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Background Device-assisted enteroscopy (DAE) has become a well-established diagnostic and therapeutic tool for the management of small-bowel pathology. We aimed to evaluate the performance measures for DAE across the UK against the quality benchmarks proposed by the European Society of Gastrointestinal Endoscopy (ESGE). Methods We retrospectively collected data on patient demographics and DAE performance measures from electronic endoscopy records of consecutive patients who underwent DAE for diagnostic and therapeutic purposes across 12 enteroscopy centers in the UK between January 2017 and December 2022. Results A total of 2005 DAE procedures were performed in 1663 patients (median age 60 years; 53% men). Almost all procedures (98.1%) were performed for appropriate indications. Double-balloon enteroscopy was used for most procedures (82.0%), followed by single-balloon enteroscopy (17.2%) and spiral enteroscopy (0.7%). The estimated depth of insertion was documented in 73.4% of procedures. The overall diagnostic yield was 70.0%. Therapeutic interventions were performed in 42.6% of procedures, with a success rate of 96.6%. Overall, 78.0% of detected lesions were marked with a tattoo. Patient comfort was significantly better with the use of deep sedation compared with conscious sedation (99.7% vs. 68.5%; P <0.001). Major adverse events occurred in only 0.6% of procedures. Conclusions Performance measures for DAE in the UK meet the ESGE quality benchmarks, with high diagnostic and therapeutic yields, and a low incidence of major adverse events. However, there is room for improvement in optimizing sedation practices, standardizing the depth of insertion documentation, and adopting marking techniques to aid in the follow-up of detected lesions. [ABSTRACT FROM AUTHOR]

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence. [ABSTRACT FROM AUTHOR]

Background: Single-balloon enteroscopy (SBE) is a valuable but difficult modality for the diagnosis and treatment of small-bowel disease. The water exchange method has the advantage of facilitating intubation during colonoscopy. Here, we evaluated the effects of water exchange on procedure-related variables related to SBE.Methods: This randomized controlled trial was conducted in a tertiary-care referral center in China. Patients due for attempted total enteroscopy were randomly allocated to undergo water exchange-assisted (water exchange group) or carbon dioxide-insufflated enteroscopy (CO2 group). All patients were planned to undergo both anterograde and retrograde procedures. The primary outcome was the total enteroscopy rate. Secondary outcomes included the maximal insertion depth, positive findings, procedural time, and adverse events.Results: In total, 110 patients were enrolled, with 55 in each group. Baseline characteristics between the two groups were comparable. Total enteroscopy was achieved in 58.2 % (32/55) of the water exchange group and 36.4 % (20/55) of the control group (P = 0.02). The mean (standard deviation) estimated intubation depth was 521.2 (101.4) cm in the water exchange group and 481.6 (95.2) cm in the CO2 group (P = 0.04). The insertion time was prolonged in the water exchange group compared with the CO2 group (178.9 [45.1] minutes vs. 154.2 [27.6] minutes; P < 0.001). Endoscopic findings and adverse events were comparable between the two groups.Conclusions: The water exchange method improved the total enteroscopy rate and increased the intubation depth during SBE. The use of water exchange did not increase the complications of enteroscopy. [ABSTRACT FROM AUTHOR]

This article, published in the journal Endoscopy, explores the impact of anxiety on patients' tolerance of endoscopic procedures. The study involved 150 patients waiting to undergo endoscopic examination, and anxiety levels were assessed using the Visual Analogue Scale (VAS) before and after the examination. The results showed that anxiety before and during the examination negatively influenced patient acceptability and tolerance of unsedated endoscopy. The study suggests that providing explanations before the examination and reducing waiting time could improve the acceptability and tolerance of endoscopy. [Extracted from the article]

This article discusses a study that aimed to assess the ability of trainees with minimal experience in narrow-band imaging (NBI) to identify gastric atrophy and intestinal metaplasia (IM) during routine upper gastrointestinal endoscopies. The trainees obtained biopsies and used the Kimura-Takemoto classification and EGGIM score to classify the findings. The results showed that the trainees were able to accurately identify extensive gastric atrophy and high-risk IM. This suggests that trainees without specific training in pre-neoplastic lesion assessment can successfully identify these conditions. [Extracted from the article]

This article, published in the journal Endoscopy, examines the readmission rates and factors associated with re-hospitalization following Double Balloon Enteroscopy (DBE) in patients with small intestinal bleeding. The study analyzed data from 59 patients who underwent DBE between March 2018 and May 2023. The results showed that readmission rates post-DBE were significant, with 30 out of 59 patients being readmitted to the hospital. Factors such as the use of antiplatelet/anticoagulant agents and the application of endoscopic therapy were correlated with all-cause readmission. The study concludes that endoscopic therapy during DBE not only reduces admissions due to bleeding relapse but also leads to all-cause readmission. [Extracted from the article]

This article, published in the journal Endoscopy, presents a study on the efficacy and safety of Single Balloon Enteroscopy (SBE) in a tertiary hospital. The study analyzed data from 687 enteroscopies performed on 493 patients between March 2011 and December 2022. The results showed a high technical success rate of 98.3% and a diagnostic yield of 80.8%. The overall intervention yield was 83.5%, and the mean total exploration time was 70 minutes. The adverse event rate was 2%, with only 3 serious adverse events reported. The study concludes that SBE is an effective and safe procedure. [Extracted from the article]

This article, published in the journal Endoscopy, discusses a case study involving a 77-year-old woman with unexplained iron deficiency anemia who was taking aspirin. The patient had previously been unable to undergo a procedure called retrograde double balloon enteroscopy (DBE) using carbon dioxide due to intolerance. However, after discussing with the patient, the medical team decided to attempt DBE again using the water exchange technique. This time, they were successful in reaching the terminal ileum and further insertion to the mid ileum under conscious sedation. The examination revealed erosions and bleeding in the distal ileum, which were consistent with aspirin-induced enteropathy. The bleeding was successfully treated with two through the scope clips. The article includes a video demonstrating the procedure. [Extracted from the article]

This article discusses the feasibility and efficacy of using double-balloon enteroscopy (DBE) for surveillance of small bowel malignancy in patients with short bowel syndrome (SBS) who are undergoing treatment with teduglutide (TED). SBS is a condition that can lead to chronic intestinal failure, and TED is a pharmacological therapy used to reduce the need for parenteral nutrition. The study found that DBE surveillance was successful in identifying small bowel residual length and detecting complications such as anastomotic stenosis and ulcers, but no small bowel malignancies were detected. The authors conclude that DBE surveillance is a feasible and effective method for oncologic surveillance in SBS patients undergoing TED treatment. [Extracted from the article]

The article discusses the advancements in device-assisted enteroscopy (DAE) and its impact on the diagnosis and treatment of small bowel diseases. The study analyzed data from 2005 DAE procedures performed in the UK and found that DAE is an effective procedure with high success rates. The study also highlighted the safety of DAE, with a low rate of adverse events. However, there are areas for improvement, such as better documentation of procedure extent and the need for standardized sedation practices. The article suggests that concentrating DAE procedures in expert centers could be a rational policy, but this would require significant changes in healthcare systems. Overall, the study supports the effectiveness of DAE in clinical practice but calls for further research and standardized practices. [Extracted from the article]

Background: Polypectomy is often the most hazardous part of colonoscopy. There is significant variability in polypectomy training and assessment internationally. DOPyS (Directly Observed Polypectomy Skills) is a validated assessment tool and is used to demonstrate polypectomy competency in the UK. This study aimed to describe the learning curve for polypectomy competency in UK trainees.Methods: Retrospective DOPyS data (January 2009 to September 2015) were obtained from the UK Joint Advisory Group (JAG) for intestinal endoscopy training system (JETS) national database. The number of lower gastrointestinal (LGI) procedures, overall cecal intubation rate (CIR), procedure intensity, and time in days to the first DOPyS assessment were recorded, and time to JAG certification was calculated.Results: 4965 DOPyS assessments from 336 trainees were analyzed. Within the study period, 124 and 53 trainees achieved provisional and full colonoscopy certification, respectively. Trainees started formative assessment of polypectomy after > 130 LGI procedures and with a CIR of > 70 %. Within 3 years from the first DOPyS assessment, 94 % of trainees achieved provisional certification, and 50 % full certification. Higher procedure intensity at baseline DOPyS assessment was associated with a higher likelihood of obtaining certification sooner.Conclusion: There is a significant variation in time to competency, and this potentially reflects the time necessary to acquire polypectomy skills. There is a need to start polypectomy training earlier, once sufficient skills, such as tip control, have been achieved to shorten the time to competency. Overall, the CIR could be used as a guide for such technical skills. Increasing exposure to training lists also potentially reduces the time to polypectomy competency. [ABSTRACT FROM AUTHOR]

Introduction:  Peutz-Jeghers syndrome (PJS) is an autosomal dominant hereditary hamartomatous polyposis with predominant localization in the jejunum and ileum and high risk of bowel perforation after traditional polypectomy. The modern enteroscopy is the only possible technique for visualizing and performing intraluminal endoscopic microsurgical manipulations in the deep sections of the small intestine. The study aims to develop an optimal method for the diagnosis and treatment of polyps in children with PJS.Materials and Methods:  During 2015 to 2018 we conducted 30 comprehensive examinations of children with PJS in The Department of Endoscopic Research of the National Medical Research Center for Children's Health. We performed esophagogastroduodenoscopy and colonoscopy with removal of polyps more than 7 mm, then video capsule endoscopy and, guided by this, therapeutic single-balloon enteroscopy. Our technique for removal of polyps is general in all parts: (1) creating a "resistant pillow"; (2) electroexcision of polyp; (3) clipping the removal site.Results:  Successfully performed electroexcision of polyps, which were located in the deep parts of the small intestine at a distance of 30 segments (one segment is 10 cm), reached a diameter of 2.5 cm, had a long pedicle. The postoperative period was uneventful.Conclusion:  We have developed an optimal method of diagnostic and therapeutic measures, the observance of which allows us to avoid delayed perforations of the small intestine in the area of polypectomy in the postoperative period in children with PJS. Thanks to this technique, modern enteroscopy is becoming the only possible alternative to bowel resection in children with PJS. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events.Methods: We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone.Results: 10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted.Conclusions: OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed. [ABSTRACT FROM AUTHOR]

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize training in small-bowel endoscopy across European centers. The following criteria and framework for training in small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE), which aim to provide uniform and high quality training to ensure that small-bowel endoscopists are competent to operate independently, are based on the current literature and experience of experts in the field. Three main areas are covered: skills required prior to commencing training in small-bowel endoscopy; structured training for trainees to become independent endoscopists; and ways of ensuring competence is achieved. 1 : Centers providing training in SBCE should perform a minimum of 75 - 100 SBCEs/year. 2 : Experience in bidirectional endoscopies is desirable for structured training in SBCE. 3 : SBCE courses should consist of at least 50 % hands-on training and cover information on technology, indications and contraindications for SBCE, pathologies that can be encountered on SBCE, and standard terminology that should be used during reporting of SBCE. An SBCE course should be completed prior to achieving competence in SBCE reporting. 4 : Competence in SBCE can be assessed by considering a minimum of 30 SBCEs. Direct Observation of Procedural Skills, short SBCE videos, and multiple-choice questions can be useful to assess improvement in the skills of trainees. 5 : Centers offering training in DAE should aim to carry out at least 75 DAEs/year, should have direct links with an SBCE service, and should allow regular discussion of cases at a radiology small-bowel MDT. Training centers with lower numbers are encouraged to offer training by "buddying-up" with other centers, or using mentoring systems. 6 : DAE trainees must be independent in bidirectional endoscopies and have experience in level 1 polypectomy prior to commencement of training. They should also be competent in reviewing SBCEs. 7 : Training in DAE should be structured with a minimum of 75 procedures, including 35 retrograde DAEs, with therapeutic procedures undertaken in at least 50 % of the DAEs performed. Training should cover the indications, contraindications, complications including prevention, and technicalities of the DAE procedure; formal evaluation should follow. DAE trainees must acquire skills to independently manage and advise on small-bowel pathology following DAE procedures. 8 : It is highly recommended that international societies develop online modules and courses on DAE, which are currently lacking across Europe. [ABSTRACT FROM AUTHOR]

This article discusses the development of a convolutional neural network (CNN) for the detection of pleomorphic lesions during device-assisted enteroscopy (DAE). DAE is a procedure used for evaluating the entire gastrointestinal tract, but its diagnostic yield is suboptimal. The CNN was trained using a dataset of 40,655 images and achieved a sensitivity of 94.6% and a specificity of 98.9%. The development of accurate deep learning models like this CNN is important for improving the diagnostic yield of DAE. [Extracted from the article]

This article discusses the performance and adverse events of motorized power spiral enteroscopy (PSE) in a case series at a single tertiary endoscopy center in Eastern Europe. The study evaluated the efficacy and safety of PSE and reported the adverse events experienced during the procedure. A total of 20 procedures were performed on 17 patients, with a technical success rate of 81% for the antegrade route and 83% for the retrograde route. The overall diagnostic accuracy was 81.82%, and the median insertion time was 75 minutes for the antegrade approach and 70 minutes for the retrograde approach. Adverse events were found in 35% of patients, with 23% experiencing severe complications. However, no perforations or deaths occurred in the patient cohort. The authors conclude that further technological development and innovation of endoscopes, along with proper training for endoscopists, are needed to ensure patient safety. [Extracted from the article]

This article, published in the journal Endoscopy, examines the role of balloon-assisted enteroscopy (BAE) in the management of adult small bowel intussusception (ASI). ASI is a rare condition that has traditionally been treated with surgery, but the introduction of BAE has allowed for preoperative diagnosis and potentially reduced the need for surgery. The study retrospectively analyzed clinicopathological features of ASI in patients with and without preoperative diagnosis by double-balloon enteroscopy (DBE). The results showed that DBE can be a valuable diagnostic and therapeutic tool for ASI, potentially avoiding surgical resection in many cases. [Extracted from the article]

This article, published in the journal Endoscopy, presents a case study of a 54-year-old male with Crohn's disease who had a bezoar in his mid-ileum. The bezoar was successfully removed using antegrade double-balloon enteroscopy (DBE) and electrohydraulic lithotripsy (EHL). Although the bezoar was only partially fractured during the procedure, it was ultimately retrieved using a retrieval net. The patient experienced no adverse events and was discharged the following day. The article concludes that DBE is an effective technique for treating small bowel conditions and can help avoid the need for surgery. [Extracted from the article]

This article, published in the journal Endoscopy, examines the technical performance of double-balloon enteroscopy (DBE) in patients with surgically altered anatomy. The study found that DBE had comparable rates of technical success in patients with and without surgically altered gastrointestinal anatomy. The most common surgical intervention was small bowel resection, and the most frequently encountered lesions were angioectasia. The study also found that a history of abdominal surgical interventions did not impact the occurrence of adverse events. [Extracted from the article]

This article discusses the role of capsule endoscopy (CE) and double-balloon enteroscopy (DBE) in the management of adult patients with coeliac disease (CD) and persisting symptoms. The study analyzed data from 132 adult patients who underwent CE and DBE at the National Centre for Refractory CD in England. The most common symptoms reported were diarrhea, abdominal pain, bloating, and weight loss. The diagnostic yield of CE and DBE was high, and CD-related complications were identified in 10.6% of patients. Older age, weight loss, and anemia were associated with poor outcomes. The study concludes that close monitoring is necessary for older patients with persistent villous atrophy, weight loss, and anemia to facilitate early diagnosis and management of complications. [Extracted from the article]

This article, published in the journal Endoscopy, describes a difficult and exceptional clinical case involving an 80-year-old man with liver cirrhosis. The patient had a lesion identified as adenocarcinoma and was evaluated for potential endoscopic treatment. Due to the urgency of the situation, alternative treatments were excluded, and a therapeutic endoscopic procedure was performed, involving the sclerosis of the esophageal varix and the removal of the lesion. The patient showed good clinical condition after the procedure, highlighting the importance of having a backup plan. The article also mentions the training of nurses in the use of cyanoacrylate, a treatment not commonly used in their center. [Extracted from the article]

Background: Balloon enteroscopy-assisted balloon dilation and temporary biliary stent placement are effective for hepaticojejunostomy anastomotic strictures (HJAS), but the re-stenosis rates are relatively high. We examined the feasibility and efficacy of a novel treatment technique for refractory HJAS, called balloon enteroscopy-assisted radial incision and cutting (BE-RIC).Methods: Between January 2016 and June 2018, 11 patients with refractory HJAS that recurred after balloon dilation and/or stent placement, underwent BE-RIC. We evaluated the technical success, clinical success, adverse events, and re-stenosis rates associated with BE-RIC.Results: The technical success rate of BE-RIC was 91 % (10/11). Clinical success was achieved in all patients who underwent technically successful procedures. The procedure-related adverse event rate was 9 % (1/11). No re-stenosis was observed during the follow-up period; 9 patients were followed up for more than 6 months, and of these, 5, 4, and 2 patients were followed up for more than 12, 18, and 24 months, respectively, without re-stenosis.Conclusions: BE-RIC for refractory HJAS showed favorable results. BE-RIC might be a useful option for treating refractory HJAS. [ABSTRACT FROM AUTHOR]

Background The advent of balloon-assisted enteroscopy (BAE) has facilitated the examination of the entire digestive tract. However, using a rigid sliding tube during the procedure reduces patient acceptance. This study evaluated the clinical application of a newly developed ultrathin single-balloon enteroscope for BAE. Methods 28 outpatients underwent enteroscopy with a novel ultrathin single-balloon enteroscope. None of the subjects required therapeutic procedures, such as balloon dilation or hemostasis. The insertability, efficacy, and safety of the ultrathin single-balloon endoscope were evaluated retrospectively. Results 7 patients underwent transoral enteroscopy and 21 patients underwent transanal enteroscopy under conscious sedation. No adverse events related to the procedure were reported in any patients. Targeted observation and/or targeted biopsy were achieved in all procedures. All transoral procedures allowed evaluation of the jejunum beyond the ligament of Treitz. All transanal procedures allowed intubation of the terminal ileum, despite several patients having severe stenosis of the colon and ileum. Conclusion A novel ultrathin single-balloon enteroscope showed adequate insertability and safety for outpatient surveillance enteroscopy under conscious sedation. [ABSTRACT FROM AUTHOR]

Abdominal computed tomography (CT) and magnetic resonance enterography (MRE) showed a thickening of the small bowel at the junction between the jejunum and ileum, at 30 cm, suggesting Crohn's disease. Small-bowel capsule endoscopy and enteroscopy are relevant tests to explore suspected refractory celiac disease [2][3]. [Extracted from the article]

Small-bowel Capsule Endoscopy (sbce): 1: ESGE recommends that prior to SBCE patients ingest a purgative (2 L of polyethylene glycol [PEG]) for better visualization.Strong recommendation, high quality evidence.However, the optimal timing for taking purgatives is yet to be established. 2: ESGE recommends that SBCE should be performed as an outpatient procedure if possible, since completion rates are higher in outpatients than in inpatients.Strong recommendation, moderate quality evidence. 3: ESGE recommends that patients with pacemakers can safely undergo SBCE without special precautions.Strong recommendation, low quality evidence. 4: ESGE suggests that SBCE can also be safely performed in patients with implantable cardioverter defibrillators and left ventricular assist devices.Weak recommendation, low quality evidence. 5: ESGE recommends the acceptance of qualified nurses and trained technicians as prereaders of capsule endoscopy studies as their competency in identifying pathology is similar to that of medically qualified readers. The responsibility of establishing a diagnosis must however remain with the attending physician.Strong recommendation, moderate quality evidence. 6: ESGE recommends observation in cases of asymptomatic capsule retention.Strong recommendation, moderate quality evidence.In cases where capsule retrieval is indicated, ESGE recommends the use of device-assisted enteroscopy as the method of choice.Strong recommendation, moderate quality evidence.Device-assisted Enteroscopy (dae): 1: ESGE recommends performing diagnostic DAE as a day-case procedure in patients without significant underlying co-morbidities; in patients with co-morbidities and/or those undergoing a therapeutic procedure, an inpatient stay is recommended.Strong recommendation, low quality evidenceThe choice between different settings also depends on sedation protocols.Strong recommendation, low quality evidence. 2: ESGE suggests that conscious sedation, deep sedation, and general anesthesia are all acceptable alternatives: the choice between them should be governed by procedure complexity, clinical factors, and local organizational protocols.Weak recommendation, low quality evidence. 3: ESGE recommends that the findings of previous diagnostic investigations should guide the choice of insertion route.Strong recommendation, moderate quality evidence.If the location of the small-bowel lesion is unknown or uncertain, ESGE recommends that the antegrade route should be generally preferred.Strong recommendation, low quality evidence.In the setting of massive overt bleeding, ESGE recommends an initial antegrade approach.Strong recommendation, low quality evidence. 4: ESGE recommends that, for balloon-assisted enteroscopy (i. e., single-balloon enteroscopy [SBE] and double-balloon enteroscopy [DBE]), small-bowel insertion depth should be estimated by counting net advancement of the enteroscope during the insertion phase, with confirmation of this estimate during withdrawal.Strong recommendation, low quality evidence.ESGE recommends that, for spiral enteroscopy, insertion depth should be estimated during withdrawal.Strong recommendation, moderate quality evidence. Since the calculated insertion depth is only a rough estimate, ESGE recommends placing a tattoo to mark the identified lesion and/or the deepest point of insertion.Strong recommendation, low quality evidence. 5: ESGE recommends that all endoscopic therapeutic procedures can be undertaken at the time of DAE.Strong recommendation, moderate quality evidence.Moreover, when therapeutic interventions are performed, additional specific safety measures are needed to prevent complications.Strong recommendation, high quality evidence. [ABSTRACT FROM AUTHOR]

2 Positron emission tomography (PET) scan showing increased hypermetabolic uptake in small bowel lesions. We report a video case series of three patients who underwent double balloon enteroscopy for diagnosis of suspicious small bowel lesions. Abdominal computed tomography (CT) scan with contrast revealed multiple enhancing polypoid small bowel lesions (Fig. [Extracted from the article]

We report the detachment of a spiral ring during motorized spiral enteroscopy during small-bowel tumor examination. This situation can be explained by a spiral defect but also suggests that attempting to pass through a neoplastic (even limited) stenosis in a small-bowel tumor may be a risky procedure with a spiral enteroscope. Motorized spiral enteroscopy is a recent technology for deep enteroscopy that uses a 3 cm diameter spiral attached to the tip of an endoscope to facilitate examination of the small bowel. [Extracted from the article]

Patients should be informed about the benefits and risks of endoscopic retrograde cholangiopancreatography (ERCP)Only specially trained and competent personnel should carry out endoscope reprocessing.Manufacturers of duodenoscopes should provide detailed instructions on how to use and reprocess their equipment.In the case of modifications to their equipment, manufacturers should provide updated instructions for use.Detailed reprocessing protocols based on the manufacturer's instructions for use should clearly lay out the different reprocessing steps necessary for each endoscope model.Appropriate cleaning equipment should be used for duodenoscopes in compliance with the manufacturer's instructions for use. Only purpose-designed, endoscope type-specific, single-use cleaning brushes should be used, to ensure optimal cleaning. As soon as the endoscope is withdrawn from the patient, bedside cleaning should be performed, followed by leak testing, thorough manual cleaning steps, and automated reprocessing, in order to: · Remove debris from external and internal surfaces;. · Prevent any drying of body fluids, blood, or debris;. · Prevent any formation of biofilms.. In addition to the leak test, visual inspection of the distal end as well as regular maintenance of duodenoscopes should be performed according to the manufacturer's instructions for use, in order to detect any damage at an early stage.The entire reprocessing procedure in endoscope washer-disinfectors (EWDs) should be validated according to the European and International Standard, EN ISO 15883. Routine technical tests of EWDs should be performed according to the validation reports.Microbiological surveillance of a proportion of the department's endoscopes should be performed every 3 months, with the requirement that all endoscopes used in the unit are tested at least once a year.In the case of suspected endoscopy-related infection, the relevant device (e. g., endoscope, EWD) should be taken out of service until adequate corrective actions have been taken. Outbreaks should be managed by a multidisciplinary team, including endoscopy, hygiene, and microbiology experts, manufacturers, and regulatory bodies, according to national standards and/or laws. In the case of suspected multidrug-resistant organism (MDRO) outbreaks, close cooperation between the endoscopy unit and the clinical health provider is essential (including infection control departments and hospital hygienists). [ABSTRACT FROM AUTHOR]

Background and study aims Short-type single-balloon enteroscope (short SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is a promising alternative treatment in postsurgical altered anatomy. However, it is technically demanding, and factors affecting its technical difficulty have not yet been clarified. This study aimed to examine the procedural success rate of short SBE-assisted ERCP and the potential factors affecting procedural failure. Patients and methods A total of 117 consecutive patients (203 procedures) with surgically altered anatomy underwent ERCP using prototype short SBEs. The procedural success rate of short SBE-assisted ERCP and the potential factors affecting procedural failure were examined retrospectively. Results The enteroscopy success rate and procedural success rate were 92.6 % (95 % confidence interval [CI] 88.1 % - 95.8 %) and 81.8 % (95 %CI 75.8 % - 86.8 %), respectively. Multivariate analyses indicated that pancreatic indication (odds ratio [OR] 4.35, 95 %CI 1.67 - 11.4), first ERCP attempt (OR 6.03, 95 %CI 2.17 - 16.8), and no transparent hood (OR 4.61, 95 %CI 1.48 - 14.3) were potential risk factors for procedural failure. Conclusions Short SBE-assisted ERCP was effective in postsurgical altered anatomy. This large case series suggested the potential factors affecting procedural failure. [ABSTRACT FROM AUTHOR]

M. Pioche and J. C. Saurin are co-investigators for Olympus spiral enteroscopy muticenter study. Ileoileal intussusception treated by polypectomy with spiral enteroscopy in Peutz-Jeghers syndrome This is the first description of an ileoileal intussusception caused by a large hamartomatous polyp being passed through using MSE, allowing polyp treatment and delayed resolution of the intussusception. [Extracted from the article]

The article presents a case study of obscure gastrointestinal bleeding caused by Ascaris lumbricoides and detected using double-balloon enteroscopy in a 79-year-old male patient presented for examination of microcytic hypochromic anemia. The patient was treated with oral mebendazol therapy for three days. It discusses Ascaris lumbricoides as an intestinal roundworm that is one of the most common helminthic infections.

Background and study aim: Cannulation of the native papilla in surgically altered anatomy is difficult in endoscopic retrograde cholangiography (ERC). There are limited data regarding the success of single-balloon enteroscopy-assisted ERC (SBE-ERC) in patients with a native papilla and Roux-en-Y gastric bypass. Use of a plastic cap may assist cannulation in these cases. The aim of the current study was to investigate the use of SBE-ERC with a cap (Cap-SBE-ERC) in patients with surgically altered anatomy referred for ERC. Patients and methods: Patients with surgically altered anatomy (hepaticojejunostomy, gastric bypass surgery, and Whipple's surgery) who underwent Cap-SBE-ERC were identified from a prospectively maintained database. Outcomes were diagnostic and procedural success. Patients with a native papilla were compared with those with a biliary-enteric anastomosis. Results: Among 56 patients with surgically altered anatomy, high rates of diagnostic and procedural success were observed (78.6% and 71.4 %, respectively). High diagnostic and procedural success rates of 72.7% and 65.9 %, respectively, were also observed for patients with Roux-en-Y gastric bypass anatomywith a native papilla (n=44). Conclusion: High rates of diagnostic and procedural success were reported for SBE-ERC with the use of a cap, including a large subgroup of patients with Roux-en-Ygastric bypass and a native papilla. [ABSTRACT FROM AUTHOR]

The article offers information on the clinical guidelines imposed by the organization the European Society of Gastrointestinal Endoscopy (ESGE). The document explores on the important role of device-assisted enteroscopy and small-bowel endoscopy in the diagnosis as well as the treatment of the small-bowel disorders. Moreover, the recommendations of the ESGE are also stated.

In this series of four patients, some modifications of the standard over-the-wire (OTW) technique for stent deployment using the balloon overtube normally used in single-balloon enteroscopy are presented. This modified technique allowed the use of OTW stents in patients where there were difficulties that meant the standard technique was unsuccessful. For each patient, the authors describe different small novel adaptations of this modified technique that enabled self-expanding metal stents (SEMSs) and biodegradable stents to be successfully deployed in different gastrointestinal locations. Moreover, in one patient the stent was placed without fluoroscopic guidance. [ABSTRACT FROM AUTHOR]

Background and study aims: The role of endoscopic submucosal dissection (ESD) in Barrett's neoplasia is ill-defined, although it might provide a higher curative resection rate and better histologic assessment than endoscopic mucosal resection (EMR). We aimed to assess efficacy, safety, and long-term results of ESD. Patients and methods: A retrospective analysis was done of 75 consecutive patients with Barrett's esophagus who underwent ESD between January 2007 and February 2014.ESD was performed for visible lesions that were multiple, larger than 15mm, or poorly lifting, or suspected of submucosal infiltration. The primary end point was the rate of curative resection of carcinoma. Results: Median patient age was 68 years (interquartile range [IQR] 61-76), median follow-up was 20 months (IQR 8.5-37.5), and median maximum specimen diameter was 52.5mm (IQR 43- 71). En bloc resection rate was 90% (66 /73), and rates of curative resection of carcinoma and high grade dysplasia/carcinoma were 85% (47 /55) and 64% (42 /66), respectively. G3 differentiation and invasion to greater than pT1m2 were observed in 25% (14 /55) and 67% (37 /55) of patients with adenocarcinoma, respectively. There were 5 early (<48 hours) adverse events (2 delayed hemorrhages and 3 perforations), all treated endoscopically. No ESD-specific death occurred. Esophageal strictures developed in 60% of patients, all treated endoscopically. Additional treatment (median sessions 2 [IQR 2-3]) for residual Barrett's esophagus were recommended to 62% (42 /68). At latest follow-up, complete remission of neoplasia and intestinal metaplasia was found in 92% (54 /59) and 73% (43 /59) of patients, respectively. Conclusion: ESD appears to be safe and effective, with a high rate of curative resection of carcinoma. ESD should be considered for patients with Barrett's neoplasia at risk of incomplete resection or poor pathologic assessment with conventional EMR. [ABSTRACT FROM AUTHOR]

Background and study aims: Balloon-assisted enteroscopy (BAE) is a well-established procedure that is used worldwide for investigation of the small intestine. Previous reports describing the factors associated with perforation related to diagnostic BAE were limited by inclusion of only small numbers of patients who were mostly treated at a few specialized centers. The aim of this study was to clarify the factors associated with perforation by analysis of a large multicenter database. Patients and methods: This study retrospectively analyzed data from the Diagnosis Procedure Combination database in Japan. Patients who underwent diagnostic BAE between July 2007 and March 2013 were included. The primary outcome was the occurrence of perforation requiring open surgery. Logistic regression analysis was used to identify factors associated with perforation. Results: A total of 29 068 patients who underwent diagnostic BAE during the study period were identified. Perforation occurred in 32 patients (0.11 %). Univariable logistic regression analysis showed that patients with inflammatory bowel disease (IBD) on steroids had a significantly higher risk of perforation (odds ratio 8.55; 95% confidence interval 2.87-25.5; P<0.001). Non-IBD patients on steroids had an approximately threefold higher risk of perforation compared with patients whowere free from IBD and not taking steroids. Conclusion: Our results suggest that patients with IBD who are using steroids have the highest risk of perforation related to diagnostic BAE. [ABSTRACT FROM AUTHOR]

The article describes the case of a direct percutaneous endoscopic jejunostomy tube placement technique with the use of single-balloon enteroscopy with fluoroscopy, and presents the patient's medical history, and discusses the three components being focused by the method.

Background and study aims: Adverse events associated with overtube-assisted enteroscopy are similar to those with routine endoscopy. Our endoscopy quality program identified a number of respiratory adverse events resulting in emergency resuscitation efforts. The aim is to report all adverse events identified by quality monitoring and outcomes of adverse events associated with overtube-assisted enteroscopy. Methods: A retrospective study used data prospectively obtained from consecutive patients undergoing overtube-assisted enteroscopy between December 2008 and July 2012. Patient characteristics, medical history, procedure indication, and procedure outcomes, including diagnosis, endoscopic therapy, and complications, were obtained. Results: In 432 overtube-assisted enteroscopies, 15 adverse events (most frequently hypoxemia, 9/15, 60%) occurred in 14 patients (3.2% of total cohort; 12 were outpatients) mostly during antegrade enteroscopy. Four patients required endotracheal intubation and 4/12 outpatients required intensive care. The procedure was aborted in 13/14 patients, and only 1 of 10 patients scheduled for repeat antegrade enteroscopy returned. There was no mortality. Based on the frequency of adverse events, and in consultation with anesthesia providers, from August 2012 all antegrade overtube-assisted enteroscopies at our institution were done with general anesthesia. From then till September 2013, 145 antegrade and 52 retrograde overtube-assisted enteroscopies have been done, with no adverse events. Conclusions: Monitoring of endoscopy practice identified adverse events associated with overtube-assisted enteroscopy. The peer-review prompted a change in practice: all patients undergoing antegrade overtube-assisted enteroscopy at our institution now have endotracheal intubation which has dramatically decreased the rate of respiratory adverse events. The impact of endoscopic quality measurements on practices, procedures, and outcomes will be of further interest. [ABSTRACT FROM AUTHOR]

Background and study aims: A new on-demand enteroscopy (ODE) device has been designed to allow deep enteroscopy using a standard adult colonoscope with the aid of a novel through-the-scope balloon. The aims of the current study were to establish the feasibility, efficacy, and safety of ODE in performing anterograde and retrograde enteroscopy. Patients and methods: A retrospective, single-center study of 28 consecutive deep ODE procedures (11 anterograde and 17 retrograde) was performed. Diagnostic yield, therapeutic yield, technical success, procedure time, depth of maximal insertion (DMI), time to DMI, and adverse events were recorded. Results: The mean diagnostic and therapeutic yields were 45% and 36% for anterograde enteroscopy and 59% and 47% for retrograde enteroscopy, respectively. Technical success was achieved in 100%. For anterograde enteroscopy, the mean total procedure time was 24 minutes, with a mean DMI of 1.2m. For retrograde enteroscopy, the mean total procedure time was 31 minutes, with a mean DMI of 1.1m. No adverse events were recorded. Conclusion: Deep enteroscopy using a novel through-the-scope balloon and standard endoscope appeared to be feasible and safe, with rapid procedures times. [ABSTRACT FROM AUTHOR]

Background and study aim: Overtube-assisted enteroscopy (OAE) techniques have increased the ability to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass. The aim of this study was to compare the efficacy and safety of OAEERCP in patients with different configurations of upper gastrointestinal anatomy. Patients and methods: A systematic review was performed following a literature search for papers published between 1966 and August 2013. The following databases were searched: MEDLINE (via PubMed), Embase, Cochrane library, and Scopus. The following end points were analyzed: diagnostic and therapeutic success rates, cannulation success rate, ERCP success rate, type of enteroscopy, types of intervention, complications. Results: A total of 23 relevant reports on OAE procedures, including single-balloon, double-balloon, and spiral enteroscopy, were analyzed. Studies included a total of 945 procedures in 679 patients (age 2-91 years) who had a variety of postsurgical upper gastrointestinal anatomical configurations. Among patients who underwent Roux-en-Y with gastric bypass, endoscopic success was 80% and ERCP success was 70%. In patients who had undergone a Roux-en-Y with either a pancreaticoduodenectomy, pylorus-preserving pancreaticoduodenectomy, or hepaticojejunostomy, endoscopic success was 85% and ERCP success was 76%. In patients who had undergone a Billroth II procedure, endoscopic success was 96% and ERCP success was 90%. In patients with native papilla who underwent successful endoscopy, cannulation was successful in 90% of patients compared with 92% in patients with an anastomosis. Overall ERCP success for all attempts was approximately 74%. Interventions included sphincterotomy, pre-cut papillotomy, anastomotic stricturoplasty, stone removal, stent insertion, stent replacement, and balloon dilation of stenotic anastomosis. There were 32 major complications among the 945 procedures (3.4 %). Conclusion: Both endoscopic and ERCP success rates were highest in patients with Billroth II anatomy, followed by those with pancreaticoduodenectomy and Roux-en-Y hepaticojejunostomy; the lowest success rates were in patients with Roux-en-Y gastric bypass. Cannulation rates appeared to be equivalent in patients with both native papilla and biliary-enteric or pancreaticoenteric anastomoses. The diagnostic and therapeutic potential of balloon-assisted ERCP were high and the adverse event rate was low. [ABSTRACT FROM AUTHOR]

Background and study aims: Few data are available concerning the long-term outcome of patients treated endoscopically for bleeding small-bowel vascular lesions (SBVL). The aim of this study was to evaluate the risk of rebleeding after endoscopic therapy for SBVLs detected by video capsule enteroscopy (VCE). The secondary aim was to assess risk factors for rebleeding. Patients and methods: A prospective, multicenter study (15 centers) was conducted, involving patients with obscure gastrointestinal bleeding and SBVL on VCE who were treated during double-balloon enteroscopy (DBE). The likelihood of bleeding was defined according to VCE findings, as high or low. Results: A total of 183 patients underwent endotherapy during DBE, and 64 (35 %) had rebleeding during the 1 year follow-up period. Multivariate analysis indicated that cardiac disease (hazard ratio [HR] 2.04, 95% confidence interval [CI] 1.20- 3.48; P<0.01) and the presence of overt bleeding (HR 1.78, 95%CI 1.07-2.97; P=0.03) at presentation were associated with the risk of rebleeding. The association between chronic renal failure and the risk of rebleeding was close to statistical significance (HR 1.77, 95%CI 0.94-3.33; P=0.08). Kaplan-Meier analysis suggested that patients treated during DBE for a lesion with low likelihood of bleeding on VCE had higher rebleeding rates than those with a high likelihood of bleeding (HR 1.87, 95%CI 0.94-3.37; P=0.07). Conclusion: Despite long-term remission in most patients, about one-third had rebleeding at 1 year. Independent risk factors for rebleeding were cardiac disease and overt bleeding at original presentation. The lesion characteristics on VCE may be useful to evaluate the bleeding potential of the lesion and may be used for better selection of patients for DBE. [ABSTRACT FROM AUTHOR]

The article discusses the study on the benefits of double-balloon enteroscopy (DBE) for mesenchymal tumors of the small bowel. The researchers conducted a nine-year study on patients undergoing DBE with the common malignant tumors during deep enteroscopy. The advent of video capsule endoscopy (VCE) and deep enteroscopy has enabled the diagnosis of common small bowel tumors including neuroendocrine tumors (NET), adenocarcinomas, and gastrointestinal stromal tumors.

Background and study aims: After radiofrequency ablation (RFA) of Barrett's esophagus, it may be difficult to determine whether complete eradication of intestinal metaplasia at the neosquamocolumnar junction (neo-SCJ) in the cardia has been achieved. It is claimed that narrow band imaging (NBI) may predict the presence of intestinal metaplasia, which would enable immediate treatment. The aim of the current study was to evaluate whether inspection of the neo-SCJ with NBI after RFA results in reliable detection of intestinal metaplasia. Patients and methods: Patients with a normal-appearing neo-SCJ who were scheduled for RFA were included in the study. Two expert endoscopists obtained images from the neo-SCJ in overview (high resolution white light and NBI mode) and from four areas using NBI zoom, followed by corresponding biopsies. Four other blinded expert endoscopists evaluated the images for the presence of intestinal metaplasia and type of mucosal pattern (round, small tubular, large tubular, villous). Endpoints were sensitivity and specificity for identifying patients and areas with intestinal metaplasia. Results: From 21 patients overview images from 21 neo-SCJs and NBI zoom images from 83 neo- SCJ areas were obtained. Intestinal metaplasia was present in five overview images (24 %) and nine zoom images (11 %). Using the overview images, sensitivity and specificity for identifying patients with intestinal metaplasia were 65% (95% confidence interval [CI] 38-86) and 46% (95 %CI 33-60), respectively. For individual zoom images, sensitivity was 71% (95 %CI 54-85) and specificity was 37% (95 %CI 32-43). Conclusions: After RFA, endoscopic inspection of the neo-SCJ with NBI in overview or zoom does not reliably predict presence or absence of intestinal metaplasia. [ABSTRACT FROM AUTHOR]

And, finally, easy placement of a metal stent was achieved using the rendezvous method. The procedure was complicated by mesh migration and rectal necrosis requiring several surgical interventions, including an anterior resection of the rectum with surgical colostomy formation. [Extracted from the article]

Background and study aims: Carbon dioxide (CO2) insufflation has previously been shown to have advantages over air insufflation in terms of procedure- related pain and oral insertion depth during double-balloon enteroscopy. The aim of this prospective studywas to evaluate the performance of CO2 vs. air insufflation during single-balloon enteroscopy. Patients and methods: This study was a randomized European multicenter trial (ClinicalTrials. gov: NCT01524055). Patients and endoscopists were blinded to the type of insufflation gas used. Patient discomfort during and after the procedure was scored using a visual analog scale. Results: A total of 107 patients were enrolled in the study (52 in the CO2 group and 55 in the air group). Patient characteristics were comparable in both groups. The mean (±SD) oral intubation depth was not significantly deeper in the CO2 group vs. the air group (254±80 vs. 238±55cm; P=0.726). However, in patients with previous abdominal surgery, oral intubation depth was significantly higher in the CO2 group compared with the air group (258±84 vs. 192±42 cm; P<0.05). In patients undergoing SBE via the anal approach, CO2 showed no significant difference in intubation depth compared with air insufflation (86± 67 vs. 110±68 cm; P=0.155). The diagnostic yield was comparable (CO2 67%; air 73%). Procedure times, dosage of sedation, and therapeutic interventions did not differ between the two groups. Patients in the CO2 group reported less pain than those in the air group. Conclusions: This study demonstrated an advantage of using CO2 insufflation during single-balloon enteroscopy in patients with a history of previous abdominal surgery. Overall, single-balloon enteroscopy was a well-tolerated procedure that may benefit from the use of CO2 insufflation to reduce post-procedural pain. [ABSTRACT FROM AUTHOR]

Abbreviations: CO2, carbon dioxide; DBE, doubleballoon enteroscopy; MGCE, magnetic-guided capsule endoscopy; PC, patency capsule; PEG, polyethylene glycol; SBE, single-balloon enteroscopy; VCE, video capsule endoscopy. [ABSTRACT FROM AUTHOR]

This section summarizes studies on the use of small-bowel enteroscopy published in various medical journals. A study by Sanaka et al. examined the effectiveness of antegrade enteroscopy for evaluation and management of suspected small-bowel disease. Samaha et al. studied the long-term outcome of patients treated with double-balloon enteroscopy for small-bowel vascular lesions. The long-term outcome for patients after deep small-bowel spiral enteroscopy is evaluated.

Background and study aims: In double-balloon enteroscopy (DBE) the use of a reliable and practical method to calculate the insertion depth of the endoscope could help to improve diagnosis accuracy and optimize the effort and cost of the technique. The objectives of this work were to compare and evaluate two methods of estimating the insertion depth and to obtain a descriptive model capable of representing the exploration dynamics and efficiency in terms of advanced distance and time. Methods: Oral DBE was performed in 25 pigs. Insertion depth was calculated during the procedure by: 1) estimation of time and distance for each push and pull cycle during progression; and 2) estimation of distance during withdrawal. At the maximum insertion depth a tattoo was placed, and the observed measures for the two methods were compared with the distance between the pylorus and the mark after euthanasia and necropsy of the animals 1 week after DBE. Results: The average insertion depth during progression, withdrawal, and after necropsy was 324.92cm, 317.23cm, and 342.05cm, respectively (PAnova=0.72). The Pearson correlation coefficient (r>0.85; P <0.001) and paired Brand-Altman plots demonstrated high agreement between progression and necropsy (0.03% difference) and between withdrawal and necropsy (6.9% difference). The exploration dynamics and efficiency in terms of advanced distance per cycle and time fitted to potential and logarithmic regression models, respectively. Conclusions: Measurement of insertion depth in vivo was validated in the porcine model during progression and withdrawal. Estimation during progression was more accurate and allowed exploration dynamics and efficiency to be plotted, which might be used as approximate reference values for humans. [ABSTRACT FROM AUTHOR]

The article presents recommendations aimed at providing a reference document for the members of the Spanish Society for Digestive Endoscopy (SEED) on the endoscopic management of small bowel (SB) diseases. It notes the technological advances in capsule endoscopy (CE) and flexible enteroscopy (FE) that allowed endoscopic access to the whole SB. The techniques for CE along with its diagnostic concordance with FE and other imaging techniques and its use in follow-up of FE therapy are discussed.