W1590: Spinning Through the Small Bowel: First Report of the UK Experience of Spiral Enteroscopy
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W1588 Urgent Capsule Endoscopy for the Diagnosis of Obscure-Overt Gastrointestinal Bleeding Atsuo Yamada, Hirotsugu Watabe, Yoshihiro Isomura, Haruka Kajiwara, Noriyuki Takano, Shuntaro Yoshida, Takafumi Sugimoto, Yoshihiro Hirata, Tsuneo Ikenoue, Shin Maeda, Yutaka Yamaji, Kazuhiko Koike Background: Obscure gastrointestinal bleeding (OGIB) is defined as a bleeding that persists or recurs after a negative initial endoscopic (colonoscopy, upper endoscopy) and radiological evaluation. Severe OGIB represents 1% of all overt digestive bleedings. Capsule endoscopy (CE) is less invasive procedure and easy to be applied to OGIB patients. CE has a high positive (95%) and negative predictive values (83-100%), but the diagnostic yield is influenced by the timing of the examination and the nature of the bleeding. Methods: We studied the role of urgent capsule endoscopy in the diagnosis of patients with obscure overt GI bleeding. All patients were found no bleeding source after conducting both upper and lower endoscopies. Patients were divided into two groups: urgent group; subjects received CE within two days after their bleeding, scheduled group; patients received CE more than two days after their bleeding. Diagnosis rate was compared. Association between timing of CE and small bowel lesions detected by CE was also analyzed.Results: 44 obscure overt GI bleeding patients received CE during the study period. CE showed active bleeding in 13 patients (30%). CE also revealed bleeding source in 19 patients (42%) (angioectasias in 8 patients (18%), erosions or ulcers in 5 (11%), submucosal tumor in 2 (4%), hemangiomas in 1 (2%), and gastric lesions in 3(7%)). The diagnosis rate was higher in urgent group than scheduled group (9/13 (69%) vs. 10/31(32%), p 0.02). Duration between bleeding and CE was longer in submucosal tumor than other abnormalities. (median duration, submucosal tumor 47 days, angioectasias 2 days, erosions or ulcers 12 days)Conclusion: Urgent capsule endoscopy increases its diagnosis rate in patients with obscure overt GI bleeding. Especially, angioectasias in the small bowel are detected more in urgent capsule endoscopy. W1589 First Report of the UK Multi-Centre DBE Registry: Broadening the International Deep Enteroscopy Experience Edward J. Despott, Stephen Hughes, Abhishek Deo, David S. Sanders, Reena Sidhu, Robert P. Willert, John N. Plevris, Ken Trimble, Jason S. Jennings, Chris H. Fraser INTRODUCTION: Double balloon enteroscopy (DBE) has been a pivotal endoscopic technology, transforming the investigation and management of small bowel (SB) disorders by facilitating direct endoscopic access of the entire small bowel. AIMS & METHODS: We report the initial experience of the UK multi-centre registry (6 centres) since the introduction of DBE in the UK in 2005. RESULTS: 550 cases (322 men) were performed. Mean age was 56 years (16-94 years). 189 cases were done under general anaesthesia, 361 cases done under conscious sedation. 372 cases were performed via the oral route, 175 were performed via the rectal route while 3 cases were performed via an ileostomy. Calculated mean depth of insertion was 27080cm and 19075cm for oral and rectal routes respectively. Mean time taken to complete procedures was 7420minutes. Carbon dioxide was used as the insufflating gas in 344 cases while air was used in the remaining 206 cases. DBE was preceded by capsule endoscopy (CE) in 403 cases. Concordance of diagnoses at CE and DBE was 66% and the overall diagnostic yield for DBE was 61%. The indications and therapies applied at DBE are shown (Table 1). Significant lesions missed by CE but diagnosed by DBE included large vascular lesions, polyps and other small bowel tumours. Endoscopic therapy at DBE was applied in 38% of procedures. There were 3 reported complications (2 perforations and 1 acute coronary syndrome); all complications occurred during therapeutic procedures. The overall complication rate for DBE in the series was 0.5%, with a complication rate for therapeutic procedures of 1.4%. There were no cases of acute pancreatitis. Limitations to DBE procedures included patient intolerance, the presence of adhesions and poor bowel preparation. CONCLUSION: The initial UK experience is favourable and echoes the results of other national series published to date, showing that DBE is a feasible and safe and endoscopic advancement that enhances the management of small bowel disorders. Indications & Endotherapy Applied Indication Cases Endo-therapy Cases OGIB/IDA 347 APC 147 Polyposis 49 Polyp-ectomy 36 Stricture 36 Dilation of strictures 18 Suspected CD 34 DPEJ tube insertion 7 Indication Cases Endo-therapy Cases Suspected Lymphoma / other tumours 28 Endoclips 2 Evaluationof CD activity 24 Thrombin injection 1 Refractorycoeliac/ mal- absorption 15 DPEJ tube 8 Intuss-usception 4 Retained SBCE 3 Surgicallyaltered SB 2 W1590 Spinning Through the Small Bowel: First Report of the UK Experience of Spiral Enteroscopy Edward J. Despott, Stephen Hughes, Peter Marden, Chris H. Fraser INTRODUCTION: This decade has seen a revolution in small bowel (SB) endoscopy. Balloon assisted enteroscopy (double-balloon and single-balloon) has expanded the capacity to endoscopically manage SB pathology. More recently, a novel device assisted enteroscopy named spiral enteroscopy (SE) promises to be an alternative method of deep enteroscopy. SE uses a pliable plastic spiral threaded onto a flexible overtube (Spirus, Endoase Discovery SB, Spirus Medical, MA, USA). Rotational torque applied to the overtube engages the spiral thread to the SB. This advances the overtube and enteroscope deeper into the small bowel. AIMS & METHODS: We report an early multicentre experience of SE since its introduction to the UK in November 2008. RESULTS: 23 procedures (12 male) were done at 2 tertiary referral centres. Mean age was 58 years (19-81 years). 11 procedures were done under conscious sedation while the remaining 12 were under general anaesthesia. 22 procedures were performed via the oral route; 1 procedure was done via the rectal route. Carbon dioxide was used as an insufflating gas in 13 procedures while air was used for rest. The most common indication for SE was mid-gut bleeding (n17). Other indications included SB polyposis (n5) and direct percutaneous endoscopic jejunostomy (DPEJ) feeding tube replacement (n1). 22 procedures were continued to the maximal point of insertion until forward advancement of the enteroscope ceased. One oral procedure was aborted due to the presence of gastric contents despite a 14 hour fast. Mean duration of procedures was 4212 minutes. In one patient, where the spiral engaged the SB throughout the procedure, pan-enteroscopy was achieved in 65 minutes. In the patient undergoing rectal SE, SB intubation distance was estimated to be 50cm proximal to the ICV. 8 patients were treated with argon plasma coagulation for angioectasias and 1 patient had multiple polypectomies. In one patient, the overtube induced some minor submucosal bruising; the patient remained well after the procedure. No other complications ensued. The main limitation to SE was related to occasional inability of the spiral to engage the SB. In another 2 patients, the SE failed to reach the location of SB tattoos placed at previous DBEs. In another patient, SE failed to reach a proximal ileal polyp (subsequently reached by DBE in the same session). CONCLUSION: The initial UK experience with SE suggests that where SB engagement readily occurs, deep SB intubation can be achieved in a relatively short time. Anecdotally, the SE also appears to provide a stable platform for therapeutic interventions. Further comparative studies would be helpful. W1591 Clinical Evaluation of Endoscopic Ultrasonography With Single- Balloon Enteroscopy for Diagnosis of Small Bowel Diseases Takuji Kawamura, Kenjiro Yasuda, Koji Uno, Kiyohito Tanaka, Masatsugu Nakajima Background and aim: Endoscopic ultrasonograhy (EUS) is a useful method to detect upper and lower gastrointestinal diseases. However, EUS for small bowel diseases has hardly been studied because of difficulties in the endoscopic approach. Recently, double-balloon enteroscopy and single-balloon enteroscopy (SBE) were developed, and easier observation of the entire small bowel is currently possible. The purpose of this study was to evaluate the clinical efficacy of EUS with SBE.Patients and methods: We performed 109 enteroscopic examinations in 82 patients, including 70 oral approaches and 39 anal approaches, using an SBE system between April 2006 and October 2009 at Kyoto Second Red Cross Hospital. Small bowel lesions were detected in 49 of the 82 patients (59.8%), and we performed EUS in 13 patients (15.9%). These 13 patients underwent 13 EUS examinations, including 10 oral approaches and 3 anal approaches, were selected for this study. The EUS probe was a UM-3X prototype that has a 20-MHz radial scan transducer developed by Olympus Medical Systems. The probe has a working length of 2600 mm with an outer diameter of 2.5 mm, which enables it to be inserted into the inner channel of a single-balloon enteroscope. After endoscopic observation of lesions, we injected water into the intestinal lumen around the lesions and inserted the EUS probe through the inner canal of the enteroscope. The diagnosis of cases included the following: malignant lymphoma (n 3), metastatic cancer (n 3), primary Abstracts AB366 GASTROINTESTINAL ENDOSCOPY Volume 71, No. 5 : 2010 www.giejournal.org
Transcript of W1590: Spinning Through the Small Bowel: First Report of the UK Experience of Spiral Enteroscopy
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1588rgent Capsule Endoscopy for the Diagnosis of Obscure-Overtastrointestinal Bleedingtsuo Yamada, Hirotsugu Watabe, Yoshihiro Isomura,aruka Kajiwara, Noriyuki Takano, Shuntaro Yoshida,akafumi Sugimoto, Yoshihiro Hirata, Tsuneo Ikenoue, Shin Maeda,utaka Yamaji, Kazuhiko Koikeackground: Obscure gastrointestinal bleeding (OGIB) is defined as aleeding that persists or recurs after a negative initial endoscopiccolonoscopy, upper endoscopy) and radiological evaluation. Severe OGIBepresents 1% of all overt digestive bleedings. Capsule endoscopy (CE) is lessnvasive procedure and easy to be applied to OGIB patients. CE has a highositive (95%) and negative predictive values (83-100%), but the diagnosticield is influenced by the timing of the examination and the nature of theleeding. Methods: We studied the role of urgent capsule endoscopy in theiagnosis of patients with obscure overt GI bleeding. All patients were foundo bleeding source after conducting both upper and lower endoscopies.atients were divided into two groups: urgent group; subjects received CEithin two days after their bleeding, scheduled group; patients received CEore than two days after their bleeding. Diagnosis rate was compared.ssociation between timing of CE and small bowel lesions detected by CEas also analyzed.Results: 44 obscure overt GI bleeding patients received CEuring the study period. CE showed active bleeding in 13 patients (30%). CElso revealed bleeding source in 19 patients (42%) (angioectasias in 8atients (18%), erosions or ulcers in 5 (11%), submucosal tumor in 2 (4%),emangiomas in 1 (2%), and gastric lesions in 3(7%)). The diagnosis rate wasigher in urgent group than scheduled group (9/13 (69%) vs. 10/31(32%),� 0.02). Duration between bleeding and CE was longer in submucosal
umor than other abnormalities. (median duration, submucosal tumor 47ays, angioectasias 2 days, erosions or ulcers 12 days)Conclusion: Urgentapsule endoscopy increases its diagnosis rate in patients with obscure overtI bleeding. Especially, angioectasias in the small bowel are detected more
n urgent capsule endoscopy.
1589irst Report of the UK Multi-Centre DBE Registry: Broadeninghe International Deep Enteroscopy Experiencedward J. Despott, Stephen Hughes, Abhishek Deo, David S. Sanders,eena Sidhu, Robert P. Willert, John N. Plevris, Ken Trimble,ason S. Jennings, Chris H. FraserNTRODUCTION: Double balloon enteroscopy (DBE) has been a pivotalndoscopic technology, transforming the investigation and management ofmall bowel (SB) disorders by facilitating direct endoscopic access of thentire small bowel. AIMS & METHODS: We report the initial experience ofhe UK multi-centre registry (6 centres) since the introduction of DBE in theK in 2005. RESULTS: 550 cases (322 men) were performed. Mean age was6 years (16-94 years). 189 cases were done under general anaesthesia, 361ases done under conscious sedation. 372 cases were performed via the oraloute, 175 were performed via the rectal route while 3 cases were performedia an ileostomy. Calculated mean depth of insertion was 270�80cm and90�75cm for oral and rectal routes respectively. Mean time taken toomplete procedures was 74�20minutes. Carbon dioxide was used as thensufflating gas in 344 cases while air was used in the remaining 206 cases.BE was preceded by capsule endoscopy (CE) in 403 cases. Concordance ofiagnoses at CE and DBE was 66% and the overall diagnostic yield for DBEas 61%. The indications and therapies applied at DBE are shown (Table 1).ignificant lesions missed by CE but diagnosed by DBE included largeascular lesions, polyps and other small bowel tumours. Endoscopic therapyt DBE was applied in 38% of procedures. There were 3 reportedomplications (2 perforations and 1 acute coronary syndrome); allomplications occurred during therapeutic procedures. The overallomplication rate for DBE in the series was 0.5%, with a complication rate forherapeutic procedures of 1.4%. There were no cases of acute pancreatitis.imitations to DBE procedures included patient intolerance, the presence ofdhesions and poor bowel preparation. CONCLUSION: The initial UKxperience is favourable and echoes the results of other national seriesublished to date, showing that DBE is a feasible and safe and endoscopicdvancement that enhances the management of small bowel disorders.
ndications & Endotherapy Applied
Indication Cases Endo-therapy Cases
GIB/IDA 347 APC 147olyposis 49 Polyp-ectomy 36tricture 36 Dilation of
strictures18
uspected CD 34 DPEJ tube 7
insertionB366 GASTROINTESTINAL ENDOSCOPY Volume 71, No. 5 : 2010
Indication Cases Endo-therapy Cases
Suspected Lymphoma /other tumours
28 Endoclips 2
Evaluationof CD activity 24 Thrombininjection
1
Refractorycoeliac/ mal-absorption
15
DPEJ tube 8Intuss-usception 4Retained SBCE 3Surgicallyaltered SB 2
W1590Spinning Through the Small Bowel: First Report of the UKExperience of Spiral EnteroscopyEdward J. Despott, Stephen Hughes, Peter Marden, Chris H. FraserINTRODUCTION: This decade has seen a revolution in small bowel (SB)endoscopy. Balloon assisted enteroscopy (double-balloon and single-balloon)has expanded the capacity to endoscopically manage SB pathology. Morerecently, a novel device assisted enteroscopy named spiral enteroscopy (SE)promises to be an alternative method of deep enteroscopy. SE uses a pliableplastic spiral threaded onto a flexible overtube (Spirus, Endoase Discovery SB,Spirus Medical, MA, USA). Rotational torque applied to the overtube engages thespiral thread to the SB. This advances the overtube and enteroscope deeper intothe small bowel. AIMS & METHODS: We report an early multicentre experienceof SE since its introduction to the UK in November 2008. RESULTS: 23procedures (12 male) were done at 2 tertiary referral centres. Mean age was 58years (19-81 years). 11 procedures were done under conscious sedation whilethe remaining 12 were under general anaesthesia. 22 procedures were performedvia the oral route; 1 procedure was done via the rectal route. Carbon dioxidewas used as an insufflating gas in 13 procedures while air was used for rest. Themost common indication for SE was mid-gut bleeding (n�17). Other indicationsincluded SB polyposis (n�5) and direct percutaneous endoscopic jejunostomy(DPEJ) feeding tube replacement (n�1). 22 procedures were continued to themaximal point of insertion until forward advancement of the enteroscope ceased.One oral procedure was aborted due to the presence of gastric contents despitea 14 hour fast. Mean duration of procedures was 42�12 minutes. In one patient,where the spiral engaged the SB throughout the procedure, pan-enteroscopywas achieved in 65 minutes. In the patient undergoing rectal SE, SB intubationdistance was estimated to be 50cm proximal to the ICV. 8 patients were treatedwith argon plasma coagulation for angioectasias and 1 patient had multiplepolypectomies. In one patient, the overtube induced some minor submucosalbruising; the patient remained well after the procedure. No other complicationsensued. The main limitation to SE was related to occasional inability of the spiralto engage the SB. In another 2 patients, the SE failed to reach the location of SBtattoos placed at previous DBEs. In another patient, SE failed to reach a proximalileal polyp (subsequently reached by DBE in the same session). CONCLUSION:The initial UK experience with SE suggests that where SB engagement readilyoccurs, deep SB intubation can be achieved in a relatively short time.Anecdotally, the SE also appears to provide a stable platform for therapeuticinterventions. Further comparative studies would be helpful.
W1591Clinical Evaluation of Endoscopic Ultrasonography With Single-Balloon Enteroscopy for Diagnosis of Small Bowel DiseasesTakuji Kawamura, Kenjiro Yasuda, Koji Uno, Kiyohito Tanaka,Masatsugu NakajimaBackground and aim: Endoscopic ultrasonograhy (EUS) is a useful method todetect upper and lower gastrointestinal diseases. However, EUS for small boweldiseases has hardly been studied because of difficulties in the endoscopicapproach. Recently, double-balloon enteroscopy and single-balloon enteroscopy(SBE) were developed, and easier observation of the entire small bowel iscurrently possible. The purpose of this study was to evaluate the clinical efficacyof EUS with SBE.Patients and methods: We performed 109 enteroscopicexaminations in 82 patients, including 70 oral approaches and 39 analapproaches, using an SBE system between April 2006 and October 2009 at KyotoSecond Red Cross Hospital. Small bowel lesions were detected in 49 of the 82patients (59.8%), and we performed EUS in 13 patients (15.9%). These 13patients underwent 13 EUS examinations, including 10 oral approaches and 3anal approaches, were selected for this study. The EUS probe was a UM-3Xprototype that has a 20-MHz radial scan transducer developed by OlympusMedical Systems. The probe has a working length of 2600 mm with an outerdiameter of 2.5 mm, which enables it to be inserted into the inner channel of asingle-balloon enteroscope. After endoscopic observation of lesions, we injectedwater into the intestinal lumen around the lesions and inserted the EUS probe
through the inner canal of the enteroscope. The diagnosis of cases included thefollowing: malignant lymphoma (n � 3), metastatic cancer (n � 3), primarywww.giejournal.org
