Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.

OBJECTIVE: Endoscopic therapy is increasingly being used in the treatment of high-grade intraepithelial neoplasia (HGIN) and mucosal adenocarcinoma (BC) in patients with Barrett's oesophagus. This report provides 5 year follow-up data from a large prospective study investigating the efficacy and safety of endoscopic treatment in these patients and analysing risk factors for recurrence. DESIGN: Prospective case series. SETTING: Academic tertiary care centre. PATIENTS: Between October 1996 and September 2002, 61 patients with HGIN and 288 with BC were included (173 with short-segment and 176 with long-segment Barrett's oesophagus) from a total of 486 patients presenting with Barrett's neoplasia. Patients with submucosal or more advanced cancer were excluded. INTERVENTIONS: Endoscopic therapy. MAIN OUTCOME MEASURES: Rate of complete remission and recurrence rate, tumour-associated death. RESULTS: Endoscopic resection was performed in 279 patients, photodynamic therapy in 55, and both procedures in 13; two patients received argon plasma coagulation. The mean follow-up period was 63.6 (SD 23.1) months. Complete response (CR) was achieved in 337 patients (96.6%); surgery was necessary in 13 (3.7%) after endoscopic therapy failed. Metachronous lesions developed during the follow-up in 74 patients (21.5%); 56 died of concomitant disease, but none died of BC. The calculated 5 year survival rate was 84%. The risk factors most frequently associated with recurrence were piecemeal resection, long-segment Barrett's oesophagus, no ablative therapy of Barrett's oesophagus after CR, time until CR achieved >10 months and multifocal neoplasia. CONCLUSIONS: This study showed that endoscopic therapy was highly effective and safe, with an excellent long-term survival rate. The risk factors identified may help stratify patients who are at risk for recurrence and those requiring more intensified follow-up.

Ileo-ileal invagination--a cause of recurrent mid-gastrointestinal bleeding: diagnostic and endoscopic therapy by means of push-and-pull enteroscopy.

The types of lesions that cause bleeding in the small bowel are similar to those found in other areas in the gastrointestinal tract, such as vascular malformations, ulcers and inflammatory lesions, neoplasms and other less common lesions like Meckel's diverticulum. This report describes three patients with suspected mid-gastrointestinal bleeding with no significant past medical history. Before presenting to our unit the diagnostic work-up such as oesophagogastroduodenoscopy, colonoscopy and radiological small bowel imaging such as conventional enteroclysis or magnet resonance imaging enteroclysis had been performed without detecting any bleeding source. Capsule endoscopy suspected an angiodysplasia in the terminal ileum in one patient, in the other two patients a polyp in the region of the ileum as the potential bleeding source was diagnosed. In all three patients, a polyp with an ulcerated tip was found with the anal push-and-pull enteroscopy. An endosocpic resection was performed in all three cases without complication with the exception of one. In this patient a perforation occured 3 days after resection and was treated surgically without further complications. Histology revealed in all three cases, a polypoid diaphragmatic invagination of the small bowel with a vast area of chronic ulceration on the tip of this pseudopolyp with infiltration of the muscularis propria. In summary, the present paper describes the rare cases of erosive pseudopolyps after ileo-ileal invagination treated with endoscopic resection by means of push-and-pull enteroscopy.

Push-and-pull enteroscopy using a single-balloon technique for difficult colonoscopy.

BACKGROUND AND STUDY AIMS: Several factors predict difficult or incomplete colonoscopy with a standard colonoscope, including female gender, low body mass index, extensive diverticulosis, and prior pelvic surgery. PATIENTS AND METHODS: A push-and-pull enteroscopy device and a single-balloon technique was used in 14 patients (six men, eight women; mean age 62 +/- 15 years) after failure of ileocolonoscopy or endoscopic therapy using either a standard or a pediatric colonoscope. The original ileocolonoscopy had been performed to investigate colon polyps (n = 6), an obscure inflammatory process in the ileocecal region (n = 6), or iron deficiency anemia with a positive fecal occult stool test (n = 2). RESULTS: Ileocolonoscopy was successfully performed using this push-and-pull technique in all 14 patients without technical problems or complications. All the endoscopic therapeutic interventions that were required were also performed without complications, with the exception of one instance of bleeding. Multiple polyps were found in six patients; a colon cancer was found in one patient; appendicitis combined with a carcinoid tumour of the appendix was diagnosed in one patient; ileocolitis was observed in two patients; one patient with Crohn's disease had stenoses in the region of an anastomosis; and in three patients no relevant pathological finding was seen. CONCLUSION: It was possible to perform ileocolonoscopy with therapeutic interventions using this new thin push-and-pull enteroscopy device with a single-balloon technique in patients who had previously undergone incomplete colonoscopy using a standard colonoscope.

Extraction of entrapped capsules from the small bowel by means of push-and-pull enteroscopy with the double-balloon technique.

The new technique of push-and-pull enteroscopy using the double-balloon technique (double-balloon enteroscopy) makes it possible to remove swallowed foreign bodies causing intestinal obstruction deep in the small bowel without the need for surgical laparotomy. This report describes two cases of enteroscopic removal of entrapped capsules. In one patient with acute recurrent intestinal bleeding and recurrent abdominal pain, Crohn's disease had been suspected on capsule endoscopy. The second patient, with known Crohn's disease, was suffering from abdominal pain and underwent capsule endoscopy for investigation of the small bowel. Prior enteroclysis had not revealed stenoses in either patient. An oral approach was chosen and the capsules were identified approximately 140 cm and 310 cm from the pylorus, respectively, in front of stenoses. The capsule endoscopes were removed successfully in both patients by means of push-and-pull enteroscopy using a new enteroscope device.

Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study.

BACKGROUND AND STUDY AIMS: The aim of this study was to evaluate the feasibility, safety, and clinical impact of push-and-pull enteroscopy (PPE) in patients with suspected or documented small-bowel diseases, in a prospective multicenter trial in three European medical centers. PATIENTS AND METHODS: A total of 100 patients (mean age 56 +/- 16 years; range 13 - 90) were included at the three institutions between July and November 2004. The leading symptoms were: acute recurrent or chronic gastrointestinal bleeding (n = 64), polyposis syndrome (n = 8), chronic abdominal pain (n = 7), chronic diarrhea (n = 7), and others (n = 14). RESULTS: No major PPE-associated complications such as perforation, bleeding, or relevant injury to the small-bowel tissue or mesentery were encountered. Minor complications occurred in 12 %. The mean time required to carry out the procedure from the oral and anal approaches was 75 +/- 19 min (32 - 150 min). The average insertion depths into the small bowel were 200 +/- 70 cm per PPE session (220 +/- 90 cm with the oral approach and 130 +/- 80 cm with the anal approach). The average radiation exposure (including diagnostic and therapeutic interventions) was 2.1 +/- 2.4 min and 155 +/- 159 dGy/cm2. PPE was fully diagnostic in 72 % of cases. The majority of the patients (34 %) were suffering from angiodysplasias; ulcerations and erosions of various etiologies were seen in 16 %, and polyps and tumors in 13 %. The PPE findings played a role in the subsequent treatment in 62 % of the patients. Endoscopic treatments, including argon plasma coagulation, polypectomy, dilation, and foreign-body extraction, were carried out in 42 %. Medical treatment was given in 12 %, and patients were referred for surgery in 8 % of cases. CONCLUSIONS: This prospective analysis shows that PPE is safe and has a high diagnostic and therapeutic yield in patients with suspected or known small-bowel disease.

Push-and-pull enteroscopy using the double-balloon technique: method of assessing depth of insertion and training of the enteroscopy technique using the Erlangen Endo-Trainer.

BACKGROUND AND STUDY AIMS: This study was conducted to test a method of measuring the depth of insertion into the small bowel during push-and-pull enteroscopy using the Erlangen Endo-Trainer. Furthermore, the Erlangen Endo-Trainer model for training in the new method of push-and-pull enteroscopy using the double-balloon technique was also evaluated. MATERIALS AND METHODS: Specially prepared packages of porcine upper visceral organs were used, including the esophagus, stomach, duodenum, and small bowel, implanted into the Erlangen Endo-Trainer. In the first step of this study, all of the modifications needed to obtain a model useful for training in the new enteroscopy technique were tested, including different lengths of small bowel. In the next step, the Erlangen Endo-Trainer was used to evaluate a special method of measuring the depth of insertion during push-and-pull enteroscopy by comparing estimated insertion depths of 100 cm and 200 cm, marked on the porcine small bowel, with endoscopic insertion depths determined afterwards by measuring the length of the small bowel from the pylorus to the mark on the porcine small bowel. Additionally, the Endotrainer was used to demonstrate the principle of double-balloon enteroscopy and to provide training in this new enteroscopy technique with a lifelike simulation. RESULTS: The modified Erlangen Endo-Trainer proved its value for demonstrating the principle of push-and-pull enteroscopy and for providing training in this enteroscopic technique as well as for testing the measurement method. The evaluation of the measurement method showed that the estimation of the insertion depths was accurate, with a mean deviation of less than 10 %. A total of 13 workshops (seven national and six international), including a total of 97 participants, were carried out between January and August 2004. Under the supervision of one of the authors, pairs of trainees were able to reach the ileal valve or the end of the small bowel from the oral route. CONCLUSIONS: The modified Erlangen Endo-Trainer is useful for training in the push-and-pull enteroscopy technique. The new specially developed method of measuring the depth of insertion during push-and-pull enteroscopy seems to be valid.

Double-balloon enteroscopy: preliminary experience in patients with obscure gastrointestinal bleeding or chronic abdominal pain.

BACKGROUND AND STUDY AIMS: Even in the era of capsule endoscopy, diseases of the small bowel are sometimes difficult to diagnose, and endoscopic treatment is not possible without surgical laparotomy. The new method of carrying out enteroscopy using a double-balloon technique allows not only diagnostic but also therapeutic endoscopic interventions for lesions in the small bowel. Preliminary experience with this new method is reported here. PATIENTS AND METHODS: Between the end of March 2003 and August 2003, eight patients (four women, four men; mean age 59 +/- 23 years, range 20 - 90) with chronic gastrointestinal bleeding or abdominal pain, or both, underwent enteroscopy using the double-balloon technique. Seven of the patients had been suffering from chronic gastrointestinal bleeding for 56 +/- 49 months (range 3 - 120 months, median 48 months). The lowest hemoglobin levels ranged from 3.6 g/dl to 8.6 g/dl (mean 6.7 +/- 1.7 g/dl), and a mean of 7.6 +/- 5.6 (range 1 - 15) blood units had been transfused. Capsule endoscopy was carried out in six patients, revealing angiodysplasias in three, suspected Crohn's disease in one, fresh blood in the small bowel without a lesion in one, and a focal enanthema in another patient. RESULTS: Enteroscopy with the double-balloon technique was carried out using the oral approach in all patients and additionally with the anal approach in four patients. In two patients with multiple angiodysplasias, it was possible to examine the whole small bowel and to treat the angiodysplasias. All of the capsule endoscopy findings were confirmed; a definite bleeding source was found and treated in two patients with unclear bleeding, and in another patient the real bleeding source was found (not angiodysplasia). The enteroscopy system was easy to handle in all cases. No complications occurred. It was possible to carry out the procedure with the patients under sedoanalgesia. CONCLUSIONS: This new enteroscopy system is easy to handle and seems to be safe. Visualization of the whole small bowel is possible using both the oral and anal approaches. Enteroscopy with the double-balloon technique promises to become a standard method for diagnostic and therapeutic endoscopy of the small bowel without surgical laparotomy.