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• W2056545231 abstract "Mönkemüller K, Weigt J, Treiber G, Kolfenbach S, Kahl S, Rocken C, Ebert M, Fry LC, Malfertheiner P (Division of Gastroenterology, Hepatology and Infectious Diseases, Department of Pathology, Otto von Guericke University, Magdeburg University Hospital, Magdeburg, Germany). Diagnostic and therapeutic impact of double-balloon enteroscopy. Endoscopy 2006;38:67–72. For many centuries, instruments have been developed to examine the innermost parts of the human body. The introduction of flexible, fiberoptic endoscopy in the latter half of the 20th century heralded a new age that revolutionized the diagnosis and treatment of many diseases of the gastrointestinal tract. Performing upper endoscopy to visualize the esophagus, stomach, and duodenum or colonoscopy to visualize the colon and distal terminal ileum still left a variable but average length of 22 feet (or 6.7 m) of unexamined small intestine. (Gastrointest Endosc 2005;62:71–75). Multiple attempts to further evaluate this last frontier were explored, including the use of push, Sonde, and intraoperative enteroscopy. It was only with the advent of wireless capsule endoscopy (CE) that complete visualization of the small intestine became possible in an ambulatory setting (Gastrointest Endosc 2006;63:539–545). Although CE is a major breakthrough, it has its limitations, such as the inability to obtain tissue for diagnosis, perform therapeutic interventions, or completely evaluate lesions in a to-and-fro manner. Moreover, a glimpse into the small intestine has only raised additional questions about the significance of mucosal breaks, nonspecific ulcerations, and the management of suspected polyps. Double balloon endoscopy (DBE) is a new endoscopic method of examining the small intestine. DBE employs a high-resolution videoendoscope with a working length of 200 cm and a 1.8–2.8 mm diameter working channel plus a flexible 140-cm overtube. Both the endoscope and overtube are equipped with latex balloons attached at their tips, which are inflated and deflated with air from a pressure-controlled pump system. The intubation is started with both balloons deflated. When both the tip of the endoscope and overtube reach the proximal small intestine, the balloon on the overtube is inflated to anchor it within the lumen and the endoscope is further inserted. When the tip of the endoscope is advanced as far as possible, the balloon on the endoscope tip is inflated; the balloon on the overtube is then deflated and advanced along the endoscope. When the distal end of the overtube reaches the end of the endoscope, the balloon on the overtube is again inflated to fix it at a second point of the intestine. At this junction, the overtube with the balloon inflated is gently withdrawn, allowing for the pleating of the intestine onto the overtube. This sequence is repeated to continue to advance the depth of insertion of the endoscope (Gastrointest Endosc 2001;53:216–220). This technique can be performed using either an oral or anal route. Over the past few years, DBE technique has been used to evaluate the small intestine worldwide. To date, however, published performance data have come mostly from Japan. Consequently, Monkemuller et al from the University of Magdeburg Medical Center from Madgeburg, Germany, set out to determine the diagnostic yield of DBE, measure the frequency of management changes made on the basis of the results, and evaluate the clinical outcome for patients undergoing the procedure in a distinct setting. Patients with suspected small bowel pathology were studied. Indications included gastrointestinal bleeding (n = 29), suspected Crohn’s disease (n = 6), abdominal pain (n = 4), polyp removal or evaluation of polyposis syndromes (n = 6), chronic diarrhea (n = 4), and surveillance or tumor search (n = 4). All examinations were performed using a Fujinon FN450-P5/20 videoenteroscope (Fujinon Inc, Saitama, Japan), which has a working length of 200 cm and a 1.8-mm diameter working channel. The oral route was performed initially, except in patients presenting with hematochezia or suspected Crohn’s disease, in which case an anal approach was used. If a diagnosis was not obtained with the initial access route, the alternative direction was used. Seventy DBE procedures were performed on 53 patients (34 men, 19 women; mean age 60 years; range 24–80), using the oral route in 46 cases, anal route in 24, and both in 16. All patients received propofol-induced sedation. The mean duration of the procedure was 72 minutes (range, 25–180 minutes) and a mean radiation exposure was 441 sGy/cm2 (range, 70–1462). The mean depth of small bowel insertion was 150 cm (range, 1–470 cm) with an average of 200 cm (range, 30–470) for the oral route versus 70 cm (range, 1–220) transanally. The entire small intestine was visualized in only 4 patients (8%), using both the oral and anal routes in 2 patients and the oral route in only 2 patients with prior small bowel resections. In 3 of the transanal cases, it was not possible to enter more than 1–2 cm of the terminal ileum. From the oral direction, 2 procedures were aborted because of difficultly passing the instrument owing to adhesions in 1 case and poor patient tolerance in the other. A diagnosis was obtained or confirmed in 36 of 53 patients (67%). Findings included angiodysplasia (n = 13), ulcerations or erosions (n = 5), jejunitis or ileitis (n = 5), tumors (n = 5), stenosis (n = 4), polyps (n = 5), lymphangiectasias (n = 4), Crohn’s disease (n = 4), and portal hypertensive jejunopathy (n = 1). Importantly, DBE resulted in therapeutic interventions in 30 of these 53 patients (57%). Endoscopic interventions (electrocoagulation in 4, argon plasma coagulation in 7, and polypectomy in 3) were performed in 14 patients (26%) during the DBE procedure. One patient underwent 2 DBEs to remove 32 polyps, ranging in size from 1–6 cm, associated with a known diagnosis of Peutz–Jeghers syndrome. The authors note that an additional 4 patients would have benefited from argon plasma coagulation but a catheter compatible with the enteroscope was not initially available. Seven patients subsequently underwent surgery for small bowel stenosis (n = 2), adhesiolysis (n = 1), or resection of a bleeding segment of the small intestine (n = 1), a bleeding lipoma (n = 1), an ileal carcinoid tumor (n = 1), and a jejunal stromal tumor (n = 1). Directed medical therapy was provided in 10 patients (19%). A clinical follow-up period of 4 months and 18 days (range, 12 days–10 months) did not reveal any recurrent bleeding, intussusception, or abdominal obstruction owing to small bowel stenosis. The only complication reported was a postpolypectomy bleed that was identified immediately and treated endoscopically with an injection of epinephrine with no subsequent hemoglobin fall and no need for blood transfusion. Based on these findings, the authors concluded that DBE is a promising and safe new technique for diagnosing and treating clinically relevant conditions of the small bowel. They acknowledged that there was difficulty advancing the endoscope in some patients, especially via the anal route, but speculated that, as experience with the technique grows, expertise will increase and better small bowel visualization rates may be obtained. They also acknowledged that DBE is a time-consuming procedure that results in patient discomfort and, in their center, required an additional physician to administer propofol sedation. Modalities for evaluating the small intestine have evolved considerably over the past decade. Using DBE, a push-and-pull technique, total enteroscopy is now possible. With growing experience, indications for DBE have expanded to include not only those common to CE (eg, obscure gastrointestinal bleeding, Crohn’s disease, unexplained diarrhea), but also pancreaticobiliary disease in patients with altered anatomy such as Roux-en-Y, access to the excluded stomach after bariatric surgery and incomplete colonoscopy (Gastrointest Endosc Clin N Am 2006;16:363–376; Endoscopy 2005;37:566–569). Although most publications to date, including those mentioned, use DBE as an acronym for “double-balloon enteroscopy,” we suggest that double-balloon endoscopy may be more appropriate. As with any new technology, there is often a lag time between the publication of small case series demonstrating feasibility and larger validation studies. The study by Monkemuller et al is a representative case series from a center outside Japan. Like its predecessors (Gastrointest Endosc 2005;62:62–70, Gastrointest Endosc 2005;62:545–550, Gastrointest Endosc 2006;63:81–86), the study comments on the diagnostic and therapeutic yield of DBE in a relatively small number of highly selected patients with multiple indications. Moreover, although all patients had reportedly undergone both upper endoscopy and colonoscopy prior to DBE, only 5 had undergone push enteroscopy (PE) with a colonoscope rather than enteroscope and 3 CE. Hence, it is impossible to assess the incremental yield of DBE compared to other small bowel imaging modalities, particularly CE, for any specific indication. Because the study was conducted at a tertiary referral center, potential selection bias also raises concerns about the generalizability of the findings to other clinical settings. Nevertheless, the study highlights some of the advantages of DBE compared with CE, particularly its ability to provide tissue for diagnosis and perform therapeutic interventions, such as polyp removal, electrocoagulation, and argon plasma coagulation. The study also highlights potential limitations, most notably an inability to visualize the entire small bowel in most patients, even if a combined approach is used (Endoscopy 2006;38:59–66). Both the endoscopes and balloons used for DBE have undergone a number of modifications since the introduction of a prototype model in 2001 (Gastrointest Endosc 2001;53:216–220). These modifications have enhanced both the diagnostic and therapeutic performance of DBE. The currently available Fujinon EN-450T5 endoscope (Fujinon Inc) has an even larger (2.8 mm) working channel than the 1.8 mm working channel of the Fujinon FN450-P5/20 enteroscope used in this study. The larger diameter not only allows for larger accessories, but might also improve the insertion depth via the anal route (Endoscopy 2006;38:67–72). It remains unproven, however, whether increased depth of insertion translates into greater diagnostic and therapeutic yield. Future studies directly comparing DBE and CE with respect to both diagnostic yield and patient outcome are needed to reconcile this issue. Historically, small bowel barium radiography has been the mainstay of small bowel imaging. Direct instillation of barium directly into the duodenum using a nasogastric tube (enteroclysis) affords significantly higher overall diagnostic yield, higher sensitivity, and shorter procedure times than conventional small bowel radiography, but increases radiation exposure and causes greater patient discomfort (Gastroenterology 2000;118:201–221). More recently, computed tomographic enterography and enteroclysis has applied the same principles using neutral/negative intraluminal contrast (Radiographics 2006;26:641–657; AJR Am J Roentgenol 2005;185:1575–1581). These techniques provide an improved anatomic evaluation and can be clinically important in diagnosing inflammatory diseases, such as Crohn’s disease, but have a limited role in evaluating obscure gastrointestinal bleeding. PE uses a longer version of the standard video endoscope, with a length of 160–250 cm, depending on whether a pediatric colonoscope or a dedicated enteroscope is used. The average depth of jejunal intubation has been reported to be about 60 cm beyond the ligament of Treitz (Endoscopy 2002;34:543–545; Am J Gastroenterol 2000;95:137–140). Various studies have documented a significant change in the working diagnosis or management plan using PE (Endoscopy 2003;35:951–956). Retrospective analysis of data comparing depth of insertion beyond the ligament of Treitz for PE and oral DBE, however, favors DBE. This greater depth of insertion for DBE also translates to a higher diagnostic yield in evaluated subjects without duodenal pathology (Gastrointest Endosc 2005;62:392–398). CE has quickly become a patient preferred diagnostic tool for visualizing the small intestine (Gastrointest Endosc 2006;63:539–545). This noninvasive test uses a capsule that contains a camera and wirelessly transmits images to a data recorder attached to the patient, which can later be downloaded onto a workstation for review. A recent meta-analysis demonstrated that CE is superior to PE and small bowel barium radiography for evaluating patients with obscure gastrointestinal bleeding, with an incremental yield of ≥30% and a number needed to test (NNT) of 3 (Am J Gastroenterol 2005;100:2407–2418). Another meta-analysis for diagnosing nonstricturing small bowel Crohn’s disease, demonstrated that CE had a NNT of 3 to yield 1 additional diagnosis of Crohn’s disease over small bowel barium radiography and NNT of 7 over colonoscopy with ileoscopy (Am J Gastroenterol 2006;101:954–964). Comparison of CE and DBE has demonstrated comparable diagnostic rates (Endoscopy 2005;37:827–832; Endoscopy 2006;38:59–66; Am J Gastroenterol 2006;101:52–57). However, these studies suggest that CE provides more complete visualization of the entire small intestine and is preferred by patients, as it is obviously less invasive. Conversely, DBE provided a therapeutic working channel for interventions where its role was paramount to the patient’s care. Although additional information is necessary, the currently available data suggest that the optimal evaluation of the small intestine should start with a noninvasive CE to visualize the entire small intestine and a targeted DBE could be performed for further clarifications or a therapeutic intervention. The 2 procedures should, therefore, be seen as complementary. In addition, DBE may allow for capsule retrieval should it be retained, thereby decreasing the likelihood of requiring a surgical intervention for capsule removal (Gastrointest Endosc 2005;62:463–465). Although DBE has a number of advantages over other small bowel imaging modalities, as discussed, there are limitations to its use. First, it is a time-consuming procedure that averages >70 minutes (Gastrointest Endosc 2005;62:62–70; Gastrointest Endosc 2005;62:545–550) and, in certain centers, is performed by 2 endoscopists under fluoroscopy. Second, conscious sedation is required, which adds potential cardiopulmonary risks, costs, and, in centers where propofol is preferred, additional personnel. Third, DBE is an invasive procedure with a potential for complications that are different than the average endoscopic procedure. Specifically, reports have been published regarding the risk of pancreatitis (Endoscopy 2006;38:82–85), intestinal necrosis from an epinephrine injection (Endoscopy 2006;38:542), intramural hematoma (Dig Dis Sci 2004;49:902–905), paralytic ileus (Gut 2005;54:1823–1824), and perforation. Fourth, there is a discrepancy between the depths of insertion between the Japanese literature and the Western series. Multiple theories have been postulated, but centers outside of Japan consistently report far lower rates of visualization of the entire small bowel (Endoscopy 2006;38:42–48; Endoscopy 2006;38:42–48) than the 86% completion rates observed in Japan (Clin Gastroenterol Hepatol 2004;2:1010–1016). In conclusion, recent technological advancements have created a broader armamentarium of diagnostic approaches for evaluating patients with suspected small bowel pathology. DBE is one such modality that also affords therapeutic capability. Future studies are needed to better define the incremental diagnostic yield of DBE compared with CE for specific indications in diverse clinical settings and long-term outcomes following therapeutic DBE. Pending completion of these studies, we strongly believe that DBE will quickly become integrated into clinical practice and extend the arm of the gastroenterologist throughout the small bowel." @default.
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• W2056545231 title "Double-balloon endoscopy: Extending the arm of the gastroenterologist" @default.
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