Impact of fluoroscopy on oral double-balloon enteroscopy: results of a randomized trial in 156 patients

Background and study aims: The routine utility of fluoroscopy during double-balloon enteroscopy (DBE) via the oral route has been not prospectively evaluated. Up to now, there have been no prospective randomized trials to assess whether fluoroscopy improves outcomes. The aim of this study was to assess the value of fluoroscopy during oral DBE.

Patients and methods: A total of 156 patients (88 men, 56.4 %) of mean (standard deviation [SD]) age 56 (19) years were randomly assigned to undergo oral DBE either with or without fluoroscopy. The majority of the patients had obscure gastrointestinal bleeding (n = 96, 62 %). The primary target criteria for the study were postpyloric insertion depth and time required to reach the deepest insertion point. A secondary target criterion was the diagnostic yield achieved.

Results: The results in the fluoroscopy and nonfluoroscopy groups did not differ significantly with respect to the mean (SD) insertion depth (fluoroscopy, 284 [89] cm, range 70 – 470 cm; nonfluoroscopy, 256 [86] cm, 40 – 430 cm), the mean time required to reach the deepest point of insertion, or the diagnostic yield achieved. In patients with previous abdominal surgery and during difficult procedures, the mean insertion depth was significantly lower.

Conclusions: Fluoroscopy during DBE via the oral route does not provide a significant gain in insertion depth, advancement time, or diagnostic yield in comparison with nonfluoroscopically guided procedures. In experienced hands, fluoroscopy does not have to be used routinely during oral DBE.

References

• 1 Yamamoto H, Sekine Y, Sato Y. et al . Total enteroscopy with a nonsurgical steerable double-balloon method.  Gastrointest Endosc. 2001;  53 216-220
• 2 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
• 3 May A, Nachbar L, Schneider M. et al . Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility, diagnostic and therapeutic yield in patients with suspected small bowel disease.  Gastrointest Endosc. 2005;  62 62-70
• 4 Ell C, May A, Nachbar L. et al . Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study.  Endoscopy. 2005;  37 613-616
• 5 Heine G DN, Hadithi M, Groenen M JM. et al . Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease.  Endoscopy. 2006;  38 42-48
• 6 May A, Nachbar L, Pohl J. et al . Endoscopic interventions in the small bowel using double-balloon enteroscopy: feasibility and limitations.  Am J Gastroenterol. 2007;  102 527-535
• 7 Möschler O, May A D, Müller M K. et al . Complications in double-balloon-enteroscopy: results of the German DBE register.  Z Gastroenterol. 2008;  46 266-270
• 8 May A, Nachbar L, Schneider M. et al . Push-and-pull enteroscopy using the double-balloon technique: method of assessing depth of insertion and training of the enteroscopy technique using the Erlangen Endo-Trainer.  Endoscopy. 2005;  37 66-70
• 9 Manner H, May A, Rabenstein T. et al . Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy.  Scand J Gastroenterol. 2007;  42 397-405
• 10 Manner H, Enderle M D, Pech O. et al . Second-generation argon plasma coagulation: two-center experience with 600 patients.  J Gastroenterol Hepatol. 2008;  23 872-878
• 11 Plum N, May A D, Manner H. et al . [Peutz–Jeghers syndrome: endoscopic detection and treatment of small bowel polyps by double-balloon enteroscopy]. [In German].  Z Gastroenterol. 2007;  45 1049-1055
• 12 Pohl J, May A, Nachbar L, Ell C. Diagnostic and therapeutic yield of push-and-pull enteroscopy for symptomatic small bowel Crohn’s disease strictures.  Eur J Gastroenterol Hepatol. 2007;  19 529-534
• 13 Fry L, Mönkemüller K, Neumann H. et al . Learning curve of double balloon enteroscopy.  Tech Gastrointest Endosc. 2008;  10 2, 59 – 61
• 14 Gross S A, Stark M E. Initial experience with double-balloon enteroscopy at a U.S. center.  Gastrointest Endosc. 2008;  67 890-897
• 15 Mehdizadeh S, Ross A, Gerson L. et al . What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.  Gastrointest Endosc. 2006;  64 740-750
• 16 Hirai F, Matsui T, Yao K. et al . Efficacy of carbon dioxide insufflation in endoscopic balloon dilation therapy using double balloon endoscopy.  Gastrointest Endosc. 2007;  66 26-29
• 17 Domagk D, Bretthauer M, Lenz P. et al . Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial.  Endoscopy. 2007;  39 1064-1067
• 18 Pohl J, Delvaux M, Ell C. et al . European Society of Gastrointestinal Endoscopy (ESGE) Guidelines: Flexible enteroscopy for diagnosis and treatment of small-bowel diseases.  Endoscopy. 2008;  40 609-618
• 19 Zhong J, Ma T, Zhang C. A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases.  Endoscopy. 2007;  39 208-215
• 20 Di Caro S, May A, Heine D G. et al . The European experience with double-balloon enteroscopy: indications, methodology, safety, and clinical impact.  Gastrointest Endosc. 2005;  62 545-550
• 21 Fry L C, Bellutti M, Neumann H. et al . Incidence of bleeding lesions within reach of upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding.  Aliment Pharmacol Ther. 2009;  29 342-349