Evaluation of the diagnostic and therapeutic utility of retrograde through-the-scope balloon enteroscopy and single-balloon enteroscopy

BACKGROUND Retrograde single balloon enteroscopy(SBE)is a minimally invasive procedure which is less frequently performed compared with antegrade SBE.There are few studies on the retrograde through-the-scope enteroscopy(TTSE),a novel technique for evaluation of the small bowel.AIM To compare the clinical utility and safety of retrograde TTSE with retrograde SBE.METHODS Clinical data and complications of retrograde TTSE(2014-2018)and retrograde SBE(2011-2018)performed in a community hospital were reviewed and presented as mean±SD or frequency(%)and compared using proper statistical tests.Technical success was defined as insertion of the enteroscope>20 cm beyond ileocecal valve.RESULTS Data obtained from 54 retrograde SBE in 49 patients and 27 retrograde TTSE in 26 patients were studied.The most common indication for retrograde enteroscopy was iron deficiency anemia(41 patients)followed by gastrointestinal bleeding(37 patients),and chronic diarrhea(7 patients).The duration of retrograde SBE procedure(91.9±34.2 min)was significantly longer compared with retrograde TTSE(70.5±30.7 min)(P=0.04).Technical success was comparable in TTSE[23/27(85.2%)]and SBE[41/54(75.9%)(P=0.33)].The mean depth of insertion beyond the ileocecal valve in retrograde SBE(92.5±70.0 cm)tended to be longer compared with retrograde TTSE(64.6±49.0 cm)(P=0.08).No complication was observed in this study.CONCLUSION Both retrograde TTSE and retrograde SBE are feasible and safe.Retrograde TTSE takes a shorter time and has a comparable technical success with SBE.TTSE has a lower capacity of small bowel insertion.

Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients

AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded. RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%. CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.

Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejuno anastomosis

AIM:To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography(ERC)in patients with Roux-en-Y hepaticojejunoanastomosis(HJA).METHODS:The study took place from January 2009to December 2011 and we retrospectively assessed 15patients with Roux-en-Y HJA who had signs of biliary obstruction.In total,23 ERC procedures were performed in these patients and a single balloon videoen-teroscope(Olympus SIF Q 180)was used in all of the cases.A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope.Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of≤5.4 kPa.The technical limitations or rather the parameters of the single balloon enteroscope(working length-200 cm,diameter of the working channel-2.8 mm,absence of Albarran bridge)showed the need for special endoscopic instrumentation.RESULTS:Cannulation success was reached in diagnostic ERC in 12 of 15 patients.ERC findings were normal in 1 of 12 patients.ERC in the remaining 11 patients showed some pathological changes.One of these(cystic bile duct dilation)was subsequently resolved surgically.Endoscopic treatment was initialized in the remaining 10 patients(5 with HJA stenosis,2 with choledocholithiasis,and 3 with both).This treatment was successful in 9 of 10 patients.The endoscopic therapeutic procedures included:balloon dilatation of HJA stenosis-11 times(7 patients);choledocholitiasis extraction-five times(5 patients);biliary plastic stent placement-six times(4 patients);and removal of biliary stents placed by us-six times(4 patients).The mean time of performing a single ERC was 72 min.The longest procedure took 110 min and the shortest took34 min.This shows that it is necessary to allow for more time in individual procedures.Furthermore,these procedures require the presence of an anesthesiologist.We did not observe any complications in these 15 patients.CONCLUSION:This method is more demanding than standard endoscopic retrograde cholangiopancreatography due to altered postsurgical anatomy.However,it is effective,safe,and widens the possibilities of resolving biliary pathology.

Performance characteristics of retrograde single-balloon endoscopy: A single center experience

AIM: To evaluate the technical success, diagnostic yield(DY) and therapeutic potential of retrograde single balloon enteroscopy(rS BE). METHODS: A retrospective review of 136 rS BE procedures performed at a tertiary academic referral center from January 2006 and September 2013 was completed. Patient characteristics including age, gender and inpatient status were collected. The indication for the procedure was categorized into one of three groups: Obscure gastrointestinal bleeding(GIB), evaluation for Crohn's disease and abnormal imaging. Procedural characteristics including insertion depth(ID), procedure time, concordance with pre-procedural imaging and complications were also recorded. Lastly, DY, defined as the percentage of cases producing either a definitive diagnosis or findings that could explain clinical symptoms and therapeutic yield(TY), defined as the percentage of cases in which a definitive intervention was performed, were determined. Mucosal tattooing and biopsy alone were not included in the TY. RESULTS: A total of 136 rS BE procedures were identified. Mean patient age was 57.5(± 16.2) years, 67(49.2%) were male, and 110(80.9%) procedures were performed on an outpatient basis. Indications for rS BE included GIB in 55(40.4%), evaluation of inflammatory bowel disease(IBD) in 29(21.3%), and imaging suggestive of pathology other than GIB or IBD in 43(31.6%). Nine(6.6%) rS BEs were performed for other indications. Mean ID was 68.3(± 39.3) cm proximal to the ileocecal valve and mean time to completion was 41.7(± 15.5) min. Overall, 73(53.7%) cases were diagnostic and 25(18.4%) cases were therapeutic in which interventions(argon plasma coagulation, stricture dilatation, polypectomy, etc.) were performed. Pre-procedural imaging was performed in 88(64.7%) patients. Endoscopic concordance of positive imaging findings was seen in 31(35.2%) cases. Follow up data was available in 93(68.4%) patients; 2(2.2%) reported post-procedural abdominal pain within 30 d following rS BE. There were no other reported complications. CONCLUSION: rS BE exhibits an acceptable diagnostic and TY, rendering it a safe and effective procedure for the evaluation and treatment of small bowel diseases.

Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography(SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76(90%) procedures and clinical success rate of 30/34(88%) patients. Mild adverse event rate was 8/76(11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30(80%) procedures( P = 0.194 vs. biliary SBEERCP) and clinical success rate of 11/17(65%) patients( P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30(20%)( P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

AIM: To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy. METHODS: Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth Ⅱ gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing,selectively applying contrast medium, and CO2 insufflations. RESULTS: The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth Ⅱ reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth Ⅱ reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth Ⅱ reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth Ⅱ anastomosis.CONCLUSION: Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.

Rotational assisted endoscopic retrograde cholangiopancreatography in patients with reconstructive gastrointestinal surgical anatomy

AIM: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography(ERCP) in surgically altered anatomy patients. METHODS: Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy(39 with gastric bypass Roux-en-Y, 2 with Billroth Ⅱ gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42(30.9%), biliary obstruction suggested on imaging: 20 of 42(47.6%), suspected sphincter of Oddi dysfunction: 4 of 42(9.5%), abnormal liver enzymes: 1 of 42(2.4%), ascending cholangitis: 2 of 42(4.8%), and bile leak: 2 of 42(4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS: Successful visualization of the major ampulla was accomplished in 32 of 42 procedures(76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla(81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bileduct was cannulated(92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients(23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients(7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d.CONCLUSION: It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.

Capsule endoscopy and single-balloon enteroscopy in small bowel diseases: Competing or complementary?

AIM To evaluate diagnostic yields of capsule endoscopy(CE) and/or single-balloon enteroscopy(SBE) in patients with suspected small bowel diseases.METHODS Were trospectively analyzed 700 patients with suspected small bowel diseases from September 2010 to March 2016. CE, SBE, or SBE with prior CE was performed in 401, 353, and 47 patients, respectively. Data from clinical and endoscopy records were collected for analysis. Indications, procedure times, diagnostic yields, and complications were summarized and evaluated.RESULTS The overall diagnostic yield for the CE group was 57.6%. The diagnostic yield of CE in patients with obscure gastroin testinal bleeding(OGIB) was significantly greater than that in patients with no bleeding(70.5% vs 43.8%, P < 0.01). The overall diagnostic yield of SBE was 69.7%. There was no difference in the diagnostic yield of SBE between patients with OGIB and those with no bleeding(72.5% vs 68.9%, P = 0.534). Forty-seven patients underwent CE prior to SBE. Among them, the diagnostic yield of SBE with positive findings on prior CE was 93.3%. In addition, SBE detected two cases with superficial ulcer and erosive lesions in the small bowel, which were missed by CE. However, one case with lymphoma and two with Crohn's disease were not confirmed by SBE. The rate of capsule retention was 2.0%. There were no significant complications during or after SBE examinations.CONCLUSION SBE is a safe and effective technique for diagnosing small bowel diseases. SBE with prior CE seemed to improve the diagnostic yield of small bowel diseases.

Comparison between double-balloon and single-balloon enteroscopy in therapeutic ERC after Roux-en-Y entero-enteric anastomosis

AIM:To compare the efficacy of double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE) in therapeutic endoscopic retrograde cholangiography (ERC) in patients with Roux-en-Y entero-enteric anastomosis.METHODS:Retrospective analysis of our patient cohort revealed 4 patients with enterobiliary anastomosis and Roux-en-Y entero-enteric anastomosis who underwent repeated ERC with DBE and SBE because of recurrent cholangitis.RESULTS:A total of 38 endoscopic retrograde cholangiopancreatography procedures were performed in 25 patients with Roux-en-Y entero-enteric anastomosis.DBE was used in 29 procedures and SBE in 9.The 4 patients who underwent repeated ERC with DBE and SBE suffered from recurrent cholangitis due to stenosis of the enterobiliary anastomosis.ERC was performed repeatedly to achieve balloon dilation with/without biliary stone extraction and multiple stent placement at the level of the enterobiliary anastomosis.In all 4 patients DBE and SBE were equally successful.Compared to DBE,SBE was equally effective in passing the Roux-en-Y entero-enteric anastomosis,reaching the enterobiliary anastomosis and performing therapeutic ERC.CONCLUSION:This retrospective comparison shows that DBE and SBE are equally successful in the performance of therapeutic ERC at the level of the enterobiliary anastomosis after Roux-en-Y entero-enteric anastomosis.

Double-balloon endoscopic retrograde cholangiopancreatography for patients who underwent liver operation: A retrospective study

BACKGROUND Double-balloon endoscopic retrograde cholangiography (DB-ERC) is widely performed for biliary diseases after reconstruction in gastrointestinal surgery,but there are few reports on DB-ERC after hepatectomy or living donor liver transplantation (LDLT).AIM To examine the success rates and safety of DB-ERC after hepatectomy or LDLT METHODS The study was performed retrospectively in 26 patients (45 procedures) who underwent hepatectomy or LDLT (liver operation:LO group) and 40 control patients (59 procedures) who underwent pancreatoduodenectomy (control group).The technical success (endoscope reaching the choledochojejunostomy site),diagnostic success (performance of cholangiography),therapeutic success(completed interventions) and overall success rates,insertion and procedure(completion of DB-ERC) time,and adverse events were compared between these groups.RESULTS There were no significant differences between LO and control groups in the technical [93.3%(42/45) vs 96.6%(57/59),P=0.439],diagnostic [83.3%(35/42) vs83.6%(46/55),P=0.968],therapeutic [97.0%(32/33) vs 97.7%(43/44),P=0.836],and overall [75.6%(34/45) vs 79.7%(47/59),P=0.617] success rates.The median insertion time (22 vs 14 min,P <0.001) and procedure time (43.5 vs 30 min,P=0.033) were significantly longer in the LO group.The incidence of adverse events showed no significant difference [11.1%(5/45) vs 6.8%(4/59),P=0.670].CONCLUSION DB-ERC after liver operation is safe and useful but longer time is required,so should be performed with particular care.

Innovations and techniques for balloon-enteroscopeassisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography(ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine.Recently,many studies have reported that balloonenteroscope-assisted ERCP(BEA-ERCP) is a safe and effective procedure.However,further improvements in outcomes and the development of simplified procedures are required.Percutaneous treatment,Laparoscopy-assisted ERCP,endoscopic ultrasoundguided anterograde intervention,and open surgery are effective treatments.However,treatment should be noninvasive,effective,and safe.We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications.BEA-ERCP still requires high expertiselevel techniques and is far from a routinely performed procedure.Various techniques have been proposed to facilitate scope insertion(insertion with percutaneous transhepatic biliary drainage(PTBD) rendezvous technique,Short type single-balloon enteroscopes with passive bending section,Intraluminal injection of indigo carmine,CO2 inflation guidance),cannulation(PTBD or percutaneous transgallbladder drainage rendezvous technique,Dilation using screw drill,Rendezvous technique combining DBE with a cholangioscope,endoscopic ultrasound-guided rendezvous technique),and treatment(overtube-assisted technique,Short type balloon enteroscopes) during BEA-ERCP.The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients.A standard procedure for ERCP yet to be established for patients with a reconstructed intestine.At present,BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as firstline treatment.In this article,we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.

Current status of single-balloon enteroscopy: Insertability and clinical applications

The single-balloon enteroscopy(SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy(DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. However, many methods have been proposed to improve the depth of insertion with the SBE system, involving several techniques and endoscopic accessories. SBE is used for investigating not only small bowel diseases, but also diseases of the pancreatobiliary and colonic structures. SBE is a necessary advancement for many endoscopic procedures and applications in modern clinical practice. In our review, we summarized the current literature concerning the insertability of SBE and described the technical aspects of improving the rate of deep insertion in SBE procedures. In addition, the recent applications of SBE to diseases besides those of the small bowel are described.

Endoscopic and retrograde cholangiographic appearance of hepaticojejunostomy strictures:A practical classifi cation

AIM:To study the endoscopic and radiological characteristics of patients with hepaticojejunostomy(HJ)and propose a practical HJ stricture classif ication.METHODS:In a retrospective observational study,a balloon-assisted enteroscopy(BAE)-endoscopic retrograde cholangiography was performed 44 times in 32 patients with surgically-altered gastrointestinal(GI)anatomy.BAE-endoscopic retrograde cholangio pancreatography(ERCP)was performed 23 times in 18 patients with HJ.The HJ was carefully studied with the endoscope and using cholangiography.RESULTS:The authors observed that the hepaticojejunostomies have characteristics that may allow these to be classif ied based on endoscopic and cholangiographic appearances:the HJ orif ice aspect may appear as small(type A)or large(type B)and the stricture may be short(type 1),long(type 2)and type 3,intrahepatic biliary strictures not associated with anastomotic stenosis.In total,7 patients had type A1,4 patients A2,one patient had B1,one patient had B(large orif ice without stenosis)and one patient had type B3.CONCLUSION:This practical classification allows for an accurate initial assessment of the HJ,thus potentially allowing for adequate therapeutic planning,as the shape,length and complexity of the HJ and biliary tree choice may mandate the type of diagnostic and thera-peutic accessories to be used.Of additional importance,a standardized classif ication may allow for better com-parison of studies of patients undergoing BAE-ERCP in the setting of altered upper GI anatomy.

Ileal gallstone obstruction:Single-balloon enteroscopic removal

Gallstone-induced ileus is a rare complication of cholelithiasis.Since localization of gallstones impacted in the small bowel,especially in the ileum,prevents access by conventional endoscopy in most cases,the mainstay of treatment remains surgical.Recent invention of double-and single-balloon enteroscopy has added much to the ability of imaging the small bowel and enables endoscopically directed therapy.Herein,for the first time,we report a successful endoscopic calculus removal via peroral single-balloon enteroscopy in an 81-year-old woman suffering from gallstone ileus of the ileum.

Single-balloon and spiral enteroscopy may have similar diagnostic and therapeutic yields to double-balloon enteroscopy:Results from a meta-analysis of randomized controlled trials and prospective studies

BACKGROUND Double-balloon,single-balloon,and spiral enteroscopy(DBE,SBE,and SE)have revolutionized the management of intestinal diseases.However,evidence about efficacies of these methods is lacking.We aimed to conduct a meta-analysis comparing the clinical outcomes among DBE,SBE,and SE.METHODS We searched randomized controlled trials and prospective studies in MEDLINE,PubMed,EMBASE,Cochrane Library,and Chinese CQVIP database.Studies referencing the comparison of at least two of these three methods were included.Primary outcome was diagnostic yield.Other outcomes were therapeutic yield,total enteroscopy,examination time,time to maximum insertion,and depth of maximal insertion(DMI).RESULTS Eleven studies including 727 patients were identified:DBE vs SE(n=6),DBE vs SBE(n=4),and SBE vs SE(n=1).The diagnostic and therapeutic yields did not differ significantly when comparing DBE with SE[odds ratio(OR)=1.19,95%confidence interval(CI):0.68-2.08;OR=1.17,95%CI:0.61-2.23]and DBE with SBE(OR=0.85,95%CI:0.55-1.33;OR=1.71,95%CI:0.64-4.60).Total enteroscopy,examination time,time to maximum insertion,and DMI were similar between SBE and DBE.DBE was superior to SE with regard to DMI[mean difference(MD)=36.76,95%CI:5.09-68.43],with longer time to maximum insertion(MD=15.14,95%CI:12-18.27)and examination time(MD=12.98,95%CI:9.57-16.38).CONCLUSION DBE and SBE have similar clinical outcomes.Compared with DBE,SE seems to have similar diagnostic and therapeutic yields,but shorter procedural time in cost of less depth of insertion.SE needs further evaluation vs SBE.DBE is recommended for complete enteroscopy.

Computed tomography three-dimensional reconstruction in the diagnosis of bleeding small intestinal polyps:A case report

BACKGROUND Computed tomography(CT)small bowel three-dimensional(3D)reconstruction is a powerful tool for the diagnosis of small bowel disease and can clearly show the intestinal lumen and wall as well as the outside structure of the wall.The horizontal axis position can show the best adjacent intestinal tube and the lesion between the intestinal tubes,while the coronal position can show the overall view of the small bowel.The ileal end of the localization of the display of excellent,and easy to quantitative measurement of the affected intestinal segments,the sagittal position for the rectum and the pre-sacral lesions show the best,for the discovery of fistulae is also helpful.Sagittal view can show rectal and presacral lesions and is useful for fistula detection.It is suitable for the assessment of inflammatory bowel disease,such as assessment of disease severity and diagnosis and differential diagnosis of the small bowel and mesenteric space-occupying lesions as well as the judgment of small bowel obstruction points.CASE SUMMARY Bleeding caused by small intestinal polyps is often difficult to diagnose in clinical practice.This study reports a 29-year-old male patient who was admitted to the hospital with black stool and abdominal pain for 3 months.Using the combination of CT-3D reconstruction and capsule endoscopy,the condition was diagnosed correctly,and the polyps were removed using single-balloon enteroscopyendoscopic retrograde cholangiopancreatography without postoperative complications.CONCLUSION The role of CT-3D in gastrointestinal diseases was confirmed.CT-3D can assist in the diagnosis and treatment of gastrointestinal diseases in combination with capsule endoscopy and small intestinal microscopy.

Characteristics and prognosis of small bowel tumors:A retrospective study

BACKGROUND Small bowel tumors(SBTs)are a heterogeneous group of difficult-to-diagnose tumors that account for 2%-5%of all gastrointestinal tumors.Single-balloon enteroscopy greatly enhances the diagnosis and treatment of SBTs.However,few epidemiological studies have been conducted in Taiwan to determine the clinical profile of SBTs.AIM To investigate the clinical characteristics,managements and prognosis of SBTs in a medical center in Taiwan.METHODS The study enrolled 51 patients aged 58.9±8.8 years(range,22-93)diagnosed with SBTs from November 2009 to July 2021.We retrospectively recorded clinical characteristics,indications,endoscopic findings,pathological results,management,and outcomes for further analysis.RESULTS A male preponderance was observed(56.8%).The most common indications were suspected small intestinal tumors(52.9%)and obscure gastrointestinal bleeding(39.2%).The most common tumor location was the ileum(41.2%).The performance of imaging studies(P=0.004)and the types of findings(P=0.005)differed significantly between malignant and benign SBTs.The most frequent imaging finding was a small intestinal mass(43.1%).The top three malignant tumor types were gastrointestinal stromal tumors(GISTs),adenocarcinomas,and lymphomas.Moreover,the proportions of benign and malignant tumors were 27.5%and 72.5%,respectively.The survival rates of patients with malignant tumors in the GIST and non-GIST groups differed significantly(P=0.015).Kaplan–Meier survival analysis showed a significant difference in survival between patients in the malignant and benign groups(P=0.04).All patients with lymphoma underwent chemotherapy(n=7/8,87.5%),whereas most patients with GISTs underwent surgery(n=13/14,92.8%).CONCLUSION Patients with GISTs have a significantly higher survival rate than those with other malignant SBTs.Therefore,a large-scale nationwide study is warranted to evaluate the population-based epidemiology of SBTs.

Intermittent melena and refractory anemia due to jejunal cavernous lymphangioma:A case report

BACKGROUND Lymphangiomas in the gastrointestinal tract are extremely rare in adults.As a benign lesion,small intestine lymphangiomas often remain asymptomatic and pose challenges for definitive diagnosis.However,lymphangiomas can give rise to complications such as abdominal pain,bleeding,volvulus,and intussusception.Here,we report a case of jejunal cavernous lymphangioma that presented with intermittent melena and refractory anemia in a male adult.CASE SUMMARY A 66-year-old man presented with intermittent melena,fatigue and refractory anemia nine months prior.Esophagogastroduodenoscopy and colonoscopy were performed many times and revealed no apparent bleeding.Conservative management,including transfusion,hemostasis,gastric acid secretion inhibition and symptomatic treatment,was performed,but the lesions tended to recur shortly after surgery.Ultimately,the patient underwent capsule endoscopy,which revealed a more than 10 cm lesion accompanied by active bleeding.After singleballoon enteroscopy and biopsy,a diagnosis of jejunal cavernous lymphangioma was confirmed,and the patient underwent surgical resection.No complications or recurrences were observed postoperatively.CONCLUSION Jejunal cavernous lymphangioma should be considered a cause of obscure gastrointestinal bleeding.Capsule endoscopy and single-balloon enteroscopy can facilitate diagnosis.Surgical resection is an effective management method.

小肠镜ERCP在治疗胆肠吻合术后良性狭窄中的应用体会

胆肠吻合术后良性狭窄是常见的并发症,处理棘手。小肠镜ERCP在治疗方面具有可重复、微创、符合正常生理结构等优势。分享本中心小肠镜ERCP在治疗胆肠吻合术后良性狭窄中的操作技巧与经验,希望有助于提高进镜和治疗成功率。

透明帽在经肛单气囊小肠镜检查中的临床应用

背景:小肠镜检查可行内镜下活检明确病灶性质,对小肠疾病有较高的诊断价值。经肛单气囊小肠镜检查(SBE)因受结肠肠段影响,操作较为困难。透明帽在内镜诊疗中已被广泛应用,有利于进镜和稳定肠腔。目的:探讨透明帽在经肛SBE检查中的作用。方法:苏州市吴中人民医院64例行经肛SBE检查的患者纳入研究,按随机数字表法分为2组,每组32例。试验组行透明帽辅助SBE检查,对照组行常规SBE检查,由同一名经验丰富的主任内镜医师完成操作。比较两组到达回盲部时间、回肠末端插管成功率、进镜深度、病变检出率和并发症发生情况。结果:试验组到达回盲部平均时间为(11.8±2.0) min,较对照组的(13.6±2.8) min明显缩短,回肠末端插管成功率明显高于对照组(100.0%对81.2%),进镜亦更为深入[(209.8±46.1) cm对(188.3±40.3) cm],差异均有统计学意义(P均<0.05)。两组间病变检出率无明显差异(81.2%对62.5%,P>0.05)。两组患者均未出现严重并发症。结论:透明帽辅助有助于降低经肛SBE检查的进镜难度,提高操作效率,缩短检查时间,适合临床推广应用。