olympus (SIF-Q180) enteroscopes. 77% of patients underwent deep sedation with propofol, and the remainder required general endotracheal anesthesia. Results: 54 procedures were successfully performed in 57 patients. Two procedures were unsuccessful due to sharp angulation in the stomach; one procedure was aborted due to respiratory instability. A mean estimated depth of 246 74 cm distal to the pylorus was achieved, corresponding to the proximal ileum. The excluded stomach was reached in 5 of the 7 patients with RYGB. Average total procedure time was 28 minutes. 16 distinct abnormalities of the small bowel were identified in 51% of the cases. Findings included: arteriovenous malformations (23%), lymphangectasia (5%), mucosal changes (3.5%), diverticuli (3.5%), an ileal and a biliary stricture, dilated jejunum, submucosal mass, polyps, afferent limb syndrome, excluded stomach gastritis, and adhesions. Interventions included 14 argon plasma coagulations, 8 biopsies, 8 India ink tattoos, 2 stricture dilations, and a biliary stent removal with stricture dilation. The overall complication rate was 7%. Two patients with a history of radiation enteritis had suspected perforation at the time of SE. Both patients underwent surgery and no perforations were identified. Conclusion: SE is emerging as a valuable tool not only in large academic centers, but also in tertiary care referral centers. Our data provides the first example that demonstrates the utility of SE in a community-based hospital setting. Caution is advised with a history of radiation enteritis.
S1537 Double Balloon Enteroscopy (DBE) in the Elderly: Indications, Findings, and Agreement with Video Capsule Endoscopy Sanjay R. Hegde, Kevan Iffrig, Sharon Downey, Stephen J. Heller, Jeffrey L. Tokar, Oleh Haluszka Introduction: DBE is useful in the diagnostic evaluation and treatment of obscure GI bleeding and small bowel pathology. Limited data are available on indications, findings and agreement between DBE and video capsule endoscopy (CE) in older patients. Aim: To evaluate the distribution of indications, findings and overall agreement of DBE with CE in patients according to age (! or O 75 years). Methods: Retrospective review of DBE procedures at our center between August 2007 and August 2008 in patients divided by age (! and O 75 years). Results: A total of 216 DBE procedures in 170 patients (87 male, 144 White) were reviewed. The mean age of patients studied was 66 þ/- 16.4 yrs. (range 20-95 yrs.). Within this group, 60 patients (79 procedures) were O age 75. The most common indications for DBE in patients O age 75 were obscure GI bleeding (96%) and abnormal CE (70.9%). The most common indications for DBE in patients ! age 75 were obscure GI bleeding (79.6%), abnormal CE (66.4%), and abnormal SBFT/CT/MRI (14.6%). A higher percentage of patients O age 75 were on anti-platelet medications (42% vs. 33.6%) and anti-coagulation therapy (26.7% vs. 11.8%) compared to patients ! age 75. The most common DBE findings in patients O age 75 were angioectasia (39%), erosion/ulcer (10.1%), and polyp/mass (9%). The most common DBE findings in patients ! age 75 were angioectasia (23%), polyp/mass (14%), and erosion/ulcer (11.5%). In patients O age 75 there was agreement between DBE findings and CE findings in 19/43 patients (44.1%). In patients ! age 75 there was agreement between DBE findings and CE findings in 23/72 patients (31.9%). Endoscopic therapy was indicated in 38/79 (48.1%) procedures for patients O age 75 and 45/137 (32.8%) procedures for patients ! age 75. Endoscopic therapy was successful in 32/38 (84.2%) cases for patients O age 75 and 34/45 (75.6%) for patients ! age 75. Conclusions: A greater percentage of patients O age 75 have angioectasias, and are more likely to require endoscopic therapy than younger patients, while patients ! age 75 have a higher percentage of polyps/mass lesions found on DBE. The agreement between findings on DBE and prior abnormal CE are relatively low in both age groups. In patients O 75 the greater likelihood of finding angioectasias requiring therapy suggests that an earlier role for DBE in elderly patients may be appropriate.
www.giejournal.org
S1538 Intra-Abnominal Air Recognized By Computed Tomography After Endoscopic Submucosal Dissection with Gastric Lesions Fumito Onogi, Hiroshi Araki, Takashi Ibuka, Kenji Yamazaki, Shinji Nishiwaki, Tomohiro Kato, Hisataka Moriwaki Introduction: Endoscopic submicosal dissection (ESD) has been established as a new treatment for gastrointesitinal lesions. However, it also has disadvantaged such as higher technical difficulty and risk of perforation or bleeding. We experienced the finding of small and focal air close to the stomach by computrd tomography (CT) after ESD, and defined it as ‘‘intra-abdominal microperforation’’. Aims and Methods: Two hundred and thirty consecutive cases with gastric lesion resected by ESD, between January, 2006 and July, 2008 in our constitution. They received CT scan and blood test shortly after ESD. The lesions were 193 early gastric cancers, 32 adenomas, 2 carcinoids and 2 hyperplastic polyps. Male to female ratio was 169: 61. The mean age was 71 years old (range 29-91). Lesion locations were U: 41/M: 86/L: 100/remaining stomach: 3 cases (Lesion location was categorized into upper third of stomach (‘‘U’’), middle third (‘‘M’’), and lower third (‘‘L’’), based on the Japanese classification of gastric carcinoma). We compared the outcome and clinical significance of intra-abnominal microperforation with gastric lesion. Results: Visible perforation during ESD occurred in two cases (0.9%) and delayed perforation occurred in one case (0.4%). Twenty nine cases had intra-abdominal microperforation (12.6%). We compared the group of intra-abdominal microperforation with the negative group. There was significant differences in the size of resected specimen, the duration of operation and the incidence of pyrexia(above 37.5 degrees after ESD), while there was no significant difference in the age, hospitalization, leukocyte count and C-reactive protein within 3 days postoperatively. No serious complication was observed in the case of perforation and intra-abdominal microperforation, respectively. The positive-cases could be classified into two types; those with microperforation completely distant from stomach (TypeA, 8 cases) and those with microperforation confined in the wall of the stomach under serosa (TypeB, 19 cases). In comparision between 2 types, there was no significant difference in either parameter (the age, the size of resected specimen, the duration of operation, hospitalization, pyrexia, the endoscopic findings at the end of ESD procedure, leukocyte count and C-reactive protein within 3 days postoperatively). Conclusion: We considers that pyrexia with longer time of treatment and larger size of resected specimen are predictors of intraabdominal microperforation but it is difficult to predict intra-abdominal microperforation after ESD with endoscopic findings. The cases with microperforation did not develop serious complications.
S1539 Single Balloon Enteroscopy: Low Incidence of Procedure Related Hyperamylasemia and Complications Huseyin Aktas, Peter Mensink, Jelle Haringsma, Ernst J. Kuipers Background: Single balloon enteroscopy (SBE) is relatively new technique for endoscopic visualization of the small bowel. Double balloon enteroscopy (DBE) has shown a complication rate of 0.8% and 4.3% for diagnostic and therapeutic procedures, respectively. The main concern after diagnostic DBE is acute pancreatitis, reported in 0.3% of cases. A relation with hyperamylasemia is suggested, and recent studies have shown a high prevalence after proximal DBE procedures. It is hypothesized that the DBE method increases intraluminal pressure and local friction of the ‘push-and-pull’ technique, both promoting pancreatic juice activation. About the complication rate of SBE little is known. The aim of this study was to evaluate the complication rate and occurrence of hyperamylasemia after SBE. Methods: Prospectively, consecutive patients undergoing a proximal SBE (Olympus XSIF-Q260Y) were evaluated. Serum amylase activity and CRP were assessed immediately before and 2-3 hours after SBE. Hyperamylasemia was defined as a serum amylase O99 U/l. Abdominal pain and complications were assessed directly and 30 days afterwards. Results In 15 months, 53 SBE procedures were performed: male 26, mean age 53 (17-79) years. In 31 (58%) patients only a proximal SBE procedure was performed and 22 (42%) patients had a combined procedure. The indications for the SBE were: anemia (nZ31), Crohn’s disease (nZ12), abdominal complaints (nZ2) and Peutz-Jeghers syndrome (nZ1). The mean proximal and distal insertion depth was 230 (60-330) and 100 (5-200) cm, respectively. In 30 patients abnormalities were found (11 angiodysplasia, 15 ulcerative lesions, 2 polyps, and 2 tumors). Therapy was performed in 11 SBE: 9 APC and 1 polypectomy. No major complications were noted. Complete serum measurements were performed in 46 patients. Eight (17%) patients had post-SBE hyperamylasemia. The mean serum amylase levels were: basal 63 U/l (SD 25,9) and post-SBE 84 U/l (SD 57,0; pZ0,02). Two (3%) patients reported abdominal pain after the procedure clinically suggestive for mild pancreatitis, both resolved on conservative treatment. Factors like sex, indication, duration, number of passes, route of SBE, findings and / or treatment showed no significant correlation with the presence of hyperamylasemia. The serum CRP level remained stable before and after SBE, within normal ranges. Conclusion SBE seems a safe endoscopic procedure with a low complication rate. The incidence of hyperamylasemia after proximal SBE procedures seems lower as compared to proximal DBE procedures (17% versus 46-51% as presented in literature). This lower incidence suggests less irritation of the pancreas by the SBE technique.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB197