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

Device-assisted enteroscopy (DAE) plays an important role in management of enteric lesions. Endoscopic observation of erosions or ulcers is frequent and can be associated in many nosologic entities, including Crohn’s disease and non-steroid anti-inflammatory drug-induced enteropathy. Despite the rapid expansion of artificial intelligence (AI) application in different image-base procedures of gastroenterology, there is still lack of evidence of AI relevance during DAE. This study aimed to develop and test a Convolutional Neural Network (CNN)-based model for automatic detection of ulcers and erosions during DAE.

Aims & Methods

A unicentric retrospective study was conducted for the development of a CNN, based on a total of 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). After double validation, a total of 29513 images were used, of which 633 were considered ulcers or erosions. Data was separated into two sets: training and validation, with the latter being used for the evaluate the model’s performance. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and area under the curve precision-recall curve (AUC-PR).

Results

Sensitivity and specificity were 86.2% and 99.8%, respectively. PPV and NPV were 91.8% and 99.7%, respectively. Overall accuracy of the CNN was 99.5%. The AUC-PR was 1.00.

Conclusion

To the best of our knowledge, this is the first CNN constructed and validated for automatic detection of ulcers and erosions during DAE, including spiral enteroscopy. The high diagnostic performance of this CNN in multidevice solves a significant issue of technological interoperability, allowing it to be replicated in many technological contexts.

Introduction

Balloon-assisted enteroscopy (BAE) is an important diagnostic tool for small bowel evaluation, especially following a positive Video Capsule Endoscopy (VCE) or Cross-Sectional Imaging (CSI). However, the diagnostic yield of BAE in this context remains variable.

Aims & Methods

This retrospective study aimed to evaluate the diagnostic yield of BAE performed following positive imaging. All BAE procedures conducted between 01/2009-12/2024 following a positive CSI (CT or MRI) or VCE within 12 months prior to the procedure were included. Clinical characteristics, procedural indications (polyp/mass, suspected bleeding or inflammation), and imaging modalities were compared between groups. A classification tree analysis explored factors associated with a positive diagnostic yield.

Results

Among 224 BAE procedures, the diagnostic yield was 58.5% (131 positive findings). No significant differences were observed between positive and negative groups regarding sex, age, indication, pre-BAE imaging modality (VCE or CSI), route, or depth of insertion. Classification tree analysis identified bleeding-related indications (e.g. overt bleeding or angioectasias) as the strongest predictor of positive yield (74.5% vs. 50%, p=0.005), particularly with antegrade BAE. However, cross-validation failed to generate a stable model, with a misclassification risk of 41.5% (±3.3), indicating limited predictive accuracy.

Conclusion

In this large retrospective study spanning 15 years, BAE following positive imaging demonstrated a diagnostic yield of nearly 60%. While demographic and procedural factors were not predictive, bleeding-related indications were significantly associated with positive findings, highlighting the importance of clinical context in guiding BAE use. These findings may help optimize patient selection and improve procedural efficacy.

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

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