Introduction Enteroscopy is a novel technique that allows mucosal visualisation, tissue sampling and therapeutic intervention in the small bowel. The use of push enteroscopy (PE) has been questioned with the advent of double balloon enteroscopy (DBE). Whilst PE can reach up to 80 cm beyond the ligament of Treitz, DBE allows greater depth of insertion via the anterograde and retrograde approach into the mid-small bowel. We aim to compare the efficacy of both modalities in terms of diagnostic and therapeutic yields, tolerability and management change.
Method A retrospective review of patients who underwent PE (from January 2002) and DBE (from July 2006) to October 2014 was performed. Data was collected on demographics, indication, yield, complications and management. Tolerability scores were assessed using a validated scoring system (1-no discomfort 2- slight discomfort 3-extremely uncomfortable 4–unbearable).
Results A total of 294 PE (mean age 55; 58% male) and 399 DBE (mean age 56; 50% male; anterograde n = 256, retrograde n = 143) were performed in this time period. There was no significant difference in the diagnostic yield between the two modalities (PE 43% vs DBE 49%, p = 0.14) however 37% of positive findings on PE were within reach of a gastroscope. The commonest indication for both was obscure bleeding (PE 63% vs DBE 48%, p = 0.02) and DBE was performed more often for suspected Crohn’s (PE 16% vs DBE 50%, p = 0.005). There was no significant difference in therapeutic yield between PE and DBE (21% vs 24% p = 0.4). Argon plasma coagulation was the most common therapeutic intervention done in both groups (PE n = 44; DBE n = 57) followed by haemostasis intervention in PE (n = 9) and polypectomy in DBE (n = 29). The median length of small bowel examined orally for PE was 130 cm vs DBE 170 cm (p < 0.001). Patient discomfort was scored 3 and above in 21% DBE vs 14% PE (p = 0.005) indicating poorer tolerability for DBE. There was a significant difference in the amount of sedation used (median midazolam dose PE 4 mg vs DBE 6 mg, p < 0.001). Few PE patients were given fentanyl (median dose PE 0 mcg vs DBE 100 mcg, p < 0.001). Management was altered by PE in 43% and by DBE in 41% of patients (p = n/s). Whilst there were no complications for PE, the complication rate for DBE was 1.25% (pancreatitis n = 2, respiratory arrest n = 1, pulmonary oedema n = 1 and NSTEMI n = 1). Since the introduction of DBE, the demand for PE has declined significantly (p = 0.03, r = -0.6).
Conclusion Both modalities have comparable efficacy with regards to diagnostic and therapeutic yield. Although the demand for PE has declined, there remains a role for PE in patients with proximal small bowel pathology requiring histology or therapeutic intervention.
Disclosure of interest None Declared.