Factors That Influence the Speed and Completion of Double Balloon Enteroscopy in Patients with Arteriovenous Malformations.

BACKGROUND: Double balloon enteroscopy remains a resource and time-intensive procedure that is not available in many endoscopy units. AIMS: We aimed to identify variables impacting the speed and completion of double balloon enteroscopy. METHODS: We retrospectively reviewed 550 patients. Using a mean time and distance for both the antegrade and retrograde approach, we determined the procedure speed and assessed factors that influenced it. In addition, we assessed the factors that contributed to a complete double balloon enteroscopy. RESULTS: A total of 386 antegrade and 164 retrograde double balloon enteroscopies were performed. Greater than 10 AVMs requiring treatment was a negative predictor (AOR 0.25, CI 0.11-0.51, p < 0.001), whereas age greater than 60 years (AOR 2.66, CI 1.18-6.65, p = 0.025) was a positive predictor of a fast antegrade enteroscopy. For retrograde, prior abdominal surgery was the only factor that trended to significance (AOR 0.38, CI 0.14-0.99, p = 0.052). A total of 120 combined procedures were performed. Female gender (AOR 2.62, CI 1.16-6.24, p = 0.02), history of prior abdominal surgery (AOR 0.31, CI 0.13-0.70, p = 0.006) and Boston bowel pre-preparation score of greater than 6 (AOR 4.50, CI 1.59-14.30, p = 0.006) were the only significant predictors of a complete procedure. CONCLUSION: By applying double balloon enteroscopy speed, a novel method of measuring procedure efficiency, we were able to more reliably identify the factors that will negatively impact the speed and success of the procedure.

Risk of bleeding following double balloon enteroscopy in patients on continued antiplatelet and/or anticoagulation therapy.

Background and study aims Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P  < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P  = 0.12) or 1 year (19.9 % vs 15.7 %, P  = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.

Safety and Diagnostic Yield of Transthoracic Needle Aspiration of the Lung in Elderly Patients.

BACKGROUND: Pulmonary nodules in elderly patients are commonly encountered in clinical practice. Tissue sampling with image guided transthoracic needle aspiration is often performed but may be complicated by pneumothorax or bleeding. To understand the outcomes of transthoracic needle aspiration in the elderly, we retrospectively reviewed outcomes of patients age 75 or greater in a single tertiary center. METHODS: Four-hundred eleven patients age 75 or greater with a pulmonary nodule identified on computed tomography who underwent needle aspiration of the lung were studied. Diagnostic yield and procedural complications were assessed for each patient and subgroups analysis of those age 85 or greater was performed. RESULTS: Malignancy was confirmed in 70% of subjects and a benign diagnosis identified in 9%. Of the 411 patents, 203 (49.4%) experienced a complication; 150 patients (36.5%) developed a pneumothorax and 79 (19.2%) had bleeding. No patient required transfusion, experienced persistent air leak or massive hemoptysis, air embolism or death. Post procedural hospitalization was required in 36 patients (8.8%) with a median hospital stay of 2 days. No factors were identified to be associated with occurrence of a complication (all p ≥ 0.16) and complications were not increased in those 85 or greater. CONCLUSION: Our results suggest that in an elderly population, image guided needle aspiration of a pulmonary nodule provides diagnostic findings in most patients. Procedural complications following are not uncommon but the severity and long-term impact are limited. The occurrence of complications is similar in those age 75-84 and age 85 and older.