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1 U.S.L. AVEZZANO - SULMONA Ospedale SS Filippo e Nicola U.O. ENDOSCOPIA DIGESTIVA (Direttore Dott. Antonio Sedici) double-balloon balloon enteroscopy new gold standard for small-bowel imaging? A. Sedici G.I. hemorrhage is a common and clinically significant health care problem, associated with meaningful percentage of hospital admissions 100/ upper G.I. bleeding sources 20/ lower G.I. bleeding sources Longstreth: Am. J.Gastroenterol
2 STANDARD ENDOSCOPY (LIMITS EXPLORED) UPPER G.I. TRACT (ligament of Treitz) Peptic lesions 70% Esophageal-gastric varices 10% Mallory-Weiss tears 7% LOWER G.I. TRACT (ileocecal valve) Divertitucolsis 20% - 55% Angiodisplasya 3% - 35% Cancer or polyps 8% - 30% Silverstein: Gastroint. Endosc Zuckerma: Gastroint. Endosc OBSCURE G.I. BLEEDING in up to 5% of cases, however, patients may present with obscure G.I. bleeding, defined as the absence of identified source of hemorrhage after standard evaluation by upper endoscopy and colonoscopy Rockey: N. Engl. J. Med
3 OBSCURE G.I. BLEEDING (diagnostic yeld) Barium contrast examinations 0% - 20% Technetium Tc99m 20% - 40% (labled red-blood-cell scintigraphy 0,1-0,5 cc/min.) Angiografy 40% - 60% (active bleeding terapeutic intervention) Gutierrez: Am. Surg Rollins: Am J roentgenol endoscopic examination of the small-bowel for G.I. bleeding is possible by using Push h enteroscopy Capsule endoscopy Intraoperatve enteroscopy Double-balloon enteroscpy the diagnostic yeld for double-balloon enteroscopy surpasses other imaging modalities and allows therapeutic intervention Keizman: Gastroint. Endosc
4 Double-balloon balloon endoscopy system EN-450T5 (enteroscope) Overtube specification PB-20 balloon pump remote controller Processor EPX-4400 Fujinon Corporation Double-balloon balloon enteroscopy: tecnique double-ballon ballon enteroscopy, first described by Yamamoto and colleagues in 2001, is an exciting new endoscopic technique that allows complete visualization of the small-bowel by using a 200- cm. Fujinon enteroscope equipped with a 140-cm. overtube Yamamoto: Gastrointest. Endosc
5 Double-balloon balloon enteroscopy: tecnique 1 the overtube than can be inserted while the endoscope balloon is inflated 2 by inflating the over tube balloon enougth to grip the intestinal wall 3 the endoscope can be inserted further without forming redundant loops in the small-bowel Yamamoto: Gastrointest. Endosc Double-balloon balloon enteroscopy: indications 1 unexplained digestive bleeding 2 crohn s diesease 3 radiographic abnormalities of the small-bowel 4 unexplained chronic diarrhea and addominal pain 5 multi multi-generating polyps May: Gastrointest. Endosc
6 Double-balloon balloon enteroscopy: outcomes 1 the mean examination time for anterograde and retrograde approaches averaged 73,5 and 75 minutes (p non significant) 2 significantly more mucosa visualized via the oral approach (235 cm. vs. 120 cm., p<0,0001) 3 patients are able to tolerate the examination with standard conscious sadation or propofol administered by anesthetist May: Gastrointest. Endosc Double-balloon balloon enteroscopy: outcomes 1 the japanese experience demostrated that total enteroscopy was possible in 86% of cases, documented by indian ink injection at the most distal point during the anterograde approach 2 in contrast to the Yamamoto series, May et al. attempted total enteroscopy in 45% of cases May: Gastrointest. Endosc
7 Preliminary experience with double-balloon balloon enteroscopy D.B.E. was introduced in the ours endoscopy unit in the fall of procedures in 6 patients with suspected small-bowel disorders 2 mean examination time was 125 minutes (range minutes) 3 mean deep exploration was 280 cm. (range ) 4 4 diagnosed pathological conditions (jejunal carcinoma, crohn s diesease, jejunal ulcer, angiodysplasia) Preliminary experience with double-balloon balloon enteroscopy 1 jejunal jj l carcinoma 2 crohn s diesease 3 jejunal ulcer 4 angiodysplasia 7
8 Preliminary experience with double-balloon balloon enteroscopy unexplained digestive bleeding (chronic anemia of strict degree) capsule endoscopy TC-scan D.B.E. surgery DIAGNOSIS: jejunal carcinoma Double-balloon balloon enteroscopy: future questions 1 because double-balloon balloon enteroscopy is a new therapeutic procedure, it is currently not known when it should be performed during the evaluation of obscure GI bleeding 2 while capsule endoscopy appears to be a reasonable initial diagnostic imaging test, miss rate of up to 36% have been reporter with the capsule because of limted 140 field of view 3 training of endoscopists in the techniques of bouble-balloon balloon enteroscopy is another area that requires investigation May: Endoscopy 2005 Appleyard: Gastroenterology
9 Double-balloon balloon enteroscopy: conclusion 1 double double-balloon balloon enteroscopy is an exciting new technology for imaging of the small bowel 2 the diagnostic yeld from double-balloon balloon enteroscopy appears to surpass other imaging modalities, while allowing the opportunity for therapeutic intervention 3 disadvantages of the technique include a long examination time and additional sedative medication, the need for supplemental staff and the need for fluoroscopy for direction of loop redution Lauren: Gastroint. Endosc nothing is too high for a man to reach but he must climb with care and confidence Hans Christian Andersen
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