Spontaneous detachment of the spiral overtube from the endoscope in the upper esophagus: a case report and literature review of a rare complication during motorized spiral enteroscopy.

BACKGROUND: Motorized spiral enteroscopy (MSE) is a recent modality for diagnostic and therapeutic examination of the small bowel using a spiral-shaped overtube with an integrated electric motor attached to an endoscope. With growing evidence of its efficacy, MSE is increasingly being used by endoscopic facilities. We herein present an uncommon case of the detachment of the spiral overtube from the endoscope during MSE. CASE REPORT: We performed antegrade MSE in a 75-year-old female under general anesthesia for coagulation of multiple small-bowel arteriovenous malformations and resection of a polyp detected on a previous capsule endoscopy. The management was successful, and we had no passage difficulties. However, during the withdrawal phase of the enteroscope, the entire spiral overtube disconnected from the endoscopic shaft and became stuck in the esophagus and pharynx. Attempts to remove the lodged spiral using various endoscopic forceps, graspers, snares, or a dilatation balloon failed. Also, the laryngoscopic use of Magill forceps did not allow grabbing the spiral properly. Eventually, the spiral could be retrieved laryngoscopically with arthroscopic grasping forceps. This incident caused laryngeal swelling and bleeding lacerations of the upper esophagus, which were clipped on a subsequent gastroscopy. No further long-lasting complications occurred in the patient. CONCLUSION: Detachment of the spiral from the enteroscope is a potentially life-threatening and challenging complication of MSE. Artificial ventilation under observation by an anesthesiologist allowed for calm management of this dangerous situation and increased the overall safety of the procedure. Hence, we believe that in the context of antegrade MSE, general anesthesia with endotracheal intubation should be mandatory.

Small-bowel capsule endoscopy in patients with Meckel's diverticulum: clinical features, diagnostic workup, and findings. A European multicenter I-CARE study.

BACKGROUND AND AIMS: Meckel's diverticulum (MD) may remain silent or be associated with adverse events such as GI bleeding. The main aim of this study was to evaluate indicative small-bowel capsule endoscopy (SBCE) findings, and the secondary aim was to describe clinical presentation in patients with MD. METHODS: This retrospective European multicenter study included patients with MD undergoing SBCE from 2001 until July 2021. RESULTS: Sixty-nine patients with a confirmed MD were included. Median age was 32 years with a male-to-female ratio of approximately 3:1. GI bleeding or iron-deficiency anemia was present in nearly all patients. Mean hemoglobin was 7.63 ± 1.8 g/dL with a transfusion requirement of 52.2%. Typical capsule endoscopy (CE) findings were double lumen (n = 49 [71%]), visible entrance into the MD (n = 49 [71%]), mucosal webs (n = 30 [43.5%]), and bulges (n = 19 [27.5%]). Two or more of these findings were seen in 48 patients (69.6%). Ulcers were detected in 52.2% of patients (n = 36). In 63.8% of patients (n = 44), a combination of double lumen and visible entrance into the MD was evident, additionally revealing ulcers in 39.1% (n = 27). Mean percent SB (small bowel) transit time for the first indicative image of MD was 57% of the total SB transit time. CONCLUSIONS: Diagnosis of MD is rare and sometimes challenging, and a preoperative criterion standard does not exist. In SBCE, the most frequent findings were double-lumen sign and visible diverticular entrance, sometimes together with ulcers.

Endoscopic management of giant gastric dilatation in an anorexia nervosa patient after binge eating.

Acute gastric dilatation is a rare and potentially life-threatening condition that may occur in patients suffering from anorexia nervosa after ingesting large amounts of food within a short period. Frequently, this condition is considered a surgical emergency due to subsequent occurrence of complications such as gastric necrosis or perforation.Here we report a case of a young female patient (23 years) with anorexia nervosa who presented with severe abdominal pain, nausea, and inability to vomit after a period of binge eating. Abdominal computed tomography revealed an extremely dilated stomach measuring 39.0 cm × 18.0 cm in size. Initial nasal decompression therapy using gastric tubes had failed. Due to the absence of complications, it was decided to treat her solely by endoscopic means under mechanical ventilation. After undergoing multiple overtube-assisted esophagogastroduodenoscopies (EGDs), she fully recovered eventually.This case demonstrates that interventional endoscopic treatment of a patient with uncomplicated acute gastric dilatation is feasible and safe, at least under general anesthesia. Hence, this option should be considered when sole gastric tube suction fails, and there is no indication of complications such as peritonitis, sepsis, perforation, or gastric ischemia. A more invasive and aggressive surgical procedure may be avoided in selected cases, and the length of hospital stay may be shortened.

CapsoCam SV-1 Versus PillCam SB 3 in the Detection of Obscure Gastrointestinal Bleeding: Results of a Prospective Randomized Comparative Multicenter Study.

BACKGROUND AND STUDY AIM: Newer capsule with a panoramic viewing mode is available and might increase the detection rate of bleeding lesions in patients with obscure gastrointestinal bleeding (OGIB). Furthermore, an improved patient acceptance rate is expected. MATERIALS AND METHODS: In a randomized prospective comparative multicenter study, patients with OGIB were included and examined either with CapsoCam SV-1 or with PillCam SB 3. Detection of bleeding lesions, transit, and evaluation time and adverse events were evaluated. Physicians were interviewed about their experience with both capsules and the evaluation software. A detailed subject questionnaire analyzed acceptance of each capsule. Follow-up was 3 months. RESULTS: In total, 181 patients with OGIB were recruited into the study. After exclusion of 28 patients 153 patients were randomized and CapsoCam SV-1 (n=78) or PillCam SB 3 (n=75) was administered. CapsoCam SV-1 detected more cases of bleeding (31/79, diagnostic yield 39.7%) compared with PillCam SB 3 (26/75, diagnostic yield 34.6%, NS). Transit time of both capsules was not different. Evaluation time with PillCam SB 3 was superior to CapsoCam SV-1 (27 vs. 40 min, P=0.01). In total, 95% of the physicians were satisfied with each capsule system and evaluation software. The acceptance rate of the patients to retrieve the CapsoCam SV-1 was high. Adverse events/serious adverse events were 17.9%/1.3% with CapsoCam SV-1 and 16%/0% with PillCam SB 3. Rebleeding rate was 28.75% within 3 months. CONCLUSIONS: CapsoCam SV-1 detected more lesions; however, relevant bleeding sources were visualized by both capsules. Physician's satisfaction was high with both capsule systems and evaluation software. Patient's acceptance with CapsoCam SV-1 was unexpectedly high. Serious adverse events were 0% with PillCam SB 3 and 1.3% with CapsoCam SV-1.

International core curriculum for capsule endoscopy training courses.

Capsule endoscopy (CE) has become a first-line noninvasive tool for visualisation of the small bowel (SB) and is being increasingly used for investigation of the colon. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines have specified requirements for the clinical applications of CE. However, there are no standardized recommendations yet for CE training courses in Europe. The following suggestions in this curriculum are based on the experience of European CE training courses directors. It is suggested that 12 hours be dedicated for either a small bowel capsule endoscopy (SBCE) or a colon capsule endoscopy (CCE) course with 4 hours for an introductory CCE course delivered in conjunction with SBCE courses. SBCE courses should include state-of-the-art lectures on indications, contraindications, complications, patient management and hardware and software use. Procedural issues require approximately 2 hours. For CCE courses 2.5 hours for theoretical lessons and 3.5 hours for procedural issued are considered appropriate. Hands-on training on reading and interpretation of CE cases using a personal computer (PC) for 1 or 2 delegates is recommended for both SBCE and CCE courses. A total of 6 hours hands-on session- time should be allocated. Cases in a SBCE course should cover SB bleeding, inflammatory bowel diseases (IBD), tumors and variants of normal and cases with various types of polyps covered in CCE courses. Standardization of the description of findings and generation of high-quality reports should be essential parts of the training. Courses should be followed by an assessment of trainees' skills in order to certify readers' competency.

Small-bowel capsule endoscopy with panoramic view: results of the first multicenter, observational study (with videos).

BACKGROUND AND AIMS: The first small-bowel video-capsule endoscopy (VCE) with 360° panoramic view has been developed recently. This new capsule has wire-free technology, 4 high-frame-rate cameras, and a long-lasting battery life. The aim of the present study was to assess the performance and safety profile of the 360° panoramic-view capsule in a large series of patients from a multicenter clinical practice setting. METHODS: Consecutive patients undergoing a 360° panoramic-view capsule procedure in 7 European Institutions between January 2011 and November 2015 were included. Both technical (ie, technical failures, completion rate) and clinical (ie, indication, findings, retention rate) data were collected by means of a structured questionnaire. VCE findings were classified according to the likelihood of explaining the reason for referral: P0, low; P1, intermediate; P2, high. RESULTS: Of the 172 patients (94 men; median age, 68 years; interquartile range, 53-75), 142 underwent VCE for obscure (32 overt, 110 occult) GI bleeding (OGIB), and 28 for suspected (17) or established (2) Crohn's disease (CD). Overall, 560 findings were detected; 252 were classified as P2. The overall diagnostic yield was 40.1%; 42.2% and 30.0% in patients with OGIB and CD, respectively. The rate of complete enteroscopy was 90.2%. All patients but one, who experienced capsule retention (1/172, 0.6%), excreted and retrieved the capsule. VCE failure occurred in 4 of 172 (2.3%) patients because of technical problems. CONCLUSIONS: This multicenter study, conducted in the clinical practice setting and based on a large consecutive series of patients, showed that the diagnostic yield and safety profile of the 360° panoramic-view capsule are similar to those of forward-view VCEs.

Minimizing procedural cost in diagnosing small bowel bleeding: comparison of a strategy based on initial capsule endoscopy versus initial double-balloon enteroscopy.

INTRODUCTION: Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) detect small bowel bleeding with equal diagnostic yield. We aimed to detect factors that influence procedural cost of CE and DBE in diagnosing and treating small bowel bleeding, and to compare them with reimbursement. METHODS: A cost model analysed procedural cost for diagnostic CE versus diagnostic, unidirectional DBE(scenario 1) and CE plus directed therapeutic DBE(positive findings in CE) versus unidirectional diagnostic plus therapeutic DBE (scenario 2). The frequency of investigations per annum (p.a.) at which cost per procedure is equalized (break-even point) was determined for CE versus DBE. A retrospectively collected cohort of patients was used to validate the cost model and to compare procedural costs with reimbursement (German diagnosis related groups, G-DRG). RESULTS: The break-even point at which cost per procedure is equalized for CE versus DBE was reached at 100 procedures p.a. in scenario 1 and 79 in scenario 2 for a rate of therapeutic enteroscopy of 14%, and 27 for a therapeutic enteroscopy rate of 30%. Personnel cost, procedure time,procedures p.a. and the rate of therapeutic enteroscopy had a major influence on procedural cost. In this patient cohort, the 'CE-first' and the 'DBE-first' strategies produced procedural costs of pound sterling 830 and pound sterling 1,076 per patient to attain a diagnosis, and pound sterling 1,042 versus pound sterling 1,181 to achieve therapeutic enteroscopy, respectively. For this cohort, potential reimbursement was pound sterling 2,320 and pound sterling 3,047 for the 'CE-first' and the 'DBE-first' strategies, respectively (G-DRG). CONCLUSION: Workflow management of CE versus DBE should consider frequency of investigations p.a. and probability for therapeutic enteroscopy to minimize procedural costs. The cost of DBE increases with less frequent or time-consuming investigations; CE is more robust with regard to these factors. From a third-party payer perspective, a strategy incorporating CE seems to minimize costs in G-DRG.