A newly developed deep learning-based system for automatic detection and classification of small bowel lesions during double-balloon enteroscopy examination.

BACKGROUND: Double-balloon enteroscopy (DBE) is a standard method for diagnosing and treating small bowel disease. However, DBE may yield false-negative results due to oversight or inexperience. We aim to develop a computer-aided diagnostic (CAD) system for the automatic detection and classification of small bowel abnormalities in DBE. DESIGN AND METHODS: A total of 5201 images were collected from Renmin Hospital of Wuhan University to construct a detection model for localizing lesions during DBE, and 3021 images were collected to construct a classification model for classifying lesions into four classes, protruding lesion, diverticulum, erosion & ulcer and angioectasia. The performance of the two models was evaluated using 1318 normal images and 915 abnormal images and 65 videos from independent patients and then compared with that of 8 endoscopists. The standard answer was the expert consensus. RESULTS: For the image test set, the detection model achieved a sensitivity of 92% (843/915) and an area under the curve (AUC) of 0.947, and the classification model achieved an accuracy of 86%. For the video test set, the accuracy of the system was significantly better than that of the endoscopists (85% vs. 77 ± 6%, p < 0.01). For the video test set, the proposed system was superior to novices and comparable to experts. CONCLUSIONS: We established a real-time CAD system for detecting and classifying small bowel lesions in DBE with favourable performance. ENDOANGEL-DBE has the potential to help endoscopists, especially novices, in clinical practice and may reduce the miss rate of small bowel lesions.

Crohn's disease with multiple jejunum and ileum lesions: A case report.

Crohn's disease (CD) affecting the jejunum and ileum is uncommon and its diagnosis can be challenging. This case report describes a 35 year old male patient who had been e xper iencing intermi ttent periu mbilica l pain , di arrho ea and fever for five years. Despite undergoing gastroscopy, co lo noscopy and capsule endoscopy; no s ignific ant abnormal ities were found. This case was se en at the Shenzhen Ho spital of Traditional Chinese Medi ci ne; Shenzhen, China. However, the pa tient u nder went a doubl e-balloon enteroscopy (DBE), which revealed multip le ulcers in the jejunum and ileum, leadin g to a confirmed diagnosis of CD. The patient was successfully treated with infliximab t o rel ieve sy mptoms. DBE can be par ticularly valuable in diagnosing CD in young patients with symptoms when conventional endoscopic techniques have been unsuccessfu l. This case highlights the impor tance of considering small bowel disease in patients wit h CD symptoms and the potential benefits of DBE in diagnosing such cases.

Device-assisted enteroscopy performance measures in the United Kingdom: DEEP-UK quality improvement project.

BACKGROUND: Device-assisted enteroscopy (DAE) has become a well-established diagnostic and therapeutic tool for the management of small-bowel pathology. We aimed to evaluate the performance measures for DAE across the UK against the quality benchmarks proposed by the European Society of Gastrointestinal Endoscopy (ESGE). METHODS: We retrospectively collected data on patient demographics and DAE performance measures from electronic endoscopy records of consecutive patients who underwent DAE for diagnostic and therapeutic purposes across 12 enteroscopy centers in the UK between January 2017 and December 2022. RESULTS: A total of 2005 DAE procedures were performed in 1663 patients (median age 60 years; 53% men). Almost all procedures (98.1%) were performed for appropriate indications. Double-balloon enteroscopy was used for most procedures (82.0%), followed by single-balloon enteroscopy (17.2%) and spiral enteroscopy (0.7%). The estimated depth of insertion was documented in 73.4% of procedures. The overall diagnostic yield was 70.0%. Therapeutic interventions were performed in 42.6% of procedures, with a success rate of 96.6%. Overall, 78.0% of detected lesions were marked with a tattoo. Patient comfort was significantly better with the use of deep sedation compared with conscious sedation (99.7% vs. 68.5%; P<0.001). Major adverse events occurred in only 0.6% of procedures. CONCLUSIONS: Performance measures for DAE in the UK meet the ESGE quality benchmarks, with high diagnostic and therapeutic yields, and a low incidence of major adverse events. However, there is room for improvement in optimizing sedation practices, standardizing the depth of insertion documentation, and adopting marking techniques to aid in the follow-up of detected lesions.

The evolving role of device-assisted enteroscopy: The state of the art as of August 2023.

Device-assisted enteroscopy (DAE), balloon-assisted enteroscopy (BAE) in particular, has become a routine endoscopic procedure which has revolutionized our approach to small-bowel disease. Evidence demonstrating the efficacy and safety of BAE spans over 22-years of experience, making it an established pillar of minimally invasive care. The robust evidence for BAE's safety and efficacy has now been incorporated into international clinical guidelines, technical reviews, benchmarking performance measures and curricula. The more recently introduced motorized spiral enteroscopy (MSE) which had replaced the previous manual version, abruptly ended its 7-year stint in clinical practice, when it was withdrawn and recalled from the market by its manufacturing company in July 2023, due to several associated serious adverse events (including fatalities). This article, written by the original developer of double-balloon enteroscopy (DBE) and other recognized international experts and pioneers in this field, focuses mainly on the technical aspects, evolving indications, and equipment-related technological advances. Despite the very recent withdrawal of MSE from clinical practice, for completeness, this technology and its technique is still briefly covered here, albeit importantly, along with a short description of reported, associated, serious adverse events which have contributed to its withdrawal/recall from the market and clinical practice.

Effectiveness and safety of novel motorized spiral enteroscopy: a systematic review and meta-analysis.

BACKGROUND: Motorized spiral enteroscopy (MSE) is a novel advance in small bowel examination that is characterized as fast with a deep insertion. The aim of this study was to elucidate the effectiveness and safety of MSE. METHODS: Relevant articles that were published before November 1, 2022 were identified by searching PubMed, EMBASE, Cochrane, and the Web of Science. The technical success rate (TSR), total (pan)-enteroscopy rate (TER), depth of maximum insertion (DMI), diagnostic yield, and adverse events were extracted and analyzed. Forest plots were graphed based on random effects models. RESULTS: A total of 876 patients from 8 studies were eligible for analysis. The pooled results of the TSR were 95.0% [95% confidence interval (CI) 91.0-98.0%, I2 = 78%, p < 0.01] and the pooled outcome of the TER was 43.1% (95% CI 24.7-62.5%, I2 = 95%, p < 0.01). The pooled results of the diagnostic and therapeutic yields were 77.2% (95% CI 69.0-84.5%, I2 = 84%, p < 0.01) and 49.0% (95% CI 38.0-60.1%, I2 = 89%, p < 0.01), respectively. The pooled estimates of adverse and severe adverse events were 17.2% (95% CI 11.9-23.2%, I2 = 75%, p < 0.01) and 0.7% (95% CI 0.0-2.1%, I2 = 37%, p = 0.13), respectively. CONCLUSION: MSE is a novel alternative approach for small bowel examination that can achieve high TER and diagnostic and therapeutic yields, and relatively low rates of severe adverse events. Head-to-head studies comparing MSE and other device-assisted enteroscopies are warranted.

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.

Primary small bowel follicular lymphoma: the role of balloon-assisted enteroscopy in diagnosis and follow-up.

An asymptomatic 38-year-old male with no significant previous medical history performed routine laboratory studies that revealed iron-deficiency anemia. Esophagogastroduodenoscopy and colonoscopy were unremarkable and he undergone videocapsule endoscopy that revealed multiple small polyps along jejunum and ileum. Double-balloon enteroscopy confirmed the presence of scattered small whitish nodules and small polyps carpeting segments of jejunal mucosal and sometimes forming conglomerates with a nodular appearance. Histopathological examination showed lamina propria expansion by neoplastic follicles, predominantly composed by small lymphoid cells that, by immunohistochemistry, showed expression of CD20, CD10 and bcl-2. Computed tomography scan of abdomen and pelvis did not reveal systemic involvement, consistent with primary small bowel follicular lymphoma. Chemotherapy was started and, at reevaluation enteroscopy, although nodular jejunal segments persisted, biopsies did not show involvement by lymphoproliferative disease, which was interpreted as complete remission. Periodic clinical and biochemical evaluation and annual enteroscopic surveillance was maintained and, after three years, local recurrence of low-grade follicular lymphoma was detected. As previously, there was no evidence of systemic involvement and the decision was to maintain close surveillance. After one year, the patient remains asymptomatic and without evidence of disease progression. This case illustrates the essential role of balloon-assisted enteroscopy for diagnosis and surveillance of primary small bowel follicular lymphoma.

Motorized Spiral Enteroscopy Is Effective in Patients with Prior Abdominal Surgery.

BACKGROUND: Motorized Spiral Enteroscopy (MSE) reduces procedure time and increases insertion depth into the small bowel; however, there is scarce evidence on factors affecting MSE efficacy. AIMS: To evaluate diagnostic yield and adverse events of MSE including patients with prior major abdominal surgery. METHODS: A prospective observational study was conducted on patients undergoing MSE from June 2019 to December 2021. Demographic characteristics, procedure time, depth of maximum insertion (DMI), technical success, diagnostic yield, and adverse events were collected. RESULTS: Seventy-four anterograde (54.4%) and 62 retrograde (45.6%) enteroscopies were performed in 117 patients (64 males, median age 67 years). Fifty patients (42.7%) had prior major abdominal surgery. Technical success was 91.9% for anterograde and 90.3% for retrograde route. Diagnostic yield was 71.6% and 61.3%, respectively. The median DMI was 415 cm (264-585) for anterograde and 120 cm (37-225) for retrograde enteroscopy. In patients with prior major abdominal surgery, MSE showed significantly longer small bowel insertion time (38 vs 29 min, p = 0.004), with similar diagnostic yield (61 vs 71.4%, p = 0.201) and DMI (315 vs 204 cm, p = 0.226). The overall adverse event rate was 10.3% (SAE 1.5%), with no differences related to prior abdominal surgery (p = 0.598). Patients with prior surgeries directly involving the gastrointestinal tract showed lower DMI (189 vs 374 cm, p = 0.019) with equal exploration time (37.5 vs 38 min, p = 0.642) compared to those with other abdominal surgeries. CONCLUSIONS: MSE is effective and safe in patients with major abdominal surgery, although longer procedure times were observed. A lower depth of insertion was detected in patients with gastrointestinal surgery.

An Unusual Small Bowel Phytobezoar Successfully Resolved by Double-balloon Enteroscopy.

We herein report a very unusual case of small bowel obstruction caused by phytobezoar in a 69-year-old woman who consumed a large amount of bracken. The patient presented with nausea and vomiting. Computed tomography revealed an air-filled foreign body in the jejunum that had likely caused the small bowel obstruction. A fibrous foreign body diagnosed as a phytobezoar was detected using double-balloon enteroscopy. The obstruction was successfully resolved by crushing the phytobezoar repeatedly using a snare. Small bowel obstructions caused by phytobezoars are often treated with surgical interventions. However, endoscopic fragmentation using a snare is a minimally invasive treatment alternative.

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.

Small bowel endoscopy for children: Collaboration of capsule endoscopy and device-assisted enteroscopy.

Capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE) have become indispensable techniques for the diagnosis and management of small bowel disease in both adult and pediatric cases. However, relevant differences exist in the indications between these cohorts, with body weight and age having particular relevance in decisions for the latter. Both CE and BAE are designed for adult physique and they were not widely used among children. In addition, the types of small intestinal diseases differ between adults and children, and consequently, the indications also differ between them. This review focuses on the issues relevant to pediatric cases and describes the practical application of endoscopy in clinical practice. In conclusion, although there are age and weight restrictions, both CE and BAE are safe and useful devices for use in children, and their indications for use in children are likely to expand in the future.

Effectiveness of double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (DBE-ERCP): A multicenter real-world study.

BACKGROUND AND AIMS: To investigate the effectiveness of double-balloon enteroscope-assisted retrograde cholangiopancreatography (DBE-ERCP) in patients with gastrointestinal surgically altered anatomy (SAA). METHODS: From May 2013 to October 2021, all consecutive patients undergoing DBE-ERCP in three gastroenterological referral centers in Northern Italy were enrolled in the study. Patients were assessed regarding their medical history, previous surgery, time from previous surgery to the DBE-ERCP procedure, and the success or failure of DBE-ERCP. RESULTS: Fifty-three patients (60% men, median age 65 (23-89) years) undergoing 67 DBE-ERCP procedures (1-3 DBE-ERCP per patient) were enrolled. Reasons for SAA included orthotopic liver transplantation (23%), ulcers (15%), malignancies (43%), difficult cholecystectomy (17%), and other causes (2%). Types of surgery included Roux-en-Y biliodigestive anastomosis (45%), Roux-en-Y gastrectomy (32%), pancreaticoduodenectomy (17%), and Billroth II gastrectomy (6%). The overall DBE-ERCP success rate was 86%. The type of surgery, indications, and the length of time between previous surgery and DBE-ERCP were not statistically associated with DBE-ERCP success. The DBE-ERCP success rate increased from 2018 to 2021. CONCLUSIONS: DBE-ERCP is a successful procedure in challenging patients with SAA. The improvement in results over time indicates the necessity of adequate training and of centralizing patients in referral centers.

Rhode Island gastroenterology video capsule endoscopy data set.

Complete endoscopic evaluation of the small bowel is challenging due to its length and anatomy. Although several advances have been made to achieve diagnostic and therapeutic goals, including double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy, video capsule endoscopy (VCE) remains the least invasive tool for complete visualization of the small bowel and is the preferred method for initial diagnostic evaluation. At present, interpretation of VCE data requires manual annotation of landmarks and abnormalities in recorded videos, which can be time consuming. Computer-assisted diagnostic systems using artificial intelligence may help to optimize VCE reading efficiency by reducing the need for manual annotation. Here we present a large VCE data set compiled from studies performed at two United States hospitals in Providence, Rhode Island, including 424 VCE studies and 5,247,588 total labeled images. In conjunction with existing published data sets, these files may aid in the development of algorithms to further improve VCE.

Single-centre empirical analysis of double-balloon enteroscopy in the diagnosis and treatment of small bowel diseases: A retrospective study of 466 cases.

BACKGROUND AND OBJECTIVE: The diagnosis and treatment of small bowel diseases (SBDs) has always been a challenge. The purpose of this study was to evaluate the value of double-balloon enteroscopy (DBE) in the diagnosis and treatment of small bowel diseases. METHOD: The clinical data of 466 patients who underwent double-balloon enteroscopy (DBE) in the Endoscope Center of Gastroenterology Department of the First People's Hospital of Yunnan Province from Jan. 2015 to Dec. 2020 were analysed retrospectively. The factors included age, sex, indications, endoscopic treatment results, pathological results, discharge diagnosis and so on. RESULTS: A total of 370 patients underwent 466 double-balloon enteroscopies, among whom 274 underwent one examination and 96 received two-way examinations (oral and transanal approaches). Abnormalities were detected in 299 cases, with a detection rate of 80.81% (299/370). The common indications were occult gastrointestinal bleeding (OGIB) (30.8%, 114/370) and abdominal pain (28.3%, 105/370). The diagnosis rates were 64.9% and 77.1%, respectively. The common positive findings included nonspecific inflammation/erosion (60 cases), ulcers (34 cases), diverticulum (32 cases), polyps (26 cases) and Crohn's disease (CD) (24 cases). The common tumours were lymphoma(12 cases), adenocarcinoma(11 cases) and stromal tumour(8 cases). Lymphoma was mostly located in the ileum, while stromal tumours and adenocarcinoma were mostly located in the duodenum and jejunum. The main endoscopic intervention measures were haemostasis and polypectomy, including haemostatic clip, argon plasma coagulation (APC), endoscopic mucosal resection (EMR), endoscopic trap resection, endoscopic foreign body extraction and other operations, without serious complications. CONCLUSION: DBE has a high success rate in the diagnosis and treatment of some SBDs, and it is a safe and effective management method.

Superior outcomes with double-balloon enteroscopy for small bowel lesion marking followed by intracorporeal as opposed to extracorporeal resection and reconstruction.

BACKGROUND: Double-balloon enteroscopy (DBE) is used for the diagnosis and therapy of small bowel disease. Endoscopic sampling and marking small bowel lesions destined for surgery permit intracorporeal resection and reconstruction (IRR), thereby facilitating a complete minimally invasive technique. There are limited data that compare outcomes of IRR to conventional extracorporeal resection and reconstruction (ERR). The purpose of this study was to evaluate the surgical outcomes of patients undergoing pre-operative DBE for lesion marking followed by laparoscopic IRR compared to those undergoing ERR. METHODS: A retrospective chart review was performed on patients who underwent DBE followed by small bowel resection from 2006 to 2017 at a single tertiary care medical center. IRR was defined as laparoscopic inspection to identify the lesion (previously marked by DBE or by laparoscopic-assisted DBE) followed by intra-abdominal bowel resection and anastomosis with specimen extraction via minimal extension of a laparoscopic port site. ERR was defined as extracorporeal resection and/or reconstruction performed via a conventional or mini-laparotomy abdominal incision. RESULTS: A total of 82 patients met inclusion criteria and were reviewed. Thirty-two patients (39%) had ERR and 50 patients (61%) had IRR. The most common indications for DBE were small bowel bleeding (76%) and small bowel mass or thickening on prior imaging studies (16%). Successful DBE was higher in the IRR group when compared to the ERR group, but not significantly different (90% vs 75%, p-value 0.07). Patients who underwent IRR had faster bowel function recovery (2 vs 4 days, p < 0.01), shorter time to discharge (3 vs 7 days, p < 0.01), and fewer post-operative complications (10 vs 18; p < 0.01), when compared to the ERR group. CONCLUSION: DBE successfully facilitated laparoscopic small bowel IRR and this approach was associated with faster return of bowel function, shorter recovery time, and decreased morbidity when compared to ERR.

Efficacy of double-balloon enteroscopy-assisted endoscopic balloon dilatation combined with stent deployment for hepaticojejunostomy anastomotic stricture.

BACKGROUND: Hepaticojejunostomy anastomotic stricture (HJAS) is a significant complication of biliary reconstruction surgery. Endoscopic management of HJAS using double-balloon enteroscopy has expanded; however, retrospective reports in this setting are limited. This study aimed to evaluate the efficacy of endoscopic balloon dilatation combined with stent deployment for HJAS. METHODS: This was a single-arm prospective clinical trial involving 40 patients with treatment-naïve HJAS enrolled between March 2016 and August 2019 at four endoscopy units in Japan. For HJAS, plastic stents combined with balloon dilatation were placed for 6 months after initial stenting. The primary outcome was HJ anastomosis patency 12 months after stent removal. RESULTS: The technical success rate was 97.5% (39/40). The failed case required percutaneous transhepatic biliary drainage using the rendezvous technique. All cases achieved successful endoscopic treatment. During the treatment period, four of 40 patients (10%) ended the study protocol due to unrelated causes and were excluded from the primary analysis. Among the 36 patients, clinical success was achieved in 34 (94.4%) patients. The remaining two patients achieved HJAS resolution after an additional 3 months. All 36 patients achieved HJAS resolution. Adverse events were observed in two patients (5.0%) who developed moderate cholangitis. During a median follow-up of 21.3 months, HJAS recurrence was observed in 8.3% (3/36) with a median time to recurrence of 4.3 months and HJ anastomosis patency at 12 months was 94.4%. CONCLUSIONS: Endoscopic balloon dilatation combined with plastic stent deployment for 6 months was a safe and effective strategy for HJAS. (Clinical Trial Registry no. UMIN000020613).