Utility of a Passive Bending Colonoscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy.

BACKGROUND AND AIM: The utility of a passive bending colonoscope (PBCS) in ERCP for patients with surgically altered anatomy has not been established. This study compared the outcome of PBCS-ERCP and balloon-assisted enteroscope (BAE)-ERCP. METHODS: This multicenter observational study included 343 patients with surgically altered anatomy who underwent ERCP. Among these, 110 underwent PBCS-ERCP and 233 underwent BAE-ERCP. Propensity score matching was applied, and a final cohort of 210 (105 in each group) with well-balanced backgrounds was analyzed. The primary outcome was the success rate of reaching anastomosis or ampulla of Vater. Secondary endpoints included the cannulation success rate, completion rate, procedure time (to reach, cannulate, complete), and adverse events. RESULTS: The success rate for reaching the target was 91.4% (96/105) with PBCS and 90.5% (95/105) with BAE (odds ratio [95% CI] 1.12, [0.44-2.89], P = 0.809). The mean time required to reach the target was significantly shorter in PBCS: 10.04 min (SD, 9.62) with PBCS versus 18.77 min (SD, 13.21) with BAE (P < 0.001). There were no differences in the success of cannulation or procedure completion, although the required times for cannulation and procedure completion were significantly shorter in PBCS. The incidence of adverse events was significantly higher in BAE (19.0%) than in PBCS (4.8%; P < 0.001). CONCLUSIONS: In patients with surgically altered anatomy, PBCS-ERCP showed promising results with shorter time to reach, cannulate, and a lower incidence of adverse events compared with BAE-ERCP. The success rate of reaching was favorable through PBCS compared with BAE. CLINICAL TRIAL REGISTRATION: UMIN000045546.

Performance of Balloon-Assisted Enteroscopy for Non-ERCP Indications in Patients with Surgically Altered Gastrointestinal Anatomy.

BACKGROUND AND AIMS: Surgically altered gastrointestinal (GI) tract anatomy hinders deep enteroscopy. While enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with altered GI anatomy has been heavily investigated, the role of non-ERCP balloon-assisted enteroscopy (BAE) has yet to be fully elucidated.Please check and confirm the author names and initials are correct. Also, kindly confirm the details in the metadata are correct.I have checked all you asked and have no correction.  Thank you. METHODS: A multicenter retrospective study of non-ERCP BAEs in patients with surgically altered GI tract anatomy at two tertiary academic hospitals was performed from January 2006 to December 2020. Altered GI tract anatomy was defined by surgical reconstruction affecting the length, angle, or overall trajectory of the endoscope during the intended approach. The main outcome measurements included technical success rate, diagnostic and therapeutic yields, and complication rate.Please check the edit made in the title of the article and correct if necessary.No more correction. Thank you. RESULTS: A total of 68 patients with surgically altered GI tract anatomy underwent 56 antegrade and 24 retrograde non-ERCP BAE procedures. The technical success rate was 86.2% in both, including 83.9% via antegrade approach and 91.7% via retrograde approach. Antegrade approach in Roux-en-Y anatomy was associated with the lowest success rate of 77.8%, whereas retrograde approach in patients with colon resection resulted in the highest rate of 100%. The diagnostic and therapeutic yields of non-ERCP BAE were 79.4% and 82.9%, respectively. The diagnostic yields varied according to the procedural indications. The major complication was luminal perforation in one case (1.3%). CONCLUSIONS: Non-ERCP BAE is effective and safe via both antegrade and retrograde approaches with a high technical success rate and diagnostic and therapeutic yields in patients with surgically altered GI tract anatomy.

Delayed Gastric Emptying Is Not Associated with a Microbiological Diagnosis of Small Intestinal Bacterial Overgrowth.

BACKGROUND: Clinical symptoms of patients with small intestinal bacterial overgrowth (SIBO) may overlap with symptoms of gastroparesis. Prior studies suggest delayed small intestinal transit is associated with SIBO, but have not shown an association between delayed gastric emptying and SIBO. However, these studies have generally relied on the indirect method of breath testing to diagnose SIBO. AIMS: The aim of this study was to examine the association between a microbiological diagnosis of SIBO and delayed gastric emptying by scintigraphy. METHODS: In a single-center retrospective study of previous research participants who presented for small bowel enteroscopy for diagnostic evaluation of SIBO, we identified 73 participants who underwent gastric emptying study by scintigraphy. A microbiological diagnosis of SIBO was made in patients based on culture results of jejunal aspirates. Clinical symptoms were assessed using the total gastroparesis cardinal symptom index (GCSI) score. We compared delayed gastric emptying, 2- and 4-h gastric retention, and gastroparesis symptoms between patients with and without a microbiological diagnosis of SIBO. KEY RESULTS: Among 29 participants with SIBO and 44 without SIBO, 33 (45%) had evidence of delayed gastric emptying. There was no significant association between a microbiological diagnosis of SIBO and delayed gastric emptying by scintigraphy. Percent retained at 2 and 4 h, and total GCSI scores did not differ significantly between those with and without SIBO. CONCLUSIONS: Although delayed gastric emptying is common in patients with suspected SIBO, gastric emptying is not associated with a microbiological diagnosis of SIBO.

An innovative technique using a percutaneously placed guidewire allows for higher success rate for ERCP compared to balloon enteroscopy assistance in Roux-en-Y gastric bypass anatomy.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in Roux-en-Y gastric bypass (RYGB). Current approaches either have high failure rate, are resource intensive, or invasive. OBJECTIVE: To describe successful adoption of an old technique for performance of ERCP in patients with RYGB anatomy employing enteroscopy with the assistance of a percutaneously placed guidewire, which facilitates both reaching and cannulating the major papilla. METHOD: A retrospective cohort study in a tertiary-care center. We included patients with RYGB from 2015 to 2017 who underwent ERCP. We compared success rate and adverse events between rendezvous guidewire-assisted (RGA) and balloon-assisted enteroscopy (BAE) ERCP techniques. RESULTS: Thirty patients with RYGB underwent 62 ERCPs. The mean age was 62.2 ± 11 years with female predominance 83.3%. The procedures were performed using BAE 43/62 (69.3%), RGA 13/62 (21%), gastrostomy tube 5/62 (8.1%), and colonoscope 1/62 (1.6%). In patients with a native papilla (n = 37 ERCPs), clinical success rate with BAE was 36.8% compared to 100% with RGA (P < 0.001). There was no significant difference in bleeding (P = 0.17), post-ERCP pancreatitis (P = 0.4), or luminal perforation (P = not estimated) between the two techniques in native papilla. The mean procedure time with the RGA was significantly shorter than successful BAE with mean difference: 33 min (95% CI 8-57 min, P = 0.01). Twenty-five ERCPs were performed in eight patients with non-native papilla. BAE success rate in non-native papilla was 95.8%. The mean procedure time of the BAE in non-native papilla was 111 ± 60 min. Native papillae were associated with a significantly higher BAE failure rate compared to non-native papillae (OR: 12; 95% CI 1.44-99.7, P = 0.02). CONCLUSION: In patients with RYGB, RGA appears to be highly successful and safe in achieving clinical success for patients with native papilla as compared to BAE.

Efficacy of a modified double-guidewire technique using an uneven double lumen cannula (uneven method) in patients with surgically altered gastrointestinal anatomy (with video).

BACKGROUND: Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) has been reported to be effective for patients with surgically altered gastrointestinal anatomy. However, selective biliary cannulation remains difficult in BE-ERCP. We examined the usefulness of a modified double-guidewire technique using an uneven double lumen cannula (the uneven method) for BE-ERCP in patients with surgically altered gastrointestinal anatomy. METHODS: To clarify the usefulness of the uneven method for selective biliary cannulation in BE-ERCP in comparison to the pancreatic guidewire (PGW) method, 40 patients with surgically altered gastrointestinal anatomy who underwent BE-ERCP with successful placement of a guidewire in the pancreatic duct were evaluated. The uneven method was used in 18 cases (uneven group) and the PGW method was used in the remaining 22 cases (PGW group). RESULTS: The technical success rate of biliary cannulation was higher in the uneven group than in the PGW group (83.3 vs. 59.0%; P = 0.165). In addition, the time to biliary cannulation were significantly shorter in the uneven group than in the PGW group (6 vs. 18 min; P = 0.004; respectively). In the PGW group, post-ERCP pancreatitis (PEP) occurred in 3 of 22 cases (13.6%). No adverse events, including PEP, occurred in the uneven group. CONCLUSIONS: The uneven method may be a useful option of selective biliary cannulation in BE-ERCP for the patients with surgically altered gastrointestinal anatomy.

Novel peroral direct digital cholangioscopy-assisted lithotripsy using a monorail technique through the overtube in patients with surgically altered anatomy (with video).

Efficacy of cholangioscopy-assisted lithotripsy for difficult stones such as huge stones, multiple large stones and an impacted stone in patients with non-altered anatomy has been reported. Herein, we describe peroral direct digital cholangioscopy (PDCS)-assisted electrohydraulic lithotripsy (EHL) with a new technique in patients with surgically altered anatomy. Five patients received PDCS-assisted EHL with the monorail technique due to failed conventional stone extraction. Balloon enteroscope was removed, leaving the stiff guidewire in the bile duct and an overtube with inflated balloons. The cholangioscope was then inserted into the bile duct over the wire through the overtube. After direct visualization of the stone, PDCS-assisted EHL was carried out. This technique was named the 'monorail technique'. Complete removal of biliary stones in one session was accomplished in four patients and only one case required two sessions. There was no adverse event in any of the cases. PDCS-assisted EHL using the monorail technique was effective and safe for difficult biliary stones in patients with surgically altered anatomy.

Evolving techniques for endoscopic retrograde cholangiopancreatography in gastric bypass patients.

PURPOSE OF REVIEW: The present review describes the current and evolving techniques available in approaching endoscopic retrograde cholangiopancreatography (ERCP) for patients with Roux-en-Y gastric bypass (RYGB) anatomy. RECENT FINDINGS: Recent studies have demonstrated that device-assisted enteroscopy (DAE) approaches have high failures rates when performing ERCP, but are currently considered the first-line approach for patients with RYGB anatomy because of lower costs and risks compared to surgery. In contrast, laparoscopicy-assisted-ERCP (LA-ERCP) exhibits high technical success rates but carries surgical risks and requires a high degree of scheduling coordination. A novel, completely endoscopic approach called endoscopic ultrasound directed transgastric ERCP (EDGE), also known as gastric access temporary for endoscopy (GATE), has in recent years shown high ERCP success rates comparable to LA-ERCPs while obviating the need for surgical assistance. SUMMARY: ERCP is technically difficult in patients with RYGB anatomy. Numerous approaches to ERCP exist, although availability of these techniques may be limited and depend on institutional expertise. The best initial approach should be considered based on patient history and institutional factors.

[Use of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction].

OBJECTIVE: To explore the function of esophageal small balloon or papillary sphincter knife in the treatment of stent implantation for colorectal malignant obstruction, and to improve the success rate of colonic stent placement in such patients.
 Methods: A total of 49 patients with colorectal cancer complicated with almost complete obstruction or colorectal cancer were enrolled for this study. The esophageal small balloon or papillary sphincter knife was used in the guide wires. The guide wires gradually crossed the tumor gap and they were placed in the contralateral intestinal cavity with balloon progression. X-ray was then used to confirm whether the guide wire was inserted in the lesion intestinal cavity, and then the metal bare stent was inserted.
 Results: The guide wires was successfully inserted with conventional methods in these 49 cases, while they were also successfully placed the guide wire and the stent in the new way.
 Conclusion: For the patients with colorectal cancer complicated with complete obstruction or colorectal cancer located in obviously angled location, the use of esophageal small balloon or papillary sphincter knife can help the guide wire insert. They greatly improve the success rate of stent implantation.

An update on small bowel endoscopy.

PURPOSE OF REVIEW: The breakthrough success of capsule endoscopy and device-assisted enteroscopy has inspired researchers to test and push the boundary of these technologies. The authors herein summarize the latest and most significant studies with clinical impact. RECENT FINDINGS: Competing capsule endoscopy models have enriched the platform of this wireless device. The role of capsule endoscopy in Crohn's disease is expanding as we learn more of the significance of disease distribution and response to treatment. The benefit of capsule endoscopy in abdominal pain has previously been sceptical, but may have a role. Device-assisted enteroscopy demonstrates significant benefit in the management of patients with Crohn's disease and Peutz-Jeghers syndrome. On the contrary, long-term data suggest that endotherapy to small bowel angioectasia may not be as beneficial to patients as we once thought. The role of device-assisted enteroscopy in novel territory, including coeliac disease and endoscopic retrograde cholangiopancreatography, continues to be tested. SUMMARY: The limit of capsule endoscopy and enteroscopy is yet to be reached. Accumulating long-term data alludes to the benefits of our current practice while spawning novel indications for small bowel endoscopy.

Pharmacologic provocation combined with endoscopy in refractory cases of GI bleeding.

BACKGROUND AND AIMS: The source of GI bleeding may elude us despite exhaustive testing in some cases. Bleeding in these cases is often related to a vascular lesion that is discernible only when actively bleeding. The objective of this study was to determine the efficacy and safety of endoscopy combined with the administration of antiplatelet and/or anticoagulant agents to stimulate bleeding in order to define a source. METHODS: A retrospective review of a database of device-assisted enteroscopy (DAE) procedures was completed to identify cases in which provocation with antiplatelet or anticoagulant agents was used as part of a GI bleeding evaluation. Procedures were divided into 3 groups based on the method of provocation: patients with a history of bleeding associated with an antiplatelet/anticoagulant (provocation-experienced); patients naïve to these medications (provocation-naïve); and cases of recurrent, overt GI bleeding in which a combination of clopidogrel and intravenous heparin was administered for provocation (Lousiana State University [LSU] protocol). RESULTS: A review of 824 DAE procedures was completed to identify a total of 38 instances in which provocation was attempted in 27 patients. These cases were subdivided into 13 provocation-experienced procedures, 18 provocation-naïve procedures, and 7 LSU protocol procedures. The diagnostic yield of provocative testing per procedure was 53% in the provocation-experienced group, 27% in the provocation-naïve group, and 71% in the full protocol group. Provocative testing was revealing in 15 of 27 patients; angioectasias and Dieulafoy lesions were the most common pathologies. Provocative testing was not beneficial in 4 patients who were eventually diagnosed with bleeding caused by intestinal angioectasias (3) and an aorto-enteric fistula (1). There were no adverse events. CONCLUSIONS: Provocative testing combined with endoscopy can be justified as an option in the diagnostic algorithm of complex cases of GI bleeding when intermittent bleeding related to a vascular lesion, such as an angioectasia or Dieulafoy, is suspected. However, this novel technique should be considered only after standard management has failed to define a bleeding source, and bleeding continues to recur. This is the first reported case series of provocative testing combined with endoscopy.

A multicenter experience of through-the-scope balloon-assisted enteroscopy in surgically altered gastrointestinal anatomy.

BACKGROUND: Surgically altered gastrointestinal anatomy poses challenges for deep enteroscopy. Current overtube-assisted methods have long procedure times and utilize endoscopes with smaller working channels that preclude use of standard accessories. A through-the-scope balloon-assisted enteroscopy (TTS-BAE) device uses standard endoscopes with a large working channel to allow metallic and plastic stent insertion. We aim to determine the efficacy and safety of TTS-BAE in patients with altered surgical anatomy. METHODS: A retrospective, multicenter study of TTS-BAE in altered anatomy patients at two USA and one German institution was performed between January 2013 and December 2014. Type of anatomy, procedure indication and duration, adverse events, and target, technical, and clinical success were recorded. RESULTS: A total of 32 patients (mean age 54 years, Caucasian 81.6%, female 42.1%, mean BMI 25.4 kg/m2) underwent 38 TTS-BAE procedures. Thirty-two percent of cases had a prior attempt at conventional enteroscopy which failed to reach the target site. The target was successfully reached in 23 (60.5%) cases. Of the 23 cases that reached the intended target, 22 (95.7%) achieved technical success and 21 (91.3%) achieved clinical success. The median procedure time was 43 min. Target, technical, and clinical success rates for TTS-BAE-assisted ERCP (n = 31) were 58.1, 54.8 and 54.8%. Seven self-expandable metallic stents (five biliary, two jejunal) were attempted, and all successfully deployed. Adverse events occurred in 4 (10.4%) cases, including one luminal perforation. CONCLUSION: TTS-BAE is an alternative to overtube-assisted enteroscopy that is comparable in safety in patients with surgically altered anatomies. Technical success in the instances where the target had been reached was excellent. TTS-BAE confers an advantage over overtube-assisted enteroscopy as it can facilitate the deployment of self-expandable metallic stents in the biliary tree and deep small bowel.

[THE RISK OF CHOLANGITIS OCCURRENCE AFTER ENDOSCOPIC INTERVENTIONS ON PAPILLA MAGNA OF DUODENUM].

Results of treatment of 72 patients, suffering choledocholithiasis, using transpapillary endoscopic interventions, were analyzed. In patients of the first group a complete endoscopic papillosphincterotomy was performed, and in the second group ­ a partial endoscopic papillosphincterotomy in combination with balloon dilatation of duodenal papilla magna. The rate of occurrence of late and immediate complications in the groups was compared.

Device-assisted enteroscopy: Are we ready to dismiss the spiral?

Motorized spiral enteroscopy (MSE) is the latest advance in device-assisted enteroscopy. Adverse events related to MSE were discussed in a recent large systematic review and meta-analysis and were directly compared with those of balloon enteroscopy in a case-matched study and a randomized controlled trial. Following the real-life application of MSE, an unexpected safety issue emerged regarding esophageal injury and the technique has been withdrawn from the global market, despite encouraging results in terms of diagnostic and therapeutic yield. We conducted an Italian multicenter real-life prospective study, which was prematurely terminated after the withdrawal of MSE from the market. The primary goals were the evaluation of MSE performance (both diagnostic and therapeutic) and its safety in routine endoscopic practice, particularly in the early phase of introduction in the endoscopic unit. A subanalysis, which involved patients who underwent MSE after unsuccessful balloon enteroscopy, demonstrated, for the first time, the promising performance of MSE as a rescue procedure. Given its remarkable performance in clinical practice and its potential role as a backup technique following a previously failed enteroscopy, it may be more appropriate to refine and enhance MSE in the future rather than completely abandoning it.