Introduction

Small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) have revolutionized the investigation and management of small bowel pathology in the past two decades. Previous studies have reported on the yield of SBCE (60%) and DAE (57%) respectively¹, but these have reported on a seven-year period at most, and none have reported concurrently on the yield of SBCE, and any DAE performed as a direct consequence of SBCE.

Aims & Methods

To evaluate the indications, diagnostic yield, procedural factors, and interventions performed in consecutive patients undergoing SBCE and associated DAE, specifically double-balloon enteroscopy (DBE) at our institution, which is a quaternary referral centre for small bowel assessment with these investigations.
This was a single centre retrospective study of consecutive patients who underwent SBCE at the Alfred Hospital between 1^st January 2009 to 31^st December 2021. After obtaining institutional ethics approval, data were collected with respect to demographics, SBCE procedural factors and findings, as well as findings and interventions of any DBE procedures performed after the SBCE.

Results

A total of 1214 SBCEs were performed, with a median age of 66 years old (IQR 52 – 76; 60.8% men). The most common indications were anaemia (n=853, 70.2%), overt gastrointestinal bleeding (n=320, 26.4%), abnormal imaging (n=17, 1.4%), polyposis syndrome (n=11, 0.9%) and Crohn’s disease (n=9, 0.7%). The preparation was adequate in 1139 studies (93.8%) and a complete small bowel study was obtained in 1132 (93.2%). Of the complete studies, abnormal findings were detected in in 588 cases (51.9%), and most commonly these were angioectasias (266/588, 45.2%), erosions (106/588, 18.0%), ulcers (97/588, 8.6%), subepithelial lesions (48/588, 8.2%) and diverticulae (27/588, 4.6%). 165 patients proceeded to a DBE: 117 with an antegrade approach, and 48 with a retrograde approach. Antegrade DBE had a higher yield than retrograde DBE (77.8% vs 54.2%; p=0.002) and there was a higher proportion of procedures where intervention was performed (69.2% vs 37.5%; p<0.001).

Table 1: Outcomes of double-balloon enteroscopy (DBE) performed as a consequence to small bowel capsule endoscopy

Conclusion

The indications for SBCE at our institution are consistent with guidelines, and there is a similar yield of abnormal findings as compared to existing literature. DBE, especially antegrade DBE, had high diagnostic and therapeutic yield when pursued after a positive SBCE study. Our findings from this large dataset of consecutively studied patients over a decade in a real-world setting may aid decision-making for clinicians when utilizing SBCE and determining whether to perform DBE (and if so by which approach) to evaluate for small bowel pathology.

References

1. Hong SM et al. Diagnostic Yields and Clinical Impacts of Capsule Endoscopy. Diagnostics (Basel) 2021, Oct 5;11(10):1842

Introduction

Device-assisted enteroscopy (DAE) has become a well-established diagnostic and therapeutic tool for various small bowel disorders. However, unlike upper and lower gastrointestinal endoscopy, performance measures for DAE have rarely been studied.

Aims & Methods

We aimed to evaluate the performance measures for DAE across 11 hospitals in the United Kingdom (UK) and compare them with the quality benchmarks proposed by the European Society of Gastrointestinal Endoscopy (ESGE). We retrospectively collected data on patient demographics and DAE performance measures from electronic endoscopy records of consecutive adult patients (≥18 years old) who underwent DAE for diagnostic and therapeutic purposes between January 2017 and December 2022.

Results

A total of 1,529 DAE procedures were performed in 1,261 patients (median age 62 years, 53.5% male), of whom 13.6% had surgically altered anatomy. Almost all procedures (97.5%) were performed for appropriate indications, including small bowel bleeding (42.5%), small bowel tumours or polyps (19.1%), and suspected Crohn’s disease (12.5%). Double-balloon enteroscopy was used for most procedures (78.4%), followed by single-balloon enteroscopy (20.6%) and spiral enteroscopy (1%). The antegrade and retrograde approaches were used in 76.8% and 23% of cases, respectively. The estimated depth of insertion was documented in 65.7% of procedures, with a median depth of insertion of 200 cm (IQR 150 – 245) using the antegrade approach and 100 cm (IQR 50 – 163) using the retrograde approach. The point of maximal insertion depth was tattooed in 37.2% of procedures. The overall diagnostic yield was 69.4%, with vascular (27.8%) and inflammatory lesions (25.2%) as the most common diagnoses. Therapeutic interventions were performed in 44.4% of procedures, including argon plasma coagulation (25.3%), endoscopic haemoclipping (15%), polypectomy (8.2%) and stricture dilatation (3.2%). The interventions success rate was 97.7%, and 75.5% of detected or treated lesions were tattooed. General anaesthesia was used in 34.3% of the procedures, while conscious and deep sedation were used in 38.3% and 25.5%, respectively. Patient comfort was significantly better with deep sedation compared with conscious sedation (98.9% vs. 34.3%, p<0.0001). Complications occurred in 0.7% of the procedures, including 5 perforations, 3 cases of pneumonia, 2 cases of post-polypectomy bleeding, 1 episode of pancreatitis and 1 case of unstable cardiac arrhythmia.

Conclusion

Performance measures for DAE in the UK meet the ESGE quality benchmarks, with high diagnostic and therapeutic yields and a low incidence of complications. However, there is room for improvement in optimising sedation practices, increasing standardisation of depth of insertion documentation, and improving marking techniques to aid in the follow-up of detected or treated lesions.

References

Spada, Cristiano, et al. "Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative." Endoscopy 51.06 (2019): 574-598.

Introduction

Device-assisted enteroscopy (DAE) is the only exam capable of a panendoscopic diagnostic and therapeutic intervention in gastrointestinal tract. Despite the limited data, DAE appears to be a safe procedure in pediatric population. In fact, a few studies demonstrate ​the feasibility and safetiness of DAE in several clinical contexts, namely small ​bowel ​bleeding, polyposis syndromes or inflammatory bowel disease.

Aims & Methods

With this study, the authors aim to describe DAE experience, specifically balloon assisted enteroscopy, in a pediatric population of a tertiary center.
A unicentric retrospective study was performed in patients up to 18 years old undergoing DAE (either by anterograde or retrograde pathway), between January 2011 and February 2024.

Results

A total of 23 DAE exams from 16 patients were included in the study, 56% from the male gender. The study population had a medium age of 13 years (ranging from 4 to 18 years old). DAE was performed due to polyposis syndromes in 8 cases (6 cases of Peutz-Jeghers syndrome and 2 cases of juvenile polyposis) and in suspicious cases of middle gastrointestinal bleeding in 8 patients (5 with melena and 3 with ferropenic anemia). There was a total of 17 anterograde DAE, 5 retrograde DAE and 1 intraoperatory enteroscopy. 35% of the procedures were performed in an inpatient setting.
DAE had a diagnostic yield of 95%, identifying polyps in the small bowel or other locations, ulcers, small bowel stenosis and foreign body. A therapeutic procedure was performed in 56% of the cases, namely polypectomy, argon plasma coagulation and foreign body removal. A self-limited bleeding was observed in the first 24 hours after an anterograde DAE, solved without the need of an additional endoscopic or surgical procedure. DAE led to a modification in the clinical outcome in over 90% of the patients.

Conclusion

The present study confirms the safety profile of DAE in the pediatric population. In a cohort from a tertiary referral center, DAE led to therapeutic procedure in the majority of patients, without significant procedure related complications.

References

1. Pennazio, Marco et al. “Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.” Endoscopy vol. 55,1 (2023): 58-95.
2. Di Nardo, Giovanni et al. “Enteroscopy in children.” United European gastroenterology journal vol. 6,7 (2018): 961-969.

Disclosure

1. Pennazio, Marco et al. “Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.” Endoscopy vol. 55,1 (2023): 58-95.
2. Di Nardo, Giovanni et al. “Enteroscopy in children.” United European gastroenterology journal vol. 6,7 (2018): 961-969.

Introduction

The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized.

Aims & Methods

Compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for intestinal preparation for SBCE.
A prospective, multicentre, randomized clinical trial including consecutive patients submitted to SBCE was conducted. All patients were instructed to comply with a clear liquid diet and 12-hour fasting before the exam. After ingesting water and 100 mg of simethicone and swallowing the capsule, once it reached the small bowel, patients ingested a booster, randomized into one of three protocols: 1) 1 liter of polyethylene glycol (PEG), 2) 1 liter of PEG and ascorbic acid, 3) 1 liter of water. The patients’ bowel preparation was evaluated with SB-CLEAR. Each patient responded to a questionnaire about their tolerability.

Results

A total of 261 patients were included, 96 patients (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (p=0.655, p=0.193 and p=0.589, respectively). The overall SB-CLEAR score was similar among the protocols (p=0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5±0.1 vs 2: 2.6±0.1 vs 3: 2.3±0.1, p=0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (p=0.850). The patients’ reported tolerability was higher in protocol 3 (protocol 1: 2.8±0.1 vs 2: 3.0±0.2 vs 3: 0.6±0.1, p<0.001).

Conclusion

Using 1 liter of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield versus PEG with or without ascorbic acid.

Introduction

Per-Oral Endoscopic Myotomy (POEM) was introduced in clinical practice few years ago, and quickly become one of the first line treatments of esophageal motility disorders. We report on the outcomes of the first 1000 patients treated with POEM in a single tertiary referral center during 11 years.

Aims & Methods

The first 1000 patients treated with POEM between May 2011 and September 2022 were identified from a prospective database and included in this study.
Demographics, clinical and technical aspects and follow-up data were collected and analysed. After treatment, patients underwent a regular follow-up, after 6 month, 2 years, 5 years and 10 years. Additional follow-up visits were performed, if clinically indicated. Timed Barium Esophagram, EGD, and esophageal manometry were performed before endoscopic treatment and during post-operative follow-up; a 24-hour esophageal pH monitoring study was performed 6 months after POEM.
Clinical failure was defined by and Eckardt score > 3 and by the need for additional treatments.

Results

Mean age of patients was 51.5 years; 36 patients were younger than 18 years and 157 older than 70 years. Four-hundred ninety-eight patients were male. One hundred seventy-seven patients had received previous treatments for achalasia (110 pneumodilation, 46 surgical myotomy; 21 botulinum toxin injection).
A total of 141 patients had a type I achalasia, 626 a type II, 111% a type III, 30 non-achalasia spastic esophageal motility disorders; in 92 patients achalasia type were not adequately classified. A sigmoid-type esophagus was present in 45 patients.
Mean symptoms duration before POEM was 24±64.6 months.
POEM was technically successful in 979 patients.
The median length of myotomy was 8.0 cm (range 4-22 cm) in the esophagus and 3.1 cm (range 0-7 cm) in the stomach. An anterior myotomy was performed in the 83% of patients. Mean operative time was 50.4 minutes (11–180 minutes).
Length of hospital stay was a mean of 2.5 days (range 1 to 48 days) after POEM.
Mild or moderate complications occurred in 28 patients (2.8%) and were managed conservatively. Severe complications occurred in 2 patients and required prolongation of hospital stay and other interventional treatment. There were no perioperative deaths in our series.
A mean follow-up of 30.4 months (3–130 months) was available for 93.8% of patients. Overall clinical success rate (Eckardt score ≤ 3) was 95.1%. Clinical success was 97.3%, 95.2%, 90.8% and 82% after 6 months, 2 years, 5 years and 10 years, respectively.
Thirty-three patients (70.2 %) with clinical failure underwent pneumodilation (78.8% with persisting clinical benefits); 5 patients (10.6% underwent surgery), one (2.1%) underwent re-POEM.
Clinical success was 93.4% in achalasia-patients and 83.3% in those with spastic motility disorders (p=0.1742).
An altered esophageal pH-study was documented in 32.6% patients; esophagitis rate was 34% (88% grade A/B; 12% grade C/D). At the date of the last follow-up, 38% of patients was receiving daily proton-pump inhibitors for gastroesophageal reflux. Two patients underwent antireflux surgery. Non cases of post-operative Barrett esophagus were identified.

Conclusion

Our results confirm the efficacy of POEM in a large cohort of patients. Benefits of POEM seem durable; adverse events are rare and no specific mortality was reported. Prevalence of GERD is relatively high, but well controlled by medications in the vast majority of patients.

Introduction

Device-assisted enteroscopy (DAE) allows deep exploration of the gastrointestinal (GI) tract, combining its diagnostic abilities with tissue sampling and the application of endoscopic therapy. Although the application of artificial intelligence (AI) is growing exponentially in various imaged-based gastroenterology procedures, there is still a lack of evidence of the AI's technical feasibility and clinical applicability of DAE. Convolutional Neural Networks (CNN) are a multi-layer AI architecture with high-performance levels for image analysis.

Aims & Methods

This study aimed to develop and test a multi-brand CNN-based algorithm for automatically detecting multiple lesions in DAE.
A unicentric retrospective study was conducted to develop a CNN based on 258 DAE exams. DAE was performed by two experienced endoscopists using the double-balloon enteroscopy system Fujifilm EN-580T (n = 152), the single-balloon enteroscopy system Olympus EVIS EXERA II SIF-Q180 (n = 98), and the Olympus PowerSpiral Motorized Enteroscope PSF-1 (n = 8). A total of 11205 images from different segments of the GI tract (stomach, small bowel, and colon) were included, 2535 images containing protruding lesions (polyps, epithelial tumors, subepithelial lesions, and nodules), 1435 containing blood or hematic residues, 1395 images containing angioectasias and 450 images containing ulcers/erosions. The remaining images showed normal mucosa (n=5390). A training dataset comprising 80% of the total pool of images (n=8964) was used to develop the network. The output provided by the network was compared to a consensus classification provided. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and an area under the curve precision–recall curve (AUC-PR).

Results

The CNN model for automatic detection of GI protruding lesions identified these lesions with a sensitivity of 97.0%, a specificity of 97.4%, and positive and negative predictive values of 94.6% and 98.6%, respectively. The component for automatic detection of blood/hematic residues had a sensitivity of 95.8%, a specificity of 97.6%, and positive and negative predictive values of 91.4% and 98.9%, respectively. The CNN’s angioectasia model automatically detected angioectasia with a sensitivity of 88.5%, a specificity of 97.1%, and positive and negative predictive values of 88.1% and 97.0%, respectively. Furthermore, the CNN ulcers/erosions model automatically detected ulcers/erosions with a sensitivity of 100%, a specificity of 96.4%, and positive and negative predictive values of 96.8% and 100%, respectively. The algorithm’s accuracy was 98.7%. The AUC-PR was 1.00. The CNN analyzed images at approximately 239 frames per second, enabling AI live application in a real-life clinical setting in DAE.

Conclusion

The authors have developed a pioneer combined deep learning system for automatically detecting a wide range of lesions in different gastrointestinal tract segments. To our knowledge, this is the first study regarding the automatic multi-brand panendoscopic detection using Olympus PowerSpiral Motorized Enteroscope, overcoming a relevant interoperability challenge. Our results highlight that using a CNN to detect pleomorphic lesions is associated with high overall accuracy. The development of these tools may enhance the diagnostic yield of device-assisted enteroscopy in the setting of AI applications in digestive endoscopy, particularly for panendoscopic evaluation.

References

1. Goenka, M.K.; Majumder, S.; Kumar, S.; Sethy, P.K.; Goenka, U. Single center experience of capsule endoscopy in patients with obscure gastrointestinal bleeding. World J. Gastroenterol. 2011, 17, 774–778. [CrossRef] [PubMed]
2. Shahidi, N.C.; Ou, G.; Svarta, S.; Law, J.K.; Kwok, R.; Tong, J.; Lam, E.C.; Enns, R. Factors associated with positive findings from capsule endoscopy in patients with obscure gastrointestinal bleeding. Clin. Gastroenterol. Hepatol. 2012, 10, 1381–1385. [CrossRef] [PubMed]
3. Iddan, G.; Meron, G.; Glukhovsky, A.; Swain, P. Wireless capsule endoscopy. Nature 2000, 405, 417. [CrossRef]
4. Aoki, T.; Yamada, A.; Aoyama, K.; Saito, H.; Tsuboi, A.; Nakada, A.; Niikura, R.; Fujishiro, M.; Oka, S.; Ishihara, S.; et al. Automatic detection of erosions and ulcerations in wireless capsule endoscopy images based on a deep convolutional neural network. Gastrointest. Endosc. 2019, 89, 357–363.e2. [CrossRef] [PubMed]
5. Pennazio, M.; Rondonotti, E.; Despott, E.J.; Dray, X.; Keuchel, M.; Moreels, T.; Sanders, D.S.; Spada, C.; Carretero, C.; Cortegoso Valdivia, P.; et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline—Update 2022. Endoscopy 2023, 55, 58–95. [CrossRef]

Introduction

Some patients undergoing Capsule Endoscopy (CE) are at risk of retention and require Patency Capsule (PC). Due to limited CT scan access, most Irish CE units consider a visible PC on abdominal x-ray, 26-28 hours after ingestion as a failed test. Some patients with delayed GI transit may falsely fail their PC. Prokinetincs; Prucalopride and Gastrograffin is widely used in CE units as booster medications but their effect on PC has yet to be established.

Aims & Methods

To evaluate the role of Gastrografin, Prucalopride, and fasting in improving the pass rates of PC
Retrospective, observational comparative study between two PC regimens in Beaumont Hospital, Ireland: Group A (Non-fasting and Prucalopride 2mg ingested with PC alone) vs Group B (Fasting, Prucalopride 2mg and Gastrografin 50mls ingested with PC and 2mg Prucalopride on day of x-ray). Data was collected from electronic records. Student t-test was used to compare pass rates and p<0.05 considered significant.

Results

Demographics: Group A, n= 59, mean age 50.3 (18-82), 47.5% (n=28) males. Group B, n=30, mean age 50.6 (21-85), 53% (n=16) males.
Pass rates: Group A 61% (n=36) vs Group B 92%(n=27), p=0.002.
No PC adverse events and no medication side effects were noted in both groups.

Conclusion

This pilot study shows that Gastrografin, fasting and Prucalopride is a promising regimen with a high pass rates in patients undergoing PC. This strategy is lucarative in centers which has limited access to CT post PC. Fasting then ingesting PC promotes the gastro-ileal reflex increasing GI motility. Prucalopride and Gastrografin both have pro-motility effects. Furthermore, Gastrografin has the advantage of delineating the colonic wall on abdominal x-ray and improving pass rates. Further prospective multi-center studies will be needed to confirm our findings.