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Sa1188 Age Over 65 Is Independently Associated With Successful Diagnostic Double Balloon Enteroscopy
Sa1188
AGA Abstracts
Age Over 65 Is Independently Associated With Successful Diagnostic Double Balloon Enteroscopy Kian Makipour, Ronald Andari Sawaya, Alexandra N. Modiri, Frank K. Friedenberg, Brintha K. Enestvedt, Jennifer Maranki, Oleh Haluszka Double Balloon Enteroscopy (DBE) is used to diagnose and treat both occult and overt obscure gastrointestinal (GI) bleeding. DBE is labor intensive, is only offered in a limited number of centers, and is frequently unrevealing. Factors predictive of a successful diagnostic DBE are needed to guide application of this invasive procedure. We aimed to identify independent predictors of a diagnostic DBE in a large referral population. Methods: All consecutive antegrade and retrograde DBE exams performed for the evaluation of obscure or overt GI bleeding at a single academic tertiary referral center from July 2011 to November 2012 were retrospectively reviewed. The primary outcome was the presence of an endoscopic finding identified on DBE that explains the clinical bleeding (diagnostic yield). Route of DBE (antegrade vs retrograde) was determined by the clinical presentation. Data collected included patient demographics (age dichotomized at 65), body mass index (BMI), duration and time of procedure (AM or PM), fellow involvement, DBE route, and prior abdominal surgery. Multivariate logistic regression was performed to determine independent factors associated with a successful diagnostic DBE. Results: There were 106 patients (mean age 46.9± 30.0 years, 65 female) who underwent DBE (89 antegrade, 36 retrograde, 17 both routes). Negative prior video capsule endoscopy was reported in 71 patients. Bidirectional endoscopy reports were available in the chart for only 77 patients and were negative. The most common indication for DBE was unexplained iron deficiency anemia (n=34) followed by melena (n=23). Forty five (42.5%) DBE exams identified a lesion which explained the clinical bleeding. The most common finding was small bowel angiodysplasia (n=34, 75.6% of findings). The diagnostic yield was similar for antegrade and retrograde exams (45.1 vs. 44.4% respectively). Successful diagnostic DBE studies occurred with similar frequency in the setting of occult and overt bleeding indications (p .0.05). In multivariate analysis, age . 65 was an independent factor associated with identifying a source of bleeding on DBE (adjusted OR =3.50; 1.47-8.35). Gender, BMI, previous abdominal surgery, duration of procedure, time of procedure (AM or PM) and fellow involvement were not significant independent predictors. The diagnostic yield in those age . 65 vs. , 65 was significant (59.5% vs. 31.3%; p = 0.04). Conclusions: In a large tertiary care referral center DBE performed for the evaluation of obscure GI bleeding had a diagnostic yield of 42.5%. Age . 65 was an independent predictor of a successful DBE exam. DBE should be strongly considered in the evaluation of obscure bleeding in patients . 65 years old.
Figure 1: Findings on spiral enteroscopy of gastric bypass patients with chronic abdominal pain (peptic ulcer disease and gastritis were noted in excluded stomach and duodenum). Sa1190 Double Balloon Enteroscopy (Case Series): An Effective and Minimally Invasive Method for Removal of Retained Video Capsules Kian Makipour, Alexandra N. Modiri, Ronald Andari Sawaya, Peter Shue, Frank K. Friedenberg, Jennifer Maranki, Brintha K. Enestvedt, Oleh Haluszka BACKGROUND: The most significant complication associated with video capsule endoscopy is symptomatic retention of the video capsule. Prior case series document removal of the capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules is limited. OBJECTIVE: To determine the etiologies of video capsule retention and to describe a highly efficacious and minimally invasive endoscopic method of retrieval using double balloon enteroscopy (DBE).. METHODS: A retrospective case series examination was performed on eight patients who underwent double balloon enteroscopy for retrieval of a retained video capsule at a large tertiary referral academic center between May 2007 to November 2012. Retained video capsules were retrieved using a roth net. Data collected included patient demographics, prior inflammatory bowel disease (IBD) diagnosis, use of non-steroidal (NSAID) medications, endoscopic location of capsule and success rate of capsule retrieval. RESULTS: Of, the total 1,399 patients who underwent DBE during the study time frame, eight were performed for the indication of video capsule retrieval. The mean age of these 8 patients was 64 ± 7 (3 female, 5 male). Four patients failed to pass the video capsule due to an ileal or jejunal stricture due to an established diagnosis of IBD with prior surgery (1 patient with ulcerative colitis; 3 patients with Crohn's disease); two patients had a small bowel stricture due to NSAID enteropathy; and 1 patient was identified to have an obstructing malignant jejunal mass. Only 1 patient reported abdominal pain due to the retained capsule. This patient was found to have an ileal stricture due to suspected Crohn's disease. All patients underwent DBE for attempted endoscopic removal of the retained capsule. Four patients underwent both upper and lower double balloon enteroscopy resulting in one successful panenteroscopy. Endoscopic removal via DBE was successful in six out of eight patients (75%). The remaining two patients, both of whom had a history of prior abdominal surgery, underwent surgical removal of the retained capsule. No deaths or complications were associated with these endoscopic procedures. CONCLUSION: The most common cause of capsule retention in this study was underlying inflammatory bowel disease, followed by use of NSAID enteropathy. Retained video capsule is a rare but significant complication of video capsule endoscopy. DBE appears to be an effective and minimally invasive means of capsule retrieval.
Sa1189 Use of Spiral Enteroscopy for Evaluation of Chronic Abdominal Pain in Patients After Gastric Bypass Surgery. Deepthi Deconda, Paul A. Akerman Background: Spiral enteroscopy is a novel technique for deep small bowel enteroscopy and has enabled us to reliably examine the entire small bowel including the excluded stomach in the gastric bypass patient. Chronic abdominal pain occurs in approximately 15-30% of patients after gastric bypass surgery. The most common causes of abdominal pain are intussusception, internal hernias, biliary disorders, disorders of the excluded stomach or pouch and stenosis of the anastomosis. Deep enteroscopy techniques to visualize the anastomosis, roux en y limb and the excluded stomach and duodenum are often considered to rule out causes of chronic abdominal pain and the utility of deep enteroscopy in these patients has not been determined. Objective: The aim of this study was to determine the utility of spiral enteroscopy in gastric bypass patients with chronic abdominal pain of unknown etiology. Methods: This was a retrospective chart review study of cases performed by the principle investigator in 2 institutions. All patients with history of gastric bypass who had a spiral enteroscopy for evaluation of abdominal pain between January 2008 and November 2012 were identified by query of the endoscopy database. We then reviewed the results to assess if spiral enteroscopy was successful in identifying the cause of abdominal pain. Results: Seventeen patients were identified. Majority (94%) were female with a mean age of 43.4 years. Spiral enteroscopy was performed at a mean of 4 years after the bypass surgery. All patients had radiologic imaging (86% CT scan, 6% ultrasound and 6% upper gastrointestinal series) and 53% had endoscopic workup before referral for a spiral enteroscopy. CT scan done for evaluation of abdominal pain prompted referral in 5 cases, when suspicious for small bowel thickening, intususseption, gastric mass and a perforated ulcer causing liver abscess. Roux-en-Y anastomosis was reached in 94% of patients; excluded stomach could not be examined in only 2 patients. Findings are shown in figure 1. Biopsies were performed in 86% of the patients. No Helicobacter pylori was identified. Gastritis and reactive changes were noted in .50% of cases. No complications occurred. Conclusions: Spiral enteroscopy enabled complete endoscopic evaluation of the surgically altered small bowel and the excluded stomach in 88% (15/17) of the patients. When spiral enteroscopy was performed after a nondiagnostic work up, significant pathologic findings were found in 76% (13/17) of patients. Deep enteroscopy using the spiral enteroscopy technique is useful for diagnosis and to guide therapy in the majority of patients with chronic abdominal pain after gastric bypass surgery. Spiral enteroscopy should be considered in the diagnostic algorithm of gastric bypass surgery patients with chronic abdominal pain of uncertain etiology.
AGA Abstracts
Sa1191 The Volume of Remnant Pancreas After Pancreatectomy Is More Closely Associated With Postoperative Pancreatic Exocrine Insufficiency Naoya Nakagawa, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Yasushi Hashimoto, Naru Kondo, Taijiro Sueda Introduction: Several published studies have reported that pancreatic exocrine function after pancreatectomy depends on disease (pancreatic cancer and chronic pancreatitis), pancreatic parenchymal thickness at the presumed resection line, location of pancreatic resection, type of pancreaticogansrointestinal anastomosis reconstruction and degree of fibrosis in the pancreatic remnant. Our objective was to measure the volume of remnant pancreas (RP) to determine the effect of pancreatoduodenectomy (PD) and distal pancreatectomy (DP) on pancreatic exocrine function. Methods: A 13C-labeled mixed triglyceride breath test was performed in 231 patients after PD and DP to assess postoperative exocrine pancreatic function. A value of percent 13CO2 cumulative dose at 7 h (%CD-7h) of less than 5% was considered diagnostic of pancreatic exocrine insufficiency (PEI). The volume of remnant pancreas was calculated using enhanced computed tomography (CT) scans. Results: The mean follow-up time for PD and DP were 17.1±1.5 and 15.2±2.7 months, respectively (P = .543). A hundred twenty-nine (55.8%) of 231 patients were found to have PEI based on the breath test (64.0% if PD, 28.3% if DP, P , .001). The mean volume of RP was 21.8±1.1ml (15.5±1.0ml if PD, 33.7±1.4ml if DP, P , .001). At correlation analysis between the %CD7h and RP, the volume of RP after PD and DP was significantly correlated with the %CD7h (R2 = .305, P , .001). A Small volume of RP increased subsequent risk of PEI in a univariate analysis (P , .001). According to multivariate analysis, a small volume of RP was an independent risk factor for postoperative PEI (odds ratio 8.12; 95% confidence interval 3.37-21.0, P , .001). Conclusions: The volume of remnant pancreas after PD and DP is more closely associated with postoperative pancreatic exocrine insufficiency.
S-224
AGA Abstracts
Age Over 65 Is Independently Associated With Successful Diagnostic Double Balloon Enteroscopy Kian Makipour, Ronald Andari Sawaya, Alexandra N. Modiri, Frank K. Friedenberg, Brintha K. Enestvedt, Jennifer Maranki, Oleh Haluszka Double Balloon Enteroscopy (DBE) is used to diagnose and treat both occult and overt obscure gastrointestinal (GI) bleeding. DBE is labor intensive, is only offered in a limited number of centers, and is frequently unrevealing. Factors predictive of a successful diagnostic DBE are needed to guide application of this invasive procedure. We aimed to identify independent predictors of a diagnostic DBE in a large referral population. Methods: All consecutive antegrade and retrograde DBE exams performed for the evaluation of obscure or overt GI bleeding at a single academic tertiary referral center from July 2011 to November 2012 were retrospectively reviewed. The primary outcome was the presence of an endoscopic finding identified on DBE that explains the clinical bleeding (diagnostic yield). Route of DBE (antegrade vs retrograde) was determined by the clinical presentation. Data collected included patient demographics (age dichotomized at 65), body mass index (BMI), duration and time of procedure (AM or PM), fellow involvement, DBE route, and prior abdominal surgery. Multivariate logistic regression was performed to determine independent factors associated with a successful diagnostic DBE. Results: There were 106 patients (mean age 46.9± 30.0 years, 65 female) who underwent DBE (89 antegrade, 36 retrograde, 17 both routes). Negative prior video capsule endoscopy was reported in 71 patients. Bidirectional endoscopy reports were available in the chart for only 77 patients and were negative. The most common indication for DBE was unexplained iron deficiency anemia (n=34) followed by melena (n=23). Forty five (42.5%) DBE exams identified a lesion which explained the clinical bleeding. The most common finding was small bowel angiodysplasia (n=34, 75.6% of findings). The diagnostic yield was similar for antegrade and retrograde exams (45.1 vs. 44.4% respectively). Successful diagnostic DBE studies occurred with similar frequency in the setting of occult and overt bleeding indications (p .0.05). In multivariate analysis, age . 65 was an independent factor associated with identifying a source of bleeding on DBE (adjusted OR =3.50; 1.47-8.35). Gender, BMI, previous abdominal surgery, duration of procedure, time of procedure (AM or PM) and fellow involvement were not significant independent predictors. The diagnostic yield in those age . 65 vs. , 65 was significant (59.5% vs. 31.3%; p = 0.04). Conclusions: In a large tertiary care referral center DBE performed for the evaluation of obscure GI bleeding had a diagnostic yield of 42.5%. Age . 65 was an independent predictor of a successful DBE exam. DBE should be strongly considered in the evaluation of obscure bleeding in patients . 65 years old.
Figure 1: Findings on spiral enteroscopy of gastric bypass patients with chronic abdominal pain (peptic ulcer disease and gastritis were noted in excluded stomach and duodenum). Sa1190 Double Balloon Enteroscopy (Case Series): An Effective and Minimally Invasive Method for Removal of Retained Video Capsules Kian Makipour, Alexandra N. Modiri, Ronald Andari Sawaya, Peter Shue, Frank K. Friedenberg, Jennifer Maranki, Brintha K. Enestvedt, Oleh Haluszka BACKGROUND: The most significant complication associated with video capsule endoscopy is symptomatic retention of the video capsule. Prior case series document removal of the capsules predominantly via surgical intervention. Data on endoscopic removal of retained capsules is limited. OBJECTIVE: To determine the etiologies of video capsule retention and to describe a highly efficacious and minimally invasive endoscopic method of retrieval using double balloon enteroscopy (DBE).. METHODS: A retrospective case series examination was performed on eight patients who underwent double balloon enteroscopy for retrieval of a retained video capsule at a large tertiary referral academic center between May 2007 to November 2012. Retained video capsules were retrieved using a roth net. Data collected included patient demographics, prior inflammatory bowel disease (IBD) diagnosis, use of non-steroidal (NSAID) medications, endoscopic location of capsule and success rate of capsule retrieval. RESULTS: Of, the total 1,399 patients who underwent DBE during the study time frame, eight were performed for the indication of video capsule retrieval. The mean age of these 8 patients was 64 ± 7 (3 female, 5 male). Four patients failed to pass the video capsule due to an ileal or jejunal stricture due to an established diagnosis of IBD with prior surgery (1 patient with ulcerative colitis; 3 patients with Crohn's disease); two patients had a small bowel stricture due to NSAID enteropathy; and 1 patient was identified to have an obstructing malignant jejunal mass. Only 1 patient reported abdominal pain due to the retained capsule. This patient was found to have an ileal stricture due to suspected Crohn's disease. All patients underwent DBE for attempted endoscopic removal of the retained capsule. Four patients underwent both upper and lower double balloon enteroscopy resulting in one successful panenteroscopy. Endoscopic removal via DBE was successful in six out of eight patients (75%). The remaining two patients, both of whom had a history of prior abdominal surgery, underwent surgical removal of the retained capsule. No deaths or complications were associated with these endoscopic procedures. CONCLUSION: The most common cause of capsule retention in this study was underlying inflammatory bowel disease, followed by use of NSAID enteropathy. Retained video capsule is a rare but significant complication of video capsule endoscopy. DBE appears to be an effective and minimally invasive means of capsule retrieval.
Sa1189 Use of Spiral Enteroscopy for Evaluation of Chronic Abdominal Pain in Patients After Gastric Bypass Surgery. Deepthi Deconda, Paul A. Akerman Background: Spiral enteroscopy is a novel technique for deep small bowel enteroscopy and has enabled us to reliably examine the entire small bowel including the excluded stomach in the gastric bypass patient. Chronic abdominal pain occurs in approximately 15-30% of patients after gastric bypass surgery. The most common causes of abdominal pain are intussusception, internal hernias, biliary disorders, disorders of the excluded stomach or pouch and stenosis of the anastomosis. Deep enteroscopy techniques to visualize the anastomosis, roux en y limb and the excluded stomach and duodenum are often considered to rule out causes of chronic abdominal pain and the utility of deep enteroscopy in these patients has not been determined. Objective: The aim of this study was to determine the utility of spiral enteroscopy in gastric bypass patients with chronic abdominal pain of unknown etiology. Methods: This was a retrospective chart review study of cases performed by the principle investigator in 2 institutions. All patients with history of gastric bypass who had a spiral enteroscopy for evaluation of abdominal pain between January 2008 and November 2012 were identified by query of the endoscopy database. We then reviewed the results to assess if spiral enteroscopy was successful in identifying the cause of abdominal pain. Results: Seventeen patients were identified. Majority (94%) were female with a mean age of 43.4 years. Spiral enteroscopy was performed at a mean of 4 years after the bypass surgery. All patients had radiologic imaging (86% CT scan, 6% ultrasound and 6% upper gastrointestinal series) and 53% had endoscopic workup before referral for a spiral enteroscopy. CT scan done for evaluation of abdominal pain prompted referral in 5 cases, when suspicious for small bowel thickening, intususseption, gastric mass and a perforated ulcer causing liver abscess. Roux-en-Y anastomosis was reached in 94% of patients; excluded stomach could not be examined in only 2 patients. Findings are shown in figure 1. Biopsies were performed in 86% of the patients. No Helicobacter pylori was identified. Gastritis and reactive changes were noted in .50% of cases. No complications occurred. Conclusions: Spiral enteroscopy enabled complete endoscopic evaluation of the surgically altered small bowel and the excluded stomach in 88% (15/17) of the patients. When spiral enteroscopy was performed after a nondiagnostic work up, significant pathologic findings were found in 76% (13/17) of patients. Deep enteroscopy using the spiral enteroscopy technique is useful for diagnosis and to guide therapy in the majority of patients with chronic abdominal pain after gastric bypass surgery. Spiral enteroscopy should be considered in the diagnostic algorithm of gastric bypass surgery patients with chronic abdominal pain of uncertain etiology.
AGA Abstracts
Sa1191 The Volume of Remnant Pancreas After Pancreatectomy Is More Closely Associated With Postoperative Pancreatic Exocrine Insufficiency Naoya Nakagawa, Yoshiaki Murakami, Kenichiro Uemura, Takeshi Sudo, Yasushi Hashimoto, Naru Kondo, Taijiro Sueda Introduction: Several published studies have reported that pancreatic exocrine function after pancreatectomy depends on disease (pancreatic cancer and chronic pancreatitis), pancreatic parenchymal thickness at the presumed resection line, location of pancreatic resection, type of pancreaticogansrointestinal anastomosis reconstruction and degree of fibrosis in the pancreatic remnant. Our objective was to measure the volume of remnant pancreas (RP) to determine the effect of pancreatoduodenectomy (PD) and distal pancreatectomy (DP) on pancreatic exocrine function. Methods: A 13C-labeled mixed triglyceride breath test was performed in 231 patients after PD and DP to assess postoperative exocrine pancreatic function. A value of percent 13CO2 cumulative dose at 7 h (%CD-7h) of less than 5% was considered diagnostic of pancreatic exocrine insufficiency (PEI). The volume of remnant pancreas was calculated using enhanced computed tomography (CT) scans. Results: The mean follow-up time for PD and DP were 17.1±1.5 and 15.2±2.7 months, respectively (P = .543). A hundred twenty-nine (55.8%) of 231 patients were found to have PEI based on the breath test (64.0% if PD, 28.3% if DP, P , .001). The mean volume of RP was 21.8±1.1ml (15.5±1.0ml if PD, 33.7±1.4ml if DP, P , .001). At correlation analysis between the %CD7h and RP, the volume of RP after PD and DP was significantly correlated with the %CD7h (R2 = .305, P , .001). A Small volume of RP increased subsequent risk of PEI in a univariate analysis (P , .001). According to multivariate analysis, a small volume of RP was an independent risk factor for postoperative PEI (odds ratio 8.12; 95% confidence interval 3.37-21.0, P , .001). Conclusions: The volume of remnant pancreas after PD and DP is more closely associated with postoperative pancreatic exocrine insufficiency.
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