Device-assisted enteroscopy: With increasing requirements, national Irish data support a centralized high-volume model to achieve performance targets

Abstract

Background and study aims

Device-assisted enteroscopy (DAE) has seen a rapid increase in demand in recent years. European Society of Gastrointestinal Endoscopy (ESGE) DAE key performance indicators (KPIs) have been published as well as some national datasets. Data suggest variation in practice and service provision impacts outcomes. The aim of this study was to review DAE services in Ireland according to ESGE KPIs and wider outcomes.

Methods

DAE data from records at Tallaght and Connolly Hospital from January 2015 to May 2024 were retrospectively collated.

Results

Overall, 941 studies were included. 798 (85%) were index procedures and 548 (58%) were on men with a mean age of 61. Double-balloon enteroscopy was used in 864 (92%), 745 (79%) were anterograde (ADBE), and 196 (21%) were retrograde (RDBE). Mean depths of insertion were 201 cm ± 101 cm for ADBE and 101 cm ± 67 cm for RDBE. Of the procedures, 868 (92%) used conscious sedation; median doses of midazolam and fentanyl were 5 mg and 75 µg, respectively, with a mean comfort score (Modified Gloucester Scale) of 1.45 ± 0.67. Overall yield was 63%. Therapeutic intervention was performed in 385 (41%), 98% successfully, whereas 91% of detected lesions were tattooed. Significant adverse events occurred in < 1%. ESGE major KPIs by intention to treat (result/target) were: approved indication (94%/95%), depth-of-insertion tattoo (64%/80%), lesion detection (59%/50%-70%), lesion marking (91%/95%), complications (3.3%/< 5%), and adequate comfort (98%/> 90%). All minor KPIs were met. KPIs were consistent between both high-volume Irish-centers and were comparable to the three high-volume UK centers published in the recent DEEP-UK study, all of which performed better than lower-volume UK centers. Conscious sedation was used predominantly in our cohort with acceptable outcomes.

Conclusions

DAE requirement is increasing. Our study suggests that a high-volume model ensures compliance with international KPIs. These data also suggest that conscious sedation is a viable option for the majority of DAEs without reducing effectiveness, while maintaining comfort.

Keywords

Endoscopy Small Bowel - Capsule endoscopy - Small intestinal bleeding - Inflammatory bowel disease

Introduction

Device-assisted enteroscopy (DAE) has significantly advanced the field of gastroenterology by providing an effective means of diagnosing and treating small bowel disorders since its introduction. Albeit DAE is now often reserved as the therapeutic arm of the less-invasive small bowel capsule endoscopy (SBCE) [1]. Small bowel pathology, traditionally inaccessible with standard endoscopic procedures, is now amenable to intervention with DAE, a much less invasive approach than traditional surgical techniques. In 2015, the European Society for Gastrointestinal Endoscopy (ESGE) published guidance on indications for DAE and in 2019 published a quality-assurance guideline including key performance indices (KPIs), with a training framework for practitioner-competency following shortly afterwards in 2020 [2] [3] [4]. Most recently, in 2025, an update to the 2019 performance measures was published [5]. These KPIs offer practitioners and trainees the opportunity to standardize care to our patient population, ensure quality, and offer opportunities to identify areas for improvement, but until very recently, large-scale studies on procedure standards and outcomes remained lacking [6] [7] [8] [9] [10].

In this study, we aimed to review national DAE services in Ireland, both to assess standards in relation to international KPIs, and to determine what, if any, elements of our practice and services could inform future developments and refinements in DAE delivery.

Patients and methods

This was a dual-center, retrospective analysis of both enteroscopy centers in Ireland. All adult patients attending for DAE for diagnostic and/or therapeutic purposes in both tertiary referral centers between January 2015 and May 2024 were reviewed. In one center, the review was from January 2015, and in the second center, it was from 2021. Endoscopy data from both centers was collected on GI Reporting Tool (Unisoft Medical Corporation, Connecticut, United States) or EndoRAAD (Manitex Limited, Dublin, Ireland) as available locally.

All procedures under conscious sedation were performed in endoscopy suites, with endoscopist-administered sedation. All cases under general anesthetic were performed in the surgical theater of a day hospital adjacent to a tertiary center, where unstable or multimorbid patients are not permitted. There is no access to deep sedation for endoscopy procedures in endoscopy suites, and no access to regular surgical theater space for enteroscopy in Ireland currently. For patients who required a prolonged or repeat procedure, the decision about sedation type and location were at the discretion of the endoscopist.

Demographic data, procedure information, and follow-up plans were taken from the local endoscopy database or electronic patient record (EPR) as appropriate on a standardized spreadsheet before being anonymized and combined. Results were analyzed using chi square, Fisher exact test, or logistical regressions as appropriate, and controlled for demographics. This study was approved in both hospitals as a service evaluation before commencement of the data collection.

Results

Patients and demographics

Results from 1014 DAE studies were reviewed and analyzed on an intention-to-treat (ITT) basis. 73 studies were excluded from per protocol analysis on the following basis: 29 patients had inadequate bowel preparation, ileal intubation failed due to looping in 16 cases, and advancement of the overtube was impeded in five cases each by technical failure and anatomical (esophageal/anal) stenosis. Eight cases were abandoned due to being poorly tolerated by the patient, and five due to presence of food bolus in the stomach. One retrograde double-balloon enteroscopy (RDBE) was stopped after diagnosis of a bleeding malignant lesion in the colon, and one patient suffered a panic attack after administration of sedation and withdrew consent before the procedure was begun; three had incomplete EPRs.

In all, 941 studies on 798 individual patients were included in PP analysis. Of the patients, 548 (58%) were male, with a mean age was 61 ± 17 years (range 17–91). Of the procedures, 745 (79%) were anterograde and 196 (21%) were retrograde ([Table 1]).

Table 1 Demographic detail of study participants.

	TUH	CHB	Total (Ireland)
CHB, Connolly Hospital, Blanchardstown; SD, standard deviation; TUH, Tallaght University Hospital.
Total procedures (ITT)	840	174	1014
Included procedures (PP)	789/840 (94%)	152/174 (87%)	941/1014 (93%)
Male (%)	462 (59%)	86 (56.5%)	548 (58%)
Mean age +/-SD	60 +/-18	61 +/- 16	61 +/- 17
Anterograde	616 (78%)	129 (85%)	745 (79%)
Retrograde	173 (22%)	23 (15%)	196 (21%)
Single balloon	77 (10%)	0	77 (8%)
Double balloon	712 (90%)	152 (100%)	864 (92%)
Prior capsule findings	528 (67%)	115 (76%)	643 (68%)
Conscious sedation	716 (91%)	152 (100%)	868(92%)
Diagnostic yield	498 (63%)	94 (62%)	592 (63%)
Required intervention	332 (42%)	53 (35%)	385 (41%)
Successful intervention	327/332 (98%)	52/53 (98%)	379/385 (98%)

Ninety-four percent of procedures (n = 883) were performed for appropriate indications per ESGE guidelines [5] which included: abnormal SBCE findings, abnormal radiology, selected patients with overt gastrointestinal bleeding, obscure gastrointestinal bleeding with normal bidirectional endoscopy and/or SBCE contraindication, suspected Crohn's disease with noncontributory ileocolonoscopy, Crohn's disease when endotherapy was indicated, and patients with nonresponsive or refractory celiac disease. Of note, most of the cases performed for “other” indications included assessment for mucosal healing in Crohn’s disease when SBCE was contraindicated (n = 51, 88%). A full breakdown of the indications for DAE, and yield by indication, can be found in [Table 2].

Table 2 Indication by center and diagnostic yield.

Indication	Total n = 941
	Number (% total CEs)	Yield (%)
CE, capsule endoscopy.
Bleeding on CE	387 (41%)	305 (79%)
Abnormal Radiology	191 (20%)	83 (43%)
Enteritis on CE	130 (14%)	70 (54%)
Known Crohn's disease	72 (7.5%)	57 (79%)
Mass on CE	54 (6%)	37 (69%)
Anemia with normal endoscopy	49 (5%)	23 (47%)
Overt bleeding without CE	24 (2.5%)	16 (67%)
Obscure bleed without CE	2 (0.2%)	2 (100%)
Celiac Assessment	20 (2.1%)	20 (50%)
Enteropathy on CE	10 (0.9%)	4 (40%)
Other	18 (1.9%)	7 (39%)
Suspected Crohn’s	9 (0.9%)	6 (67%)
Submucosal mass on CE	8 (0.5%)	5 (63%)
CE retention	4 (0.4%)	3 (75%)
No Indication	4 (0.4%)	1 (25%)

Procedure and technical success

The most common procedure was DBE (864; 92%) followed by single balloon enteroscopy (SBE) (77; 8%). There were no cases of spiral enteroscopy performed in Ireland during this time. SBCE was performed in advance in 643 patients (68%), with cross-sectional imaging in 191 (20%).

Estimated depth of insertion was documented in 909 procedures (97%). Overall, mean depths of insertion were 201 cm +/- 101 cm for antegrade DBE (ADBE) and 101 cm +/- 67 cm for RDBE.

In all, only three patients had a complete enteroscopy as a single procedure, all with altered anatomy, whereas one further patient had laparoscopic-assisted complete bidirectional enteroscopy.

Maximal depth of insertion was marked with a tattoo in 645 (69%), whereas 62 of 68 lesions (91%) requiring further treatment/assessment were tattooed. Significantly more tattoos were placed during anterograde enteroscopy (564/745, 76% anterograde, 80/196, 41% retrograde, P = 0.0001). There was no difference between the conscious sedation group and general anesthetic group in estimated depth (P = 0.8942) or number of cycles (0.7261), nor between genders (P = 0.2328, and P = 0.1718 respectively).

Xylocaine spray 50 mg was used as topical anesthetic on the oropharynx for all anterograde studies. Of the patients, 868 (92%) received conscious sedation and 73 (8%) received general anesthetic.

Median dose of midazolam in the sedation cohort was 5 mg, (interquartile range [IQR] 3–7 mg), whereas the median dose of fentanyl was 75 µg (IQR 50–100 µg). Male gender was associated with higher doses of sedation (P = 0.0245 for midazolam, P = 0.0287 for fentanyl). Similarly, age, by logistical regression showed an inverse correlation with midazolam dose (P = 0.0003), but this was not seen for fentanyl (P = 0.7487).

Hyoscine n-butyl bromide was used as an intravenoujs antispasmodic in 254 patients (27%) (mean dose 15.4 mg). Glucagon 1 mg was used as an alternative in those with contraindications in 11 patients, each receiving 1 mg.

Comfort score was recorded in 751 conscious sedation cases (87%). Overall mean patient comfort scores were 1.48 (+/-0.745). Of these, 716 (95%) had an adequate comfort score (Modified Gloucester Comfort Scale score ≤ 3).

There was a weak negative correlation between comfort and cycles/depth (spearman R = 0.13/R = 0.14), but this was not seen for medication dose (R = -0.05 for midazolam, R = 0.02 for fentanyl. Poor patient tolerance limited duration and extent of eight of 868 procedures (0.92%) performed under conscious sedation.

The overall technical success rate for the whole cohort by ITT was 941 of 1014 (93%). Failed procedures (procedures abandoned before reaching the intended target lesion/appropriate diagnostic depth due to patient, technical or other factors) were more likely to be retrograde than antegrade (46/242, 19%, vs. 27/772, 3.5%; P < 0.0001), primarily due to poor bowel preparation or excess looping in the colon. The adequate preparation rate was significantly lower for RDBEs (213/242, 88%) than for ADBEs (767/772, 99%), P < 0.0001. The ileal intubation rate was 197 of 242 overall (81%), with no statistically significant difference between sites. There was, however, a significant difference in ileal intubation rate between conscious sedation and general anesthesia groups (175/220, 80% vs 22/22, 100% P = 0.0177).

Diagnostic and therapeutic yield

In all, 607 abnormalities were identified, in 592 studies. The overall diagnostic yield was 592 of 941 (63%). The most common findings included; angiodysplasia 305 (51%), small bowel Crohn’s disease 65 (11%), nonspecific enteritis 79 (13.5%), small bowel polyps 51 (8.5%), malignancy 24 (4%), and Dieulafoy 23 (4%), as seen in [Table 3].

Table 3 DAE findings in order of frequency.

Finding	Total	% of all DAEs N = 941	% of all positive capsules N = 592
AVM, arteriovenous malformation; DAE, device-assisted enteroscopy; GIST, gastrointestinal stromal tumor; NET, neuroendocrine tumor; SB, small bowel; SCC, small cell carcinoma
Angioectasia	305	32.5%	51.5%
Enteritis (unspecified)	79	8.5%	13.5%
Crohn’s disease	65	7%	11%
SB polyp	51	5.5%	8.5%
Dieulafoy	23	2.5%	4%
Stricture	20	2%	3.5%
Celiac disease	14	1.5%	2.5%
Ulcerative jejunitis	4
Malignancy	(24)	2.6%	4%
Adenocarcinoma	6
GIST	2
NET	4
Lymphoma	4
Leiomyosarcoma	1
SCC	1
Melanoma	2
“Tumor”	4
Submucosal mass	10	1%	1.5%
Anastomotic ulcer	8	0.85%	1.5%
AVM	3	0.3%	0.5%
Capsule endoscopy	2	0.2%	0.3%
SB varices	1	0.1%	0.15%
CMUSE	1	0.1%	0.15%
Duodenal web	1	0.1%	0.15%

There was no difference in overall diagnostic yield between centers (P = 0.855) or whether DBE or SBE was used (P = 0.801); however, those undergoing ADBE were more likely to have pathology identified than those undergoing RDBE (P < 0.0001).

A therapeutic intervention was performed 385 times, accounting for 41% of procedures, with a success rate of 378 of 385 (98%). Recorded interventions included: argon plasma coagulation (305; 79%), endoscopic clipping (53; 14%), polypectomy (42; 11%), stricture dilation (16; 4%), injection therapy (15; 4%), and SBCE retrieval (2; 0.5%). Patients attending both centers were equally likely to require intervention (332 of 789 vs 53 of 152; P = 0.1055) and to have successful intervention (327 of 332 vs 52 of 53, both 98%; P = 0.5914).

Yield for those with valid ESGE indication vs those without was higher 64% vs 35% (P = 0.001). Unsurprisingly, patients who had pathology identified on capsule endoscopy had a higher yield than those diagnosed by cross-sectional imaging (445 of 643, 69% vs 83 of 191, 43%; P < 0.0001).

Adverse events

Minor adverse events occurred in 24 cases (2.5%). There were 19 (2%) who had small mucosal tears or trauma related to overtube advancement. Only one of these cases required endotherapy, and none required repeat endoscopy, surgical intervention or hospital admission. There were four cases of post-polypectomy bleeding, which were all managed endoscopically. Hemostasias was achieved in all cases with endoscopic therapy. No patients documented a significant drop in serum hemoglobin levels, presented with complications after the procedure, or required repeat endoscopic assessment or intervention. One patient developed symptomatic hypoglycemia in the recovery room.

Major AEs occurred in nine of 1014 cases (0.88%). There were two bowel perforations related to stricture dilatation. Both patients had a known history of structuring Crohn’s disease and attended for dilatation due to symptoms. Both patients underwent balloon dilatation of a short stricture (identified previously on magnetic resonance enterography) after MDT discussion. Both patients were well interprocedurally, and had satisfactory result endoscopically. One patient had persistent bloating in the recovery room and CT revealed small amount of free air in the abdomen without evidence of bowel perforation. The second patient had multiple distal small bowel strictures identified on imaging, of various severity. Due to previous surgeries, it was decided at multidisciplinary team (MDT) discussion to proceed with endoscopic dilatation. This patient was well post procedure, an endoscopic clip was placed at the site of the dilated stricture to facilitate computed tomography (CT) mapping, and rediscussion at MDT regarding the remaining strictures. He was discharged from the endoscopy department and attended the radiology department later that day for CT, after which, still feeling well, he was discharged. Later that day, the gastroenterology team was contacted to report the presence of free air in the abdomen. This gentleman was contacted to return to the hospital for assessment. In both cases a diagnosis of iatrogenic microperforation was made. Both patients were managed conservatively, observed, and discharged after a short admission when interval imaging demonstrated resolution of pneumoperitoneum without surgical intervention. Two patients had intraprocedure hypotension and two intraprocedure hypoxia, all managed by reversal agent, and did not require subsequent inpatient stay. One patient developed massive epistaxis intra-procedurally, that was treated appropriately and discharge occurred the same day. One patient became hypothermic and acidemic due to a malfunction with the heating unit for water pump and received supportive care and was later discharged well. One patient undergoing DAE for bleeding had massive uncontrollable intraprocedural bleeding and later died of hemorrhagic shock, unrelated to the procedure.

There were no direct procedure-related mortalities. The overall 30-day mortality rate for this cohort was one in 941 (0.1%).

KPIs and minor performance indices

ESGE major performance measures were analyzed over the duration of the data collection, and five of eight were successfully met on both an ITT and per-protocol basis, as outlined in [Table 4].

Table 4 ESGE key performance indices.

KPIs	ITT (n = 1014)	PP (n = 941)	ESGE Target
ESGE, European Society of Gastrointestinal Endoscopy; ITT, intention to treat; KPI, key performance index; PP, per protocol.
Appropriate Indication	955 (94%)	883 (94%)	≥ 95%
Tattoo depth of insertion	645 (64%)	645 (69%)	≥ 80%
Lesion detection rate (Yield)	594 (59%)	592 (63%)	50%-70%
Lesions tattooed	63/69 (91%)	62/68 (91%)	≥ 95%
Complication rate (total)	34 (3.3%)	31 (3.3%)	< 5%
Complication rate (minor)	24 (2.4%)	24 (2.5%)	N/A
Complication rate (major) unselected cohort	9 (0.88%)	7 (0.7%)	< 1%
Complication rate (major) post therapeutics	2/375 (0.5%)	2/375 (0.2%)	< 5%
Adequate patient comfort	735/751 (97.7%)	910/941 (98.5%)	> 90%

Major performance measures on ITT analysis (result/target) were as follows: Lesion detection rate (59%/50%-70%), overall complication rate (3.3%/< 5%), overall major complication rate (0.88%/< 1%), major complication rate post-therapeutics (0.5%/< 5%), and adequate patient comfort (97.7%/> 90%).

Appropriate indication (94%/≥ 95%), tattooing the maximal depth of insertion (59%/≥ 95%), and proportion of lesions tattooed (91%/≥ 95%) showed room for improvement.

Analysis of these KPIs before 2020 vs after 2020 is outlined in [Table 5]. The appropriate indication rate fell from 96% to 93%, although increases were seen across all other KPIs: tattooing the maximal depth of insertion (51% to 70%), lesion detection rate (55% to 60%), proportion of lesions tattooed (85% to 93%), total complications (3.8% to 3.1%), minor complications (2.7% to 2.2%), overall major complications (1.1% to 0.89%), major complications post-therapeutics (1% to 0.4%), and adequate patient comfort (97% to 99%).

Table 5 KPIs by ITT over time.

KPIs	2015–2019 N = 339	2020–2024 N = 675	ESGE Target
ESGE, European Society of Gastrointestinal Endoscopy; ITT, intention to treat; KPI, key performance indices.
Appropriate Indication	325 (96%)	630 (93%)	≥ 95%
Tattoo depth of insertion	174 (51%)	471 (70%)	≥ 80%
Lesion detection rate (Yield)	185 (55%)	407 (60%)	50%-70%
Lesions tattooed	11/13 (85%)	52/56 (93%)	≥ 95%
Complication rate (total)	13 (3.8%)	21 (3.1%)	< 5%
Complication rate (minor)	9 (2.7%)	15 (2.2%)	N/A
Complication rate (major) *unselected cohort	4 (1.1%)	6 (0.89%)	< 1%
Complication rate (major) *Post therapeutics	1/94 (1%)	1/281 (0.4%)	< 5%
Adequate patient comfort	308/319 (97%)	425/430 (99%)	> 90%

All minor KPIs were met over the duration of the study as seen in [Table 6]: Adequate prep (100%/> 95%), report states insertion depth (93%/> 80%), successful intervention (98%/> 80%).

Table 6 Minor performance indices.

Minor performances indices	Ireland	ESGE Target
ESGE, European Society of Gastrointestinal Endoscopy.
Proper instructions to patients	100%	≥ 95%
Report states insertion depth	909/941 (97%)	≥ 80%
Photodocumentation	N/A*	≥ 95%
Successful intervention	378/385 (98%)	≥ 80%
Adequate bowel preparation	907/941 (96%)	≥ 95%

Discussion

Overall, this national study of DAE performance in Ireland demonstrates good compliance with KPIs as recommended by ESGE, which are improving over time.

Five of eight major KPIs and all minor performance measures were met, and this was consistent between both referral centers. Both centers perform a high volume of procedures annually, as defined in the recent UK-DEEP paper as > 50 procedures/year. Performance in Irish and UK high-volume centers was comparable, all of which performed better than low-volume centers reported in the UK study. This is further evidence to support centralization of DAE services in high-volume referral centers where both the human resources and infrastructure can be optimized. A further advantage of a high-volume model would include access to the case volume and mix to support training and research/innovation.

Of interest, conscious sedation was used frequently in Ireland (92%), with only 8% receiving general anesthetic. The mean comfort score for these patients was adequate at 1.4, whereas only eight of the 941 (0.85%) had procedures limited due to intolerance. Overall performance was not affected by sedation type, apart from ileal intubation rates in retrograde procedures, which was higher with general anesthesia. Potential biases could affect these data, including local strict anesthetic protocols for day case surgery limiting access to general anesthetic in elderly and comorbid patients, which would bias results in favor of general anesthetic. Unlike recent publications which have called for deep sedation or genal anesthetic for all DAEs, our study suggests conscious sedation can be used in the majority of cases without impacting performance. A prospective study from our group of patients reported that outcomes would also support this approach [11]. One caveat, however, is that the majority of patients undergoing DAE in Irish centers have had prior small bowel assessment with capsule endoscopy (68%), suggesting a possible bias toward selecting patients with targets requiring intervention in the first or third tertile, thereby requiring shorter depth of insertion and, by inference, a shorter procedure. However, this is unlikely because our mean depth of insertion for both anterograde and retrograde procedures (ADBE: 201 cm ± 101 cm, RDBE: 101 cm ± 67 cm.) exceeds those recently published in the DEEP-UK study. Endoscopist experience is well documented to positively impact patient comfort [12], and maintaining two high-volume centers in Ireland, with sufficiently large annual numbers to facilitate DBE training, was recommended by ESGE and JAG [5] [13].

Although we fell short of the ESGE standard for “appropriate indication” for DAE (result 94%, target > 95%), on review of these cases, the majority (approximately 88%) were for visual reassessment for mucosal healing in patients with known Crohn’s disease with contraindications for capsule endoscopy and noncontributory cross-sectional imaging. ESGE only includes patients with Crohn’s disease requiring endotherapy or for suspected Crohn’s disease for histological diagnosis. Because mucosal healing is the current target per STRIDE guidelines [14], and many centers report high patency capsule failure rates [15] [16] we suggest expanding the approved indications list to include assessment for mucosal healing in established small bowel Crohn’s disease when capsule endoscopy is contraindicated.

Similarly, although room for improvement exists for both remaining KPIs, both saw promising increases from 2015–2019 to 2020–2024, from 51% to 70% for “tattooing the maximal depth of insertion” and 85% to 93% for “proportion of lesions tattooed”. Reports in which these measures were not met often included locational descriptors e.g. “there is an ulcerated mass located 1.5 cycles proximal to the ICV,” “distally adjacent to the known large diverticulum in D4,” or “depth of insertion was only three cycles past the OGJ.” It is also possible that in some cases tattoos were placed, but omitted from the report. Overall, the improvement over time shows increasing awareness among endoscopists of the importance of these guidelines.

Data on appropriate photodocumentation were not available from the endoscopy database for most of the data collection period due to a recent cyberattack on the Irish National Health Service Executive servers in 2021, preventing the electronic linking of photodocuments to patient EPRs, because data transfer was by external memory device, and not recorded in the EPR, but printed on paper-based files, which were not easily amenable to retrospective review.

This study demonstrates a significantly higher diagnostic yield via anterograde approach compared with retrograde (P < 0.0001). This may be due to the higher technical success rate seen in ADBE due to difficulties with ileal intubation and colonic preparation, or the deeper average insertion depths. This is in agreement with previous studies, and indeed, ESGE recommends an anterograde approach in the first instance when distal pathology is not identified or prior imaging ambiguous [17] [18].

Our 9-year study clearly shows that DAE performance is improving over time in Irish centers, particularly since the publication of international quality improvement measures, for example, the recent increase in key performance metrics. Over the same 9 years, annual activity has also increased (63 procedures in 2016 and 204 procedures in 2023) and, as such, enhanced performance is likely to reflect a combination of increased awareness as well as improved technical skill and proficiency from performing a large volume of procedures. The increased activity, which is likely to continue, suggests that additional investment in DAE services is required. Our study would support a regionalized, high-volume, referral-center model to maintain quality and standards. In addition, our study would support the ongoing use of conscious sedation in most patients undergoing DAE.

Conclusions

DAE is an important, safe, and effective diagnostic and therapeutic procedure in gastroenterology. Our study suggests that preassessment with capsule endoscopy and activity levels are important factors in maintaining quality and enabling use of conscious sedation in the majority of patients, which is important if we are to meet the growing demand for DAE services.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publication History

Received: 25 March 2025

Accepted after revision: 02 September 2025

Accepted Manuscript online:
22 December 2025

Article published online:
26 January 2026