A meta-analysis on efficacy and safety: single-balloon vs. double-balloon enteroscopy

Background and aim: Double-balloon enteroscopy (DBE) and single-balloon enteroscopy (SBE) are new techniques capable of providing deep enteroscopy. Results of individual studies comparing these techniques have not been able to identify a superior strategy. Our aim was to systematically pool all available studies to compare the efficacy and safety of DBE with SBE for evaluation of the small bowel. Methods: Databases were searched, including PubMed, Embase, and the Cochrane Central Register of Controlled Trials. The main outcome measures were complete small-bowel visualization, diagnostic yield, therapeutic yield, and complication rate. Statistical analysis was performed using Review Manager (RevMan version 5.2). Meta-analysis was performed using fixed-effect or random-effect methods, depending on the absence or presence of significant heterogeneity. We used the χ2 and I2 test to assess heterogeneity between trials. Results were expressed as risk ratios (RR) or mean differences with 95% confidence intervals (CI). Results: Four prospective, randomized, controlled trials with a total of 375 patients were identified. DBE was superior to SBE for visualization of the entire small bowel [pooled RR = 0.37 (95% CI: 0.19–0.73; P = 0.004)]. DBE and SBE were similar in ability to provide diagnosis [pooled RR = 0.95 (95% CI: 0.77–1.17; P = 0.62)]. There was no significant difference between DBE and SBE in therapeutic yield [pooled RR = 0.78 (95% CI: 0.59–1.04; P = 0.09)] and complication rate [pooled RR = 1.08 (95% CI: 0.28–4.22); P = 0.91]. Conclusions: DBE was superior to SBE with regard to complete small bowel visualization. DBE was similar to SBE with regard to diagnostic yield, ability to provide treatment and complication rate, but these results should be interpreted with caution as they is based on very few studies and the overall quality of the evidence was rated as low to moderate, due to the small sample size

Endoscopic Submucosal Dissection: A Cognitive Task Analysis Framework Toward Training Design

Background: One of the major impediments to the proliferation of endoscopic submucosal dissection (ESD) training in Western countries is the lack of sufficient experts as instructors. One way to address this gap is to develop didactic systems, such as surgical simulators, to support the role of trainers. Cognitive task analysis (CTA) has been used in healthcare for the design and improvement of surgical training programs, and therefore can potentially be used for design of similar systems for ESD. Objective: The aim of the study was to apply a CTA-based approach to identify the cognitive aspects of performing ESD, and to generate qualitative insights for training. Materials and methods: Semi-structured interviews were designed based on the CTA framework to elicit knowledge of ESD practitioners relating to the various tasks involved in the procedure. Three observations were conducted of expert ESD trainers either while they performed actual ESD procedures or at a training workshop. Interviews were either conducted over the phone or in person. Interview participants included four experts and four novices. The observation notes and interviews were analyzed for emergent qualitative themes and relationships. Results: The qualitative analysis yielded thematic insights related to four main cognition-related categories: learning goals/principles, challenges/concerns, strategies, and decision-making. The specific insights under each of these categories were systematically mapped to the various tasks inherent to the ESD procedure. Conclusions: The CTA approach was applied to identify cognitive themes related to ESD procedural tasks. Insights developed based on the qualitative analysis of interviews and observations of ESD practitioners can be used to inform the design o

Modeling haptic interactions in endoscopic submucosal dissection (ESD)

The ability to provide realistic haptic feedback is indispensable for virtual-reality (VR) based endoscopic colorectal surgery simulators. Despite its importance, force feedback is commonly simulated by simplified approximations with parameters manually tuned in preliminary evaluations due to the complexity of the dynamics of haptic interaction in colonoscopy interventions. Endoscopic submucosal dissection (ESD) is a particularly challenging intervention that requires advanced manual skills for endoscopic control. This work proposes a mechanical impedance model for haptic interactions in ESD formulated via an experimental methodology applied to endoscopic colorectal interventions in general. The developed model is shown to capture the variations in the interaction force during two operations performed at distinct locations on a porcine sample. Salient cues in the recorded haptic interaction data are presented, and changes in the impedance characteristics of the tool-tissue interaction between the steps of the operation are analyzed

Persistent psychological or physical symptoms following endoscopic procedures: an unrecognized post-endoscopy adverse event.

BACKGROUND: Depression and post-traumatic stress disorder have been described after surgical procedures, but not after gastrointestinal endoscopy. AIMS: The aim of our retrospective survey was to determine if new-onset, persistent (\u3e1 month) psychological and/or physical symptoms develop after gastrointestinal endoscopy. We also sought to assess how endoscopy teams respond to patient discomfort during the procedure. METHODS: We conducted in-person interviews among 57 gastroenterologists and endoscopy nurses at two large academic medical centers and a community hospital. Response rate was 81% (57/70). RESULTS: Among gastroenterologists surveyed, 62% had encountered at least one patient with persistent new-onset unexplained physical symptoms, and 48% had encountered at least one patient with persistent new-onset psychological symptoms that started after an endoscopic procedure. A total of 44 such patients were identified, and most were women between 20 and 40 years of age. Common new symptoms that developed after gastrointestinal endoscopy were abdominal discomfort, diarrhea, globus sensation, anxiety disorder and depression. Duration of these symptoms was 1 month to 3 years. Gastroenterologists reported that 4% and endoscopy nurses reported that 10% of patients undergoing endoscopy gestured or requested that the endoscopic procedure be prematurely stopped due to discomfort. Only 11/29 (38%) physicians reported that while obtaining consent for endoscopic procedures, they routinely discuss the possibility of stopping prematurely if the patient becomes uncomfortable. Conclusion Persistent physical or psychological symptoms can develop in some patients after endoscopic procedures

The location of obstruction predicts stent occlusion in malignant gastric outlet obstruction

Background: Gastric outlet obstruction (GOO) can occur with locally invasive or metastatic cancer involving the upper gastrointestinal tract at the pylorus or the duodenum. Endoscopic management with self-expanding metal stents (SEMSs) is often the preferred palliative approach. Stent occlusion is a common reason for failure and reintervention. We set out to determine whether the location of the malignant obstruction is associated with the angulation of the stent and can predict stent occlusion. Methods: We performed a retrospective review of consecutive patients who underwent successful duodenal stenting with SEMS for malignant GOO between 2006 and 2015 at a large advanced endoscopy referral center. We determined the location of obstruction, the stent angle, and the rate of technical and clinical success of stent placement. We then identified cases of subsequent stent occlusion confirmed by endoscopic evaluation. Results: A total of 100 consecutive patients were included in the study; 91 of these patients had enough data to evaluate SEMS occlusion. A total of 21 patients (23%) developed stent occlusion with a median time of 39 days. The risk of occlusion sequentially increased as the obstruction occurred more distally from the antrum to the third or fourth portion of the duodenum ( p = 0.006). This relationship was maintained after controlling for stent angle ( p = 0.05). Conclusions: A distal location of malignant GOO was strongly predictive of stent occlusion, independent of stent angle. This may be due to longer and more complex distal obstructions, along with foreshortening of the stent during placement and tumor infiltration. If replicated, these results will have implications for endoscopic practice and future device development