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R.marmo l. l'enteroscopia

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R.marmo l. l'enteroscopia

  1. 1. Forum Nazionale di Gastroenterologia “AIGO 2010” L’enteroscopia R. Marmo Roma, Palazzo della Cancelleria , 14 -15 Maggio 2010
  2. 2. Publications Number – Assisted Enteroscopy 2001 - 2009
  3. 3. Prospective Multicenter Trial Comparing Push-and- Pull Enteroscopy With the Single- and Double-Balloon Techniques in Patients With Small-Bowel Disorders Andrea May et al .Am J Gastroenterol 2010; 105:575–581 Double Balloon Single balloon p Complete enteroscopy ( n , % ) 33 / 50 (66 % ) 11 / 50 (22 % ) <0.0001 Therapeutic yield ( n , % ) 36 / 50 (72 % ) 24 / 50 (48 % ) <0.025
  4. 4. Prospective Multicenter Trial Comparing Push-and- Pull Enteroscopy With the Single- and Double-Balloon Techniques in Patients With Small-Bowel Disorders Andrea May et al .Am J Gastroenterol 2010; 105:575–581 Double Balloon Single balloon p Complete enteroscopy ( n , % ) 33 / 50 (66 % ) 11 / 50 (22 % ) <0.0001 Therapeutic yield ( n , % ) 36 / 50 (72 % ) 24 / 50 (48 % ) <0.025
  5. 6. Diagnostic gain CE vs DB Marmo R et al DLD sept 2007
  6. 8. MAJOR LIMITS V.C.E : ORIENTATION BIOPSY CLEANING
  7. 11. Controindication to Capsule enteroscopy Pohl J et al. Current status of DBE…Endoscopy 2008; 40: 156 -160
  8. 12. CE SHOWING ONLY BLOOD OR CLOTS IN THE LUMEN WHAT TO DO? Courtesy dr. Pennazio
  9. 13. DBE clarified the origin of bleeding in 2/3 of patients with CE showing only blood or clots in the lumen
  10. 15. Lesions of mid gastrointestinal tract and treatment Bleeding lesions Polyps, tumors Stenosis Foreign bodies Polypectomy EMR Dilation, stent Extraction Injection, thermal, mechanical therapy PEG, PEJ ERCP
  11. 16. Indications for DBE <ul><li> No. (%) </li></ul><ul><li>OGIB 98 (62.8%) </li></ul><ul><li>Obstruction 14 (8.9%) </li></ul><ul><li>Tumor 13 (8.3%) </li></ul><ul><li>Inflammatory bowel disease 10 (6.4%) </li></ul><ul><li>Investigation for postoperative GI tract 9 (5.8%) </li></ul><ul><li>Further evaluation SBD 3 (1.9%) </li></ul><ul><li>Foreign body 2 (1.3%) </li></ul><ul><li>Miscellaneous 14 (8.9%) </li></ul><ul><li>Total 163 (100%) </li></ul>
  12. 17. Bleeding lesions - Angiodysplasias
  13. 20. Rebleeding-free interval after first DBE for 50 patients with OGIB N.Ohmiya et al. Gastrointest. Endosc 2007;66:S72-7.
  14. 21. DB Endoscopic treatment Occult Overt Bleeding Pennazio M. Gastrointest Endosc Clin N Am 2009
  15. 22. 59% 24% 18% Outcomes data at 30-month follow-up after DBE (n=85)
  16. 23. <ul><li>Patients with AVMs or normal examinations to the depth of insertion are most likely to report recurrent hemorrhage. </li></ul>
  17. 24. Marmo et al.Endoscopy 2009, 41: 587-592 Capsule Endoscopy Double Balloon Endoscopy No lesion detected 18/193 (9.3%) No lesion detected 61/193 (31.6%) Negative also on DBE 11/18 Negative also on CE 11/61 Positive findings on DBE Vascular lesion Ulcer(s) Jejunal diverticula Neoplasia 7 2 (10.51%) 2 (10.5%) 2 (10.5%) 1(5.5%) Positive findings on CE Vascular lesion Mass n eoplasia Polyp(s) Ulcer(s) Blood or clots in the lumen Other 50 13 (2.3%) 8 (13.1%) 7 (11.5%) 6 (9.8%) 12 (19.7%) 4 (7.2%)
  18. 25. Mehdizadeh GIE 2006 Kaffes GIE 2006 Marmo Endoscopy 2009 M ö nkem ü ller Endoscopy 2006 Heine Endoscopy 2006 May GIE 2005 Yamamoto CGH 2004 0% 5% 8% 20% 35% 42% 45% 86% Zhong Endoscopy 2007 56% Eenteroscopia in 2 sessioni (%) 61% Ohmiya GIE 2007 Occidente Oriente Gross GIE 2008 Total enteroscopy DB
  19. 26. Endoscopic treatment failure <ul><li>The use of hormonal therapy is highly controversial; </li></ul><ul><li>ineffective in a randomized controlled trial. </li></ul><ul><li>The somatostatin analogue octreotide has been examined as a therapy for diffuse vascular ectasia bleeding. However, controlled studies have not been </li></ul><ul><li>performed. . </li></ul>Rockey, D. C. Nat. Rev. Gastroenterol. Hepatol. May 7, 265–279;2010
  20. 27. Endoscopic treatment failure <ul><li>The use of hormonal therapy is highly controversial; </li></ul><ul><li>ineffective in a randomized controlled trial. </li></ul><ul><li>The somatostatin analogue octreotide has been examined as a therapy for diffuse vascular ectasia bleeding. However, controlled studies have not been </li></ul><ul><li>performed. . </li></ul>Rockey, D. C. Nat. Rev. Gastroenterol. Hepatol. May 7, 265–279;2010
  21. 28. Octreotide for mid-GI-bleeding <ul><li>12 papers (4 on LAR) mainly case reports and not controlled studies </li></ul><ul><li>The results are positive and the effect seems to remain even after drug suspension </li></ul><ul><li>A sigle controlled (not randomized) study: </li></ul><ul><ul><li>32 vs 38 patients </li></ul></ul><ul><ul><li>Recurrence of bleeding in 23% vs 48% </li></ul></ul><ul><ul><li>77- 68% vs 55-36% free of bleeding at 1 and 2 yrs </li></ul></ul><ul><ul><li>No difference in nr of bleeding and blood transfusions </li></ul></ul>Junquera et al, Am J Gastroenterol 2007
  22. 30. <ul><li>17 /114 DBE emergency < 24 hrs </li></ul><ul><li>(9 oral ; 8 anal ) </li></ul><ul><li>10 pts mean age 68 </li></ul><ul><li>Mean Hb 7.4 g/dL, range 4.2–8.4. </li></ul><ul><li>ASA median (American Society of Anesthesiologists) 2 </li></ul>Endoscopy 2009; 41: 715–717
  23. 31. Diagnosis and treatment 9/10 pts ongoing bleeding <ul><li>Neoplasia n = 4 </li></ul><ul><li>Dieulafoy n = 2 </li></ul><ul><li>Vascular lesion n = 2 </li></ul><ul><li>Crohn’s disease n = 1 </li></ul>
  24. 32. <ul><li>13 / 108 </li></ul><ul><li>Mean age 61 years </li></ul><ul><li>Mean Hb gr/dl 7.2 ± 2.8 </li></ul>Gastrointest Endosc 2008;68:683-91
  25. 33. <ul><li>Neoplasia n = 6 </li></ul><ul><li>Vascular lesion n = 6 (1 Surgery) </li></ul><ul><li>Crohn’s disease n = 1 </li></ul>Diagnosis and treatment 13/13 pts ongoing bleeding
  26. 35. Endoscopic Interventions in the Small Bowel Using Double Balloon Enteroscopy A. May et al. Am J Gastroenterol 2007;102:527–535
  27. 36. Outcome after double balloon dilatation H. Tochigi Gastrointest Endosc 2007;66:S108-12 Surgery Relapse Long term success Crohn’s disease 23 pts 2 (8.7%) 4 (17.4%) 17 (73.9%)
  28. 37. Failure Double Balloon Enteroscopy <ul><li>9 cases (4.6 %) </li></ul><ul><li>1) 7 terminal ileum not explored </li></ul><ul><li>2 duodenum not explored </li></ul><ul><li>1 tongue 1 pylorus stricture </li></ul>R. Marmo , Endoscopy. 2009 ;41(7):587-92
  29. 38. <ul><li>6/178 (3.4%) </li></ul><ul><li>Polipectomy (N = 2) </li></ul><ul><li>Dilation (N = 3) </li></ul><ul><li>Stenting (N = 1) </li></ul><ul><li>Anatomical or technical reasons </li></ul>May A - Am J Gastroenterol - 01-MAR-2007; 102(3): 527-35 Failure on intention treatment Double Balloon Enteroscopy
  30. 39. Therapeutic enteroscopy complications <ul><li>2367 procedures </li></ul><ul><li>4.3 % therapeutics (bleeding, perforation APC , dilation, polipectomy) </li></ul>Mensik P GE 2007 May et al AJG 2007
  31. 40. <ul><li>2476 patients </li></ul>Pancreatitis 6 (0.2%), 1 anal route Bleeding 4 (0.2%) Perforation 11 (0.4%), L. B. GERSON et al. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009; Enteroscopy diagnostic Patients with normal anatomy
  32. 41. Complications Perforation <ul><li>Previous surgery 8/ 219 (3.6%) vs </li></ul><ul><li>Normal anatomy 11/ 2476 (0.4%) </li></ul><ul><li>O.R. 7.4 [C.L. 95% 2.4 – 21.1] </li></ul><ul><li>p <.005 </li></ul>
  33. 42. Forum Nazionale di Gastroenterologia “AIGO 2010” L’enteroscopia R. Marmo Roma, Palazzo della Cancelleria , 14 -15 Maggio 2010 Grazie dell’attenzione
  34. 44. Publications Number – Assisted Enteroscopy 2001 - 2009

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