Device-assisted enteroscopy: take-home messages and open issues from everyday clinical practice

Over the last two decades, technological innovations have completely changed the diagnostic and therapeutic work-up of several diseases involving the small bowel. The introduction of small-bowel capsule endoscopy (SBCE) first, and later of device-assisted enteroscopy (DAE), has not only allowed a direct and accurate study of the small-bowel mucosa, but also enabled the implementation of effective endoscopic therapy.

Although DAE is currently acknowledged as an established tool to study and treat small-bowel lesions, most of the available evidence comes from small series, primarily collected in tertiary centers, where procedures are performed by experienced endoscopists on highly selected patients, this strongly limits the generalizability of the available data. Besides, there is a paucity of large-scale real-life data on DAE, with just a handful of retrospective surveys collecting self-reported outcomes [11] [22] or analyses of administrative databases [33]. Last, but not least, studies focused on performance measures are still lacking.

In the current issue of Endoscopy, Shiha et al. [44] present a comprehensive analysis of DAE procedures registered in the National Endoscopy Database, a large database of endoscopy procedures populated by data automatically extracted from the endoscopy reporting systems at endoscopy services in the UK. A total of 2005 DAEs carried out in 1663 adult patients across twelve enteroscopy centers in the UK between January 2017 and December 2022 were analyzed. Performance measures were calculated, and the results were compared with the quality benchmarks outlined by the European Society of Gastrointestinal Endoscopy (ESGE) [55].

"the current study confirms that device-assisted enteroscopy is an effective endoscopic procedure, because the majority of the ESGE quality thresholds were met. In detail, the technical success rate was remarkably high (98.0%), with overall diagnostic and therapeutic yields of 70.0% and 42.6%, respectively."

The authors deserve praise for providing a reliable snapshot of the performance of DAE in everyday clinical practice. What lesson can we learn from this? First, the current study confirms that DAE is an effective endoscopic procedure, because the majority of the ESGE quality thresholds were met. In detail, the technical success rate was remarkably high (98.0%), with overall diagnostic and therapeutic yields of 70.0% and 42.6%, respectively. Moreover, therapeutic interventions were technically successful in 96.6% of cases. These results highlight the importance of a rigorous patient selection process. In fact, most procedures (98.1%) were performed for appropriate indications, many patients received a previous diagnostic test (either SBCE or dedicated small-bowel cross-sectional imaging), and the diagnostic yield was significantly higher for DAE performed in accordance with internationally approved indications.

Second, this study sweeps away the general belief that DAE is a potentially hazardous procedure owing to various technique-related risks, difficult therapeutic maneuvers, and prolonged sedation. Indeed, the present study strongly emphasizes the excellent safety profile of DAE, as major adverse events occurred in only 0.6% of procedures, a figure which is far below the ESGE minimum standard threshold.

Third, despite some methodological study limitations in defining the ideal DAE sedation regimen (e.g. data about sedation regimen according to the insertion route, patient age, and ASA status were missing), the study results unequivocally suggest that this procedure should no longer be routinely performed with patients under conscious sedation. Of note, 6% of DAEs performed in the subset of patients receiving conscious sedation (about one-third of all procedures) were interrupted early, despite the administration of high dose of benzodiazepines and opioids. In addition, patient comfort measured by the endoscopist was significantly greater in patients receiving deep sedation than in those undergoing DAE with conscious sedation.

Along with the abovementioned take-home messages, the current study also helps in identifying areas for further improvement and raises important practical and organizational issues for both physicians and national healthcare providers. Concerning areas for improvement, the documentation of procedure extent was available in less than 80% of DAEs and a tattoo was placed at the point of maximum insertion in only 34.5% of cases and close to a detected lesion in 78.0% of procedures. While these interventions might seem of limited clinical relevance when compared with DAE diagnostic performance or complex therapeutic interventions, we should keep in mind that precise documentation of the extent of the inspected small bowel represents a key issue when dealing with small-bowel disorders. In fact, this plays a crucial role in planning the subsequent patient management, especially when further investigations or surgical exploration are needed.

Because the current study was carried out in a clinical practice setting, it also provides the unique opportunity to address some practical organizational issues. Interestingly, no differences in either diagnostic or therapeutic yield were observed according to center volume. However, certain methodological issues (e.g. the retrospective design, the lack of a detailed description of the centers and endoscopists involved, the relatively low number of included procedures, the focus on a single endoscopic procedure instead of a broader clinical topic, etc.) make this study insufficiently robust to support such a subanalysis. On the other hand, the study did reveal that high volume centers had a greater proportion of DAEs performed for appropriate indications, procedures with the deepest insertion point marked, detected lesions tattooed, and patients receiving deep sedation.

Taking into account the DAE-related technical issues, the need for monitored anesthesia care and, last but not least, the need for dedicated and well-trained personnel, a rationale policy might involve concentrating DAE procedures in a limited number of expert and fully equipped centers. However, implementing such a policy would demand substantial and long-lasting structural changes in current healthcare systems. This poses challenges related to the geographic distribution of centers, which often hinders achieving homogeneous nationwide coverage, particularly when compared with other small-bowel diagnostic tests [22] [33] [66].

The implementation of DAE in clinical practice has contributed to change in the natural history of several small-bowel clinical conditions, and the results of the paper by Shiha et al. [44] further support the effectiveness of DAE in everyday clinical practice. Nevertheless, several open issues still need to be addressed in large prospective multicenter international trials, collecting not only technical data, but also clinical follow-up data and patient-reported outcomes, in order to decrease the variation across centers performing DAE and contribute to updated performance measures and quality benchmarks.

Publication History

Article published online:
17 January 2024

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