Long-term follow-up of patients undergoing capsule and double-balloon enteroscopy for identification and treatment of small-bowel vascular lesions: a prospective, multicenter study

Background and study aims: Few data are available concerning the long-term outcome of patients treated endoscopically for bleeding small-bowel vascular lesions (SBVL). The aim of this study was to evaluate the risk of rebleeding after endoscopic therapy for SBVLs detected by video capsule enteroscopy (VCE). The secondary aim was to assess risk factors for rebleeding.

Patients and methods: A prospective, multicenter study (15 centers) was conducted, involving patients with obscure gastrointestinal bleeding and SBVL on VCE who were treated during double-balloon enteroscopy (DBE). The likelihood of bleeding was defined according to VCE findings, as high or low.

Results: A total of 183 patients underwent endotherapy during DBE, and 64 (35 %) had rebleeding during the 1 year follow-up period. Multivariate analysis indicated that cardiac disease (hazard ratio [HR] 2.04, 95 % confidence interval [CI] 1.20 – 3.48; P < 0.01) and the presence of overt bleeding (HR 1.78, 95 %CI 1.07 – 2.97; P = 0.03) at presentation were associated with the risk of rebleeding. The association between chronic renal failure and the risk of rebleeding was close to statistical significance (HR 1.77, 95 %CI 0.94 – 3.33; P = 0.08). Kaplan–Meier analysis suggested that patients treated during DBE for a lesion with low likelihood of bleeding on VCE had higher rebleeding rates than those with a high likelihood of bleeding (HR 1.87, 95 %CI 0.94 – 3.37; P = 0.07).

Conclusion: Despite long-term remission in most patients, about one-third had rebleeding at 1 year. Independent risk factors for rebleeding were cardiac disease and overt bleeding at original presentation. The lesion characteristics on VCE may be useful to evaluate the bleeding potential of the lesion and may be used for better selection of patients for 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 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
• 3 May A, Nachbar L, Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease. Gastrointest Endosc 2005; 62: 62-70
• 4 Heine GD, Hadithi M, Groenen MJ 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
• 5 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
• 6 Zhi F, Yue H, Jiang B et al. Diagnostic value of double balloon enteroscopy for small-intestinal disease: experience from China. Gastrointest Endosc 2007; 66 : 19-21
• 7 Di Caro S, May A, Heine DGN et al. The European experience with double-balloon enteroscopy: indications, methodology, safety, and clinical impact. Gastrointest Endosc 2005; 62: 545-550
• 8 Manabe N, Tanaka S, Fukumoto A et al. Double-balloon enteroscopy in patients with GI bleeding of obscure origin. Gastrointest Endosc 2006; 64: 135-140
• 9 Fujimori S, Seo T, Gudis K et al. Diagnosis and treatment of obscure gastrointestinal bleeding using combined capsule endoscopy and double balloon endoscopy: 1-year follow-up study. Endoscopy 2007; 39: 1053-1058
• 10 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
• 11 Raju GS, Gerson L, Das A et al. American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology 2007; 133: 1694-1696
• 12 Saurin J-C, Delvaux M, Gaudin J-L et al. Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: blinded comparison with video push-enteroscopy. Endoscopy 2003; 35: 576-584
• 13 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
• 14 Hirai F, Beppu T, Nishimura T et al. Carbon dioxide insufflation compared with air insufflation in double-balloon enteroscopy: a prospective, randomized, double-blind trial. Gastrointest Endosc 2011; 73: 743-749
• 15 Shinozaki S, Yamamoto H, Yano T et al. Long-term outcome of patients with obscure gastrointestinal bleeding investigated by double-balloon endoscopy. Clin Gastroenterol Hepatol 2010; 8: 151-158
• 16 Samaha E, Rahmi G, Landi B et al. Long-term outcome of patients treated with double balloon enteroscopy for small bowel vascular lesions. Am J Gastroenterol 2012; 107: 240-246
• 17 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 . Erratum published in Endoscopy 2012; 44: 304
• 18 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
• 19 Arakawa D, Ohmiya N, Nakamura M et al. Outcome after enteroscopy for patients with obscure GI bleeding: diagnostic comparison between double-balloon endoscopy and videocapsule endoscopy. Gastrointest Endosc 2009; 69: 866-874
• 20 Dulic-Lakovic E, Dulic M, Hubner D et al. Bleeding Dieulafoy lesions of the small bowel: a systematic study on the epidemiology and efficacy of enteroscopic treatment. Gastrointest Endosc 2011; 74: 573-580