Small-bowel endoscopy

• Improved visibility of lesions of the small bowel intestine via capsule endoscopy with computed virtual chromoendoscopy (Imagawa et al., Gastrointest Endosc 2011 1)
• Prospective, randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding (Pioche et al., Gastrointest Endosc 2011 6)
• Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use (Xin et al., Gastrointest Endosc 2011 9)
• Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial (Takano et al., Gastrointest Endosc 2011 14)
• Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding (May et al., Endoscopy 2011 18)
• References

Improved visibility of lesions of the small bowel intestine via capsule endoscopy with computed virtual chromoendoscopy (Imagawa et al., Gastrointest Endosc 2011 [1])

In recent years, several studies have reported on an improvement in the visualization and classification of lesions in the upper and lower gastrointestinal tract using computed virtual chromoendoscopy (CVC), such as narrow-band imaging (NBI), flexible spectral imaging color inhancement (FICE) or i-Scan. CVC enhances the contrast of the mucosal surface without the use of dyes. The FICE system is based on narrowing of the bandwidth of the conventional endoscopic image arithmetically by a spectral estimation technology and enhances the vascular network as well as the pit pattern, facilitating the assessment of gastrointestinal mucosal lesions [2]. Neumann et al. described for the first time the use of double-balloon enteroscopy (DBE) and the FICE system for classification of small-bowel lesions in a case series [3]. FICE was found to be a helpful method for the evaluation of adenomatous small-bowel polyps and angiodysplasias [3].

The retrospective trial by Imagawa et al. investigated the value of the FICE system for detection of small-bowel lesions using video capsule endoscopy (PillCam SB1; Given Imaging Ltd., Yokneam, Israel) for evaluation of the small bowel [1]. For this new technique the FICE software was installed in the video capsule workstation (CE-FICE). The FICE images were compared with the conventional capsule images by five physicians, using 145 lesions from 122 patients who underwent capsule endoscopy for suspected small-bowel disease. The main indication was suspected mid-gastrointestinal bleeding. The analysis of the images was carried out with Rapid Reader 6 software. Three FICE settings were evaluated. The authors found an improved image quality for angiodysplasias (87 %), erosions and ulcerations (53 %), and tumors (25 %) for FICE setting 1 and similar results for FICE setting 2. They therefore concluded that the CE-FICE system improves the visibility of these small-bowel lesions.

These findings confirm the results of a pilot study of 10 consecutive patients, which was conducted by our working group and published in 2010 [4]. Pohl et al. demonstrated that FICE technology could facilitate the detection of lesions that had a tendency to bleed. However, the number of non-relevant lesions detected using this technology also increased. In contrast to these latter two studies, Gupta et al. found that it was mainly the detection of non-pathological lesions that was improved, and that there was only a slight advantage for detection of vascular lesions [5]. One reason might be the use of different PillCam devices. The PillCam SB1 device was used in the study by Imagawa et al., whereas Gupta et al. used the PillCam SB2 device, which is equipped with better technology and provides higher white light image quality. As has already been shown for Barrett’s esophagus and colon polyps, CVC cannot increase the detection rate of lesions, but does help to classify them. This might be different in the small bowel due to different indications. It seems that the best results from CE-FICE can be achieved in bleeding lesions, which are the main indication for evaluation of the small bowel. Multicenter trials are necessary to clarify the real value of the CE-FICE and to determine the best indications for this modality.

Prospective, randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding (Pioche et al., Gastrointest Endosc 2011 [6])

The Pillcam SB capsule manufactured by Given Imaging was the first small-bowel capsule device on the market. Since then, another two systems have become available: the Endocapsule (Olympus, Tokyo, Japan) and the MiroCam (IntroMedic, Seoul, Korea). Most of the published studies have been done with the Given device, with only very few studies having been performed with the other two systems. The main differences between the devices are the technology for data transmission and the operation time. In contrast to PillCam and Endocapsule, which use radiofrequency telemetry for data transmission, MiroCam uses the so-called Human Body Communication (HBC), which has a relevant lower power consumption. The longer operation time of approximately 11 hours for the MiroCam leads to a high cecum transmission rate of 97 %, and was first reported in the study by Bang et al. [7].

In the prospective, randomized comparative multicenter trial of PillCam and MiroCam by Pioche et al. [6], 73 patients with suspected mid-gastrointestinal bleeding were enrolled. Seven endoscopy units participated in the study. Both capsule devices were given one after the other to the same patients with a 1-hour interval in a randomized sequence. The main objective was the concordance rate between both capsules as well as image quality and diagnostic yield. A satisfactory concordance between both devices could be demonstrated (κ = 0.66). In approximately half of the patients, a diagnosis could be made with a tendency in favor of the MiroCam (56 % vs. 46 % with PillCam). In the per patient analysis, it was shown that the MiroCam identified 95 % of the positive cases, whereas the PillCam identified only 79 %. Small-bowel transit time and consequently the capsule reading time were significantly longer with the MiroCam.

These results are similar to the findings of Kim et al., who performed the first comparative trial of MiroCam and PillCam in 24 patients [8]. The concordance between the two capsules was good with a kappa value of 0.74. The diagnostic yield of the MiroCam also showed a slightly better result (46 % vs. 42 % with PillCam). The cecum intubation rate differed significantly with 83 % for MiroCam and 58 % for PillCam. The low cecum transmission rate of only 58 % was surprising and is generally higher at approximately 75 – 85 %. Altogether there are no distinct differences found between the two devices. However, the diagnostic yield of the MiroCam seems to be higher, which can be explained by the longer operating time of this device.

Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use (Xin et al., Gastrointest Endosc 2011 [9])

The DBE system, developed by Yamamoto, was presented for the first time in Japan in 2001, and by our own research group in Germany in 2003 [10] [11]. Since then, the system has become established throughout the world for diagnostic and therapeutic small-bowel examinations, and it is now used universally in routine clinical work. A systematic review on the application and results of DBE within the past decade was published by a group from China [9].

Altogether, almost 13 000 DBE procedures from 66 published articles were included in this analysis. About two-thirds of the patients suffered from suspected mid-gastrointestinal bleeding, which is still the main indication for small-bowel endoscopy. The pooled diagnostic yield was 68 %, with the highest detection rate of 85 % for intestinal obstruction. There were differences in the bleedings sources between Eastern and Western countries. In the Eastern hemisphere inflammatory lesions were the main bleeding source, whereas vascular malformations were the leading bleeding source in the Western hemisphere. The pooled total enteroscopy rate was 44 %, nearly all from a combined oral and anal approach. The pooled major complication rate was 0.7 %. The leading complications were perforation and pancreatitis (0.49 %).

For achievement of an adequate diagnostic yield, proper patient selection is mandatory. The clinical indications that are associated with the highest diagnostic yield are mid-gastrointestinal bleeding and intestinal obstruction [12]. This finding could be confirmed by this large systematic review. Recently, another paper on complications and performance of DBE in a large prospective database was published, which reported an overall complication rate of 1.2 % [13]. Again, pancreatitis (0.3 %) and perforation (mainly after polypectomy) were the leading complications. These results are similar to the Chinese paper. Altogether, the complication rate of DBE procedures is acceptable, but seems to be slightly higher compared with upper and lower gastrointestinal endoscopy.

Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial (Takano et al., Gastrointest Endosc 2011 [14])

Last year the first prospective randomized multicenter trial comparing DBE with the single-balloon technique (SBE) was published [15]. The study of 100 patients demonstrated that the rate of complete enteroscopy with DBE was three times higher than that with SBE (66 % vs. 22 %). Complete enteroscopy was chosen as the main end point of the study because this was the most objective parameter compared with measurement of insertion depth, which is a rough estimation and depends upon the experience of the endoscopist. Additionally, DBE was associated with a higher diagnostic and therapeutic yield compared with SBE, including the complete negative enteroscopies, which sometimes have a distinct influence on the management of the patients, and complete enteroscopies in patients with known small-bowel diseases for determination of the extent of their disease. The major argument against this study was that both balloon techniques were performed with the Fujinon device.

Recently, a Japanese prospective, single-center trial was published, using the Fujinon device for DBE and the Olympus device for SBE. The major endpoint of the study was also complete enteroscopy [14]. For DBE, similar results were achieved, with a complete enteroscopy rate of 57 %, whereas the results for SBE were poor, at 0 %. Because of the clear disadvantage in the SBE group, the investigators aborted the study after the interim analysis of 38 patients, before the calculated sample size number of patients had been enrolled. There was no significant difference found in the therapeutic outcome between DBE and SBE (35 % vs. 28 %), probably due to the small number of patients analyzed.

Different results were also published recently from a randomized multicenter trial in Münster, Rotterdam, and Oslo. A complete enteroscopy rate was achieved in 11 % with the SBE device and 18 % with the DBE device [16]. Because of the poor rates of complete enteroscopy with both systems, the major clinical endpoint of the study was changed after an interim analysis (presented at the United European Gastroenterology Week; Barcelona, Spain, 23 – 27 October 2010) to comparison of insertion depths. After finishing the study, no differences were found between DBE and SBE. Comparing these poor results of total enteroscopy with for example the published pooled results of the above-mentioned Chinese study [9], this study cannot be regarded as the right study for a comparison of both methods, because training for both techniques seems to be necessary for the participants. In summary, DBE still has to be regarded as superior to SBE. Complete enteroscopy rates (if attempted) of DBE in specialized centers are about 70 – 90 % [15] [17], and in general daily routine practice it is estimated to be between 20 % and 40 % [9] [13].

Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding (May et al., Endoscopy 2011 [18])

The development of DBE (Fujinon, Inc., Saitama, Japan) was a decisive breakthrough for diagnostic and therapeutic nonsurgical endoscopy in the deep small bowel. As the most common bleeding sources in the small bowel are vascular malformations, at least in Western countries, argon plasma coagulation (APC) is the most frequently used hemostatic procedure for endoscopic treatment of small-bowel lesions. Studies published to date have only had short- or medium-term follow-up periods after endoscopic hemostasis of small-bowel lesions using DBE, and the results have been contradictory [19] [20]. The technique is time-consuming, and the question therefore arises of whether the effort required is justified. The effectiveness of APC in treating small-bowel bleeding had therefore still not been demonstrated clearly.

The aim of the retrospective analysis by our group was to determine the value of APC in small-bowel lesions during the long-term in relation to increasing and stabilizing hemoglobin values, reducing the need for blood transfusions, and the rate of rebleeding [18]. A total of 50 patients who had undergone APC treatment for small-bowel lesions between 2003 and 2005 were included in the analysis. The most frequent bleeding sources treated with APC were angiodysplasias (88 %). Hemoglobin levels increased distinctly and stabilized after APC during a mean long-term follow-up of approximately 5 years, with mean levels of 7.6 g/dL before APC and 11.0 g/dL afterwards. Blood transfusion requirements substantially declined, from 60 % of patients before APC to 16 % afterwards. However, small-bowel bleeding recurred in 42 %, particularly in patients with Osler disease. The majority of the patients developed the first recurrent bleeding episode in the first year after APC (20.5 %). No new cases of rebleeding were documented after the third year.

The present study has, for the first time, clearly demonstrated a distinct increase and stabilization of hemoglobin levels after APC using DBE for vascular lesions, including Dieulafoy lesions. In addition, nearly 75 % of the patients who had been receiving blood transfusions before APC required no further transfusion after the procedure. A major decline in blood transfusion requirement was therefore observed during the follow-up period. These outcome results have for the first time been confirmed for a long-term follow-up period of nearly 5 years. Therefore this paper is important because it confirms the efficacy of APC with DBE and justifies the use of this method.

Competing interests: AM has received speaker honorarium from Fujinon. The Department receives support for research from Fujinon, Given, Hitachi, and Erbe.

• References

• 1 Imagawa H, Oka S, Tanaka S et al. Improved visibility of lesions of the small bowel intestine via capsule endoscopy with computed virtual chromoendoscopy. Gastrointest Endosc 2011; 73: 299-306
  CrossrefPubMedSearch in Google Scholar
• 2 Pohl J, May A, Rabenstein T et al. Computed virtual chromoendoscopy: a new tool for enhancing tissue surface structures. Endoscopy 2007; 39: 80-83
  Thieme ConnectPubMedSearch in Google Scholar
• 3 Neumann H, Fry LC, Bellutti M et al. Double-balloon enteroscopy-assisted virtual chromoendoscopy for small-bowel disorders: a case series. Endoscopy 2009; 41: 468-471
  Thieme ConnectPubMedSearch in Google Scholar
• 4 Pohl J, Aschmoneit I, Schuhmann S et al. Computed image modification for enhancement of small-bowel surface structures at video capsule endoscopy. Endoscopy 2010; 42: 490-492
  Thieme ConnectPubMedSearch in Google Scholar
• 5 Gupta T, Ibrahim M, Deviere J et al. Evaluation of Fujinon intelligent chromo endoscopy-assisted capsule endoscopy in patients with obscure gastroenterology bleeding. World J Gastroenterol 2011; 17: 4590-4595
  CrossrefPubMedSearch in Google Scholar
• 6 Pioche M, Gaudin JL, Filoche B et al. Prospective randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding. Gastrointest Endosc 2011; 73: 1181-1188
  CrossrefPubMedSearch in Google Scholar
• 7 Bang S, Park JY, Jeong S et al. First clinical trial of the “MiRo” capsule endoscope by using a novel transmission technology: electric-field propagation. Gastrointest Endosc 2009; 69: 253-259
  CrossrefPubMedSearch in Google Scholar
• 8 Kim HM, Kim YJ, Kim HJ et al. A pilot study of sequential capsule endoscopy using MiroCam and PillCam SB devices with different transmission technologies. Gut Liver 2010; 4: 192-200
  CrossrefPubMedSearch in Google Scholar
• 9 Xin L, Liao Z, Jiang YP et al. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc 2011; 74: 563-570
  CrossrefPubMedSearch in Google Scholar
• 10 Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53: 216-220
  Search in Google Scholar
• 11 May A, Nachbar L, Wardak A et al. Double-balloon enteroscopy: preliminary experience in patients with obscure gastrointestinal bleeding or chronic abdominal pain. Endoscopy 2003; 35: 985-991
  Thieme ConnectPubMedSearch in Google Scholar
• 12 Zhong J, Ma T, Zhang C et al. A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases. Endoscopy 2007; 39: 208-215
  Thieme ConnectPubMedSearch in Google Scholar
• 13 Möschler O, May A, Müller MK et al. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy 2011; 43: 484-489
  Thieme ConnectPubMedSearch in Google Scholar
• 14 Takano N, Yamdada A, Watabe H et al. Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial. Gastrointest Endosc 2011; 73: 734-739
  CrossrefPubMedSearch in Google Scholar
• 15 May A, Färber M, Aschmoneit I et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010; 105: 575-581
  CrossrefPubMedSearch in Google Scholar
• 16 Domagk D, Mensink P, Aktas H et al. Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trail. Endoscopy 2011; 43: 472-476
  Thieme ConnectPubMedSearch in Google Scholar
• 17 Yamamoto H, Kita H, Sunada K et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol 2004; 2: 1010-1016
  CrossrefPubMedSearch in Google Scholar
• 18 May A, Friesing-Sosnik T, Manner H et al. Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding. Endoscopy 2011; 43: 759-765
  Thieme ConnectPubMedSearch in Google Scholar
• 19 Madisch A, Schmolders J, Brückner S et al. Less favorable clinical outcome after diagnostic and interventional double balloon enteroscopy in patients with suspected small-bowel bleeding?. Endoscopy 2008; 40: 731-734
  Thieme ConnectPubMedSearch in Google Scholar
• 20 Gerson LB, Batenic MA, Newsom SL et al. Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding. Clin Gastroenterol Hepatol 2009; 7: 664-669
  CrossrefPubMedSearch in Google Scholar

Corresponding author

• References

• 1 Imagawa H, Oka S, Tanaka S et al. Improved visibility of lesions of the small bowel intestine via capsule endoscopy with computed virtual chromoendoscopy. Gastrointest Endosc 2011; 73: 299-306
  CrossrefPubMedSearch in Google Scholar
• 2 Pohl J, May A, Rabenstein T et al. Computed virtual chromoendoscopy: a new tool for enhancing tissue surface structures. Endoscopy 2007; 39: 80-83
  Thieme ConnectPubMedSearch in Google Scholar
• 3 Neumann H, Fry LC, Bellutti M et al. Double-balloon enteroscopy-assisted virtual chromoendoscopy for small-bowel disorders: a case series. Endoscopy 2009; 41: 468-471
  Thieme ConnectPubMedSearch in Google Scholar
• 4 Pohl J, Aschmoneit I, Schuhmann S et al. Computed image modification for enhancement of small-bowel surface structures at video capsule endoscopy. Endoscopy 2010; 42: 490-492
  Thieme ConnectPubMedSearch in Google Scholar
• 5 Gupta T, Ibrahim M, Deviere J et al. Evaluation of Fujinon intelligent chromo endoscopy-assisted capsule endoscopy in patients with obscure gastroenterology bleeding. World J Gastroenterol 2011; 17: 4590-4595
  CrossrefPubMedSearch in Google Scholar
• 6 Pioche M, Gaudin JL, Filoche B et al. Prospective randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding. Gastrointest Endosc 2011; 73: 1181-1188
  CrossrefPubMedSearch in Google Scholar
• 7 Bang S, Park JY, Jeong S et al. First clinical trial of the “MiRo” capsule endoscope by using a novel transmission technology: electric-field propagation. Gastrointest Endosc 2009; 69: 253-259
  CrossrefPubMedSearch in Google Scholar
• 8 Kim HM, Kim YJ, Kim HJ et al. A pilot study of sequential capsule endoscopy using MiroCam and PillCam SB devices with different transmission technologies. Gut Liver 2010; 4: 192-200
  CrossrefPubMedSearch in Google Scholar
• 9 Xin L, Liao Z, Jiang YP et al. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc 2011; 74: 563-570
  CrossrefPubMedSearch in Google Scholar
• 10 Yamamoto H, Sekine Y, Sato Y et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53: 216-220
  Search in Google Scholar
• 11 May A, Nachbar L, Wardak A et al. Double-balloon enteroscopy: preliminary experience in patients with obscure gastrointestinal bleeding or chronic abdominal pain. Endoscopy 2003; 35: 985-991
  Thieme ConnectPubMedSearch in Google Scholar
• 12 Zhong J, Ma T, Zhang C et al. A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases. Endoscopy 2007; 39: 208-215
  Thieme ConnectPubMedSearch in Google Scholar
• 13 Möschler O, May A, Müller MK et al. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy 2011; 43: 484-489
  Thieme ConnectPubMedSearch in Google Scholar
• 14 Takano N, Yamdada A, Watabe H et al. Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial. Gastrointest Endosc 2011; 73: 734-739
  CrossrefPubMedSearch in Google Scholar
• 15 May A, Färber M, Aschmoneit I et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010; 105: 575-581
  CrossrefPubMedSearch in Google Scholar
• 16 Domagk D, Mensink P, Aktas H et al. Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trail. Endoscopy 2011; 43: 472-476
  Thieme ConnectPubMedSearch in Google Scholar
• 17 Yamamoto H, Kita H, Sunada K et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol 2004; 2: 1010-1016
  CrossrefPubMedSearch in Google Scholar
• 18 May A, Friesing-Sosnik T, Manner H et al. Long-term outcome after argon plasma coagulation of small-bowel lesions using double-balloon enteroscopy in patients with mid-gastrointestinal bleeding. Endoscopy 2011; 43: 759-765
  Thieme ConnectPubMedSearch in Google Scholar
• 19 Madisch A, Schmolders J, Brückner S et al. Less favorable clinical outcome after diagnostic and interventional double balloon enteroscopy in patients with suspected small-bowel bleeding?. Endoscopy 2008; 40: 731-734
  Thieme ConnectPubMedSearch in Google Scholar
• 20 Gerson LB, Batenic MA, Newsom SL et al. Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding. Clin Gastroenterol Hepatol 2009; 7: 664-669
  CrossrefPubMedSearch in Google Scholar