Characterization of oral double balloon endoscopy in the dog.

Exploration of the canine small intestine using conventional endoscopy is restricted to the duodenum and/or the ileum. Double balloon endoscopy (DBE) is a 'push and pull' technique that has been described in humans and permits a complete exploration of the small intestine. In this study, oral DBE was performed on 12 healthy dogs (10-34kg) to characterize for the first time the efficiency, exploration dynamics and safety of the technique. DBE was successful in 83% of dogs; the average estimated insertion depth of the endoscope was 287±36cm, and the average duration of the exploration was 84±8min. No complications or relevant adverse clinical effects were observed, and there was no indication of post-procedure pancreatitis based on serology of two specific markers of pancreatitis (amylase and lipase) and the immediate nonspecific inflammatory mediator C-reactive protein. The study showed that oral DBE is viable and safe in the dog, allowing for the diagnosis and treatment of gastrointestinal diseases deep in the small intestine to an extent that has not previously been possible using conventional endoscopy.

Validity of insertion depth measurement in double-balloon endoscopy.

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 324.92 cm, 317.23 cm, and 342.05 cm, respectively (P Anova = 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.

Morphometric study of the layers of the canine small intestine at five sampling sites.

The histology of the canine intestine has not been accurately defined. To establish the precise thickness of its different layers, whole wall samples of the small intestine were removed from 41 cadavers at five standardised sampling sites (duodenum, proximal jejunum, distal jejunum, proximal ileum and distal ileum). The total thickness was estimated by morphometry, as was the thickness of the mucosa, muscularis mucosae, submucosa and muscularis externa. In addition, the size of the lymphoid aggregates in the submucosa and the thickness of the circular and longitudinal layers within both the muscularis mucosae and the muscularis externa were estimated. The total intestinal thickness depended very much upon the thickness of the mucosa and submucosa. The mucosa decreased progressively from proximal to distal parts of the small intestine (47% reduction). The thickness of the submucosa, however, changed little from the duodenum to the distal jejunum, but increased significantly in the ileum; this change was positively correlated with the amount of lymphoid tissue. Sex influenced the thickness of the intestinal wall, with males displaying higher thickness values along the small intestine. Conversely, no correlation between bodyweight and intestinal thickness was found for any of the five sampling sites. This study gives absolute and relative values for the thickness of the layers of the dog intestine which might help in the diagnosis of small intestinal pathology from postmortem samples and/or endoscopic biopsies.

Morphometry of the canine intestine with reference to the use of double balloon endoscopy.

Double balloon endoscopy (DBE) enables the diagnosis and treatment of small intestinal disease. The dog is a potential animal model for DBE training and also a candidate for the clinical application of this technique. However, the anatomy of the canine small intestine may limit the use of DBE by restricting the push-and-pull manoeuvres required for DBE. To establish what these limitations are, the length and width of different portions of the small intestine as well as the mesenteric dependences were measured in 55 dogs. Several external parameters related to body size plus the age, weight, sex and breed were recorded. Potential restriction of the progress of the enteroscope due to narrow intestinal diameter is expected in the jejunum of mid- and small size dogs.

Gastrojejunal anastomosis stricture after laparoscopic gastric bypass. Our experience with 62 patients.

OBJECTIVE: Gastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass (LGBP), but its frequency is about 15% according to bibliography. Our aim is to present our experience after 62 LGBP. PATIENTS AND METHOD: From January 2004 to September-2006, we performed 62 consecutive laparoscopic gastric bypass (Wittgrove's technique). The gastrojejunal anastomosis is performed with auto suture material type CEAA No 21 termino-lateral (ILS, Ethicon). In 4 cases (6.45%) was converted to laparotomy, perform the anastomosis in the same way. Monitoring has a range of 3-35 months, conducted in 61 patients because one patient died of pulmonary thromboembolism in the immediate postoperative period after reoperation, after two weeks of gastric bypass, by necrosis of a small fragment of the remnant gastric. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation (recommending dilate the anastomosis to a maximum 1.5 cm). RESULTS: Five cases (8.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and in 1 case by endoscopy. Two patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion (circumferentially sclerosis within 48 hours of surgery and sclerosis of bleeding points). All cases were resolved by endoscopic dilatation. At follow-up has not been detected re-stricture. CONCLUSION: Clinically, gastrojejunal stricture results in a progressive oral intolerance, revealing stenosis between 1 and 3 months postoperatively. The situations of sclerosis of the bleeding lesions favor, especially in cases of extensive sclerosis. In cases of suspected barium transit offers us a high diagnostic yield. Endoscopic dilatation resolved, so far, all cases.

Transesophageal access to the cardiac cavities and descending thoracic aorta via echoendoscopy. An experimental study.

OBJECTIVE: The applications of endoscopic ultrasonography have diversified over recent years. The possibility of reaching cardiac territory has been successfully explored in experimental models, opening up a new field of possibilities for diagnostic and therapeutic interventions that were unthinkable until very recently. The aims set out in this study are to evaluate cardiac anatomy, its approach, the safety of the experimental procedure and the resulting morphological and histological changes after the procedure. MATERIAL AND METHODS: The study has been performed on two adult pigs. They have undergone different surgical approaches to the cardiac cavities and descending thoracic aorta with excellent results. RESULTS: Different cardiac structures have been identified and operated upon (right auricle, left auricle, left ventricle, cardiac valves), as well as major vessels. The use of contrast, both intracavitary and from a peripheral vein, enabled us to verify the anatomical spaces studied. During the procedures we monitored for arrhythmias, hemodynamic behavior, possibility of infection by obtaining sample hemocultures before and after procedures, and response to punctures. CONCLUSIONS: The present study has enabled us to evaluate access to the heart from the esophageal lumen using endoscopic ultrasonography, with results that are very similar to those described in the current bibliography. However, we offer two novelties: puncture of the right auricle through the interauricular partition and puncture of the descending thoracic aorta, both performed with ease and apparent safety.

Colonoscopy quality assessment.

AIM: Colonoscopy has become accepted as the most effective method for colon exploration. Some application problems have been detected in the setting of normal clinical care due to its wide range of uses in recent years, and therefore there is a need to measure colonoscopy quality. For that purpose valid quality indicators are necessary to be defined. The application process of some quality indicators is presented in this study. The proposed indicators in this study are: quality of bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate, and adenoma removal rate. MATERIAL AND METHOD: This is a prospective 12-month study where colonoscopies performed in the VI health area of Murcia Region were evaluated. From February 2006 to February 2007 a total of 609 subjects were eligible for colonoscopy after a positive fecal blood test in the setting of a colorectal cancer screening program. A sample of thirty patients (n: 30) was considered representative to assess the reliability of quality indicators and for a preliminary analysis of results. RESULTS: Indicators results are: quality of bowel preparation (87%), kappa 0.74 (95% CI: 0.48-0.99); cecal intubation rate (90%) 0.74 (95% CI: 0.49-0.99); adenoma detection and removal rate (96%), kappa: 0.78 (95% CI: 0.53-0.99); withdrawal time: 13.36 min (95% CI: 10.48-16.11). Kappa: 0.78 (95% CI: 0.49-0.99). CONCLUSIONS: Quality indicators definition and application in colonoscopy performance is possible. More studies are necessary to define the role of these indicators in the setting of clinical practice.

Double-balloon enteroscopy in two dogs.

It is difficult to insert a flexible endoscope deep into the small intestine. A new method, double-balloon enteroscopy, has been developed to improve access to the small intestine, and the aim of this study was to evaluate its usefulness for examination of the small intestine of dogs. The method uses two balloons, one attached to the tip of the endoscope and another attached to the tip of an overtube. The double-balloon endoscope is advanced through the intestine by being held alternately by the balloon on the endoscope and the balloon on the overtube. The technique was applied in two dogs of medium size, using both oral and anal approaches, and it was possible to examine the whole surface of the mucosa of their small intestines.

Complications of double balloon enteroscopy: a multicenter survey.

BACKGROUND AND STUDY AIMS: Double balloon enteroscopy (DBE) is a new technique for the visualization of the small bowel. Although the technique is widely used, little is known about the complications. A few complications have been reported in the literature, mainly in case reports. The aim of this study was to establish the complication rate of both diagnostic and therapeutic DBE. PATIENTS AND METHODS: A total of 10 centers (nine academic centers and one teaching hospital) across four continents participated in the study. Complications were defined according to the literature. A therapeutic DBE was defined as a DBE with use of argon plasma coagulation, a polypectomy snare, injection of fluids (other than ink for marking), removal of foreign body, or balloon dilation. RESULTS: A total 85 adverse events were reported in 2362 DBE procedures. In all, 40 events fulfilled the definition of a complication, 13 in 1728 diagnostic DBE (0.8 %) and 27 during 634 therapeutic procedures (4.3 %). The complications were rated minor in 21 (0.9 %), moderate in 6 (0.3 %) and severe in 13 procedures (0.6 %). No fatal complications were reported. Seven cases of pancreatitis were reported, six after diagnostic (0.3 %) and one after therapeutic (0.2 %) DBE. CONCLUSIONS: Diagnostic DBE is safe with a low complication rate. The complication rate of therapeutic DBE is high compared with therapeutic colonoscopy. The reason for this is unclear. The incidence of pancreatitis after DBE is low (0.3 %), but has to be considered in patients with persistent abdominal complaints after a DBE procedure.

Double-balloon enteroscopy: a descriptive study of 50 explorations.

AIM: To evaluate the utility of double-balloon enteroscopy for small-bowel disease. DESIGN: A prospective study of 50 consecutive enteroscopies performed from December 2004 to July 2005 to analyze diagnoses and treatments. PATIENTS: 44 patients (33 had undergone a previous capsule endoscopy) with indications for obscure digestive hemorrhage, angiodysplasia, Peutz-Jeghers syndrome, ulcer, suspected Crohn's disease, tumors, and refractory celiac disease. RESULTS: We carried out enteroscopy studies in 44 patients by the oral route and, in 6 additional patients, by both the oral and anal routes. We reached the ileon with the oral route in all cases but one (jejunal stenosis), and in 4 cases out of 7 with the anal route, with an average duration of 73 minutes. We found angiodysplasia in 19 cases, as well as NSAID-related enteropathy, Crohn's disease, diverticulosis, and Waldenström's disease. We performed biopsies in 31% of cases with diagnoses of adenocarcinoma, lymphangiectasia secondary to tumor in celiac disease, and Whipple's disease. We treated 19 patients with angiodysplasia (1 to 20 synchronous lesions) with argon, and 4 patients with polyps using polipectomy (sporadic polyps or Peutz-Jeghers syndrome). A retained capsule in one patient with stenosis was removed. CONCLUSIONS: Double-balloon enteroscopy is a useful and effective technique in the diagnosis and treatment of small intestine diseases, thus complementing capsule endoscopy. More studies are needed to analyze its impact on the management of this condition.

A shortened, 2-hour rifampin test: a useful tool in Gilbert's syndrome.

INTRODUCTION: Diagnosis of Gilbert's disease often involves unnecessary testing and patient anxiety. Rifampin test can support the diagnosis; it has been described in short series and lacks standardization in dose, collection times, result presentation and interpretation. Our objective was to compare the response to oral rifampin in a series of patients with Gilbert's disease, 2 and 4 h after drug administration. PATIENTS AND METHODS: Eighty-nine patients with Gilbert's disease (elevated total bilirubin with no hepatopathy or hemolysis) were recruited. After a basal blood collection, 900 mg rifampin were administered per os and new samples were drawn 2 and 4 h later. Total and esterified bilirubin were measured in every sample. Haptoglobin concentration was also analyzed. RESULTS: When expressed as relative increase with respect to basal values, variations observed 2 h after rifampin intake were all above 15%. A significant correlation (r = 0.902; p = 0.000) was found between relative increases 2 and 4 h after drug administration. No significant variations were found in haptoglobin concentrations. CONCLUSION: Rifampin test is useful in diagnosing Gilbert's disease, but variations in total bilirubin concentrations (basal and post-rifampin) make that no absolute cut-off value can be used. Correlation between 2- and 4-h relative increases suggests that a shortened version could simplify the test.