Double-Balloon Enteroscopy in Elderly Patients: Is It Safe and Useful?

ORIGINAL ARTICLE ISSN 1598-9100(Print) • ISSN 2288-1956(Online) http://dx.doi.org/10.5217/ir.2014.12.4.313 Intest Res 2014;12(4):313-319 Double-Balloon Enteroscopy in Elderly Patients: Is It Safe and Useful? Dae Han Choi, Seong Ran Jeon*, Jin-Oh Kim*, Hyun Gun Kim, Tae Hee Lee, Woong Cheul Lee, Byung Soo Kang, Jun-Hyung Cho, Yunho Jung, Wan Jung Kim, Bong Min Ko, Joo Young Cho, Joon Seong Lee, Moon Sung Lee Department of Internal Medicine, Digestive Disease Center, Institute of Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea *Both authors contributed equally to this work. Background/Aims: Providers may be hesitant to perform double-balloon enteroscopy (DBE) in the elderly because the increased number of co-morbidities in this population poses a greater risk of complications resulting from sedation. There are limited data on the use of DBE in the elderly. Here, we assessed the safety and efficacy of DBE in the elderly compared to those in younger patients. Methods: We retrospectively analyzed the medical records of 158 patients who underwent 218 DBEs. Patients were divided into an elderly group (age ≥65 years; mean 71.4±5.4; n=34; 41 DBEs) and a younger group (age <65 years; mean 39.5±13.5; n=124; 177 DBEs). Results: In both groups, the most common indication for DBE was obscure gastrointestinal bleeding. Mucosal lesions (33.3% vs. 60.9%; P=0.002) were the most common finding in both groups, followed by tumors (30.8% vs. 14.1%; P=0.036). The elderly were more likely to receive interventional therapy (51.3% vs. 23.5%; P=0.001). The diagnostic yield of DBE was slightly higher in the elderly group (92.3% vs. 86.5%; P=0.422), but was not statistically significant. The therapeutic success rate of DBE was 100% in the elderly group compared to 87.5% in the younger group (P=0.536). The overall DBE complication rate was 1.8% overall, and this rate did not differ significantly between the groups (2.6% vs. 1.7%; P=0.548). Con- clusions: DBE is safe and effective in the elderly, and has a high diagnostic yield and high therapeutic success rate. (Intest Res 2014;12:313-319) Key Words: Double-balloon enteroscopy; Elderly; Safety; Efficacy INTRODUCTION Double-balloon enteroscopy (DBE) was introduced in 2003 in Korea and has been used in clinical practice for the Received May 4, 2014. Revised May 26, 2014. Accepted May 27, 2014. Correspondence to Seong Ran Jeon, Institute of Digestive Research, past 10 years. DBE has become an important tool for the Digestive Disease Center, Department of Internal Medicine, Soonchunhyang evaluation and management of small bowel diseases be- University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 140- 743, Korea. Tel: +82-2-709-9202, Fax: +82-2-709-9696, E-mail: 94jsr@ cause it allows endoscopists to obtain biopsies of suspicious 1-3 hanmail.net lesions, treat bleeding, and dilate small bowel strictures. Co-Correspondence to Jin-Oh Kim, Institute of Digestive Research, According to previous studies, obscure gastrointestinal Digestive Disease Center, Department of Internal Medicine, Soonchunhyang 4,5 University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 140- bleeding (OGIB) is the most common indication for DBE, 743, Korea. Tel: +82-2-709-9202, Fax: +82-2-709-9696, E-mail: jokim@ and the diagnostic yield is 69.8−80.6%.6-9 The complication schmc.ac.kr rate and therapeutic success rate are approximately 1−4% *This paper has two corresponding authors. and 85−92%, respectively.5,7,10-12 Financial support: This work was supported by Soonchunhyang University The use of endoscopic techniques is increasing along with Research Fund. Conflict of interest: None. © Copyright 2014. Korean Association for the Study of Intestinal Diseases. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Dae Han Choi, et al. • Enteroscopy in the Elderly 13 the continued increase of age-related diseases. The safety Table 1. American Society of Anesthesiologists (ASA) Physical Status of conventional endoscopy and endoscopic retrograde chol- Classi fication System17 angiopancreatography (ERCP) for elderly patients has been ASA class Definition 14-16 studied, and the results suggest these procedures are well I A normal healthy patient tolerated in the elderly. II A patient with mild systemic disease However, DBE-specific issues such as procedural com- III A patient with severe systemic disease plexity, complications, and extended procedure time may discourage certain providers from using DBE, especially in IV A patient with severe systemic disease that is a constant threat to life elderly patients who are at increased risk resulting from se- V A moribund patient who is not expected to survive dation owing to a higher incidence of co-morbidities. While without the operation a number of clinical studies on DBE have been published, VI A patient declared brain-dead whose organs are being there are little data on its use in elderly patients. In addition, removed for donor purposes most of these studies involved Western populations, and DBE outcomes have not yet been compared in young and elderly Korean patients. We therefore assessed the efficacy performed with patients under monitored anesthesia care and safety of DBE in elderly patients compared to those in with a fluoroscopy unit. During the procedure, additional young patients. midazolam was administered selectively to achieve suf- ficient sedation. Patient status was determined by the METHODS American Society of Anesthesiologists (ASA) physical status classification system (Table 1).17 After DBE, all patients were 1. Study Design and Patients monitored in the recovery room until fully recovered from sedation to observe the development of serious complica- This study was conducted at a tertiary care referral center. tions and manage them accordingly. We retrospectively analyzed database records of all patients who had undergone DBE for small bowel evaluation 3. Measurement Factors between September 2003 and August 2013. A total of 158 patients and 218 DBE procedures were identified during We analyzed DBE indications, positive findings, diagnostic the study period. Patients were divided into an elderly group yield, therapeutic success rate, and complications. Primary (age ≥65 years; n=34; 41 DBEs) and a younger group (age DBE indications were classified into seven categories based <65 years; n=124; 177 DBEs). Data collection and analysis on previous studies: (1) OGIB; (2) abnormalities observed were approved by the institutional review board of Soonc- by another modality (e.g., CE or abdominal CT); (3) CD; hunhyang university hospital. (4) symptoms/signs only (e.g., abdominal pain, diarrhea, or weight loss); (5) therapeutic purposes (e.g., bleeding control, 2. DBE Procedure polypectomy, or removal of a foreign body); (6) surveillance (e.g., Peutz-Jeghers syndrome); and (7) others.3 Abnormali- Endoscopy procedures for small bowel evaluation were ties observed using other modalities were suspected gastro- performed with a commercially available DBE system (EN- intestinal lesions that required DBE for further confirmation. 450P5/20, T5/20; Fujinon Inc., Saitama, Japan). In DBE with Positive findings were classified into five categories as fol- an oral approach, the patient received nothing by mouth lows: (1) vascular lesions (e.g., angioectasia, arterio-venous for at least 12 hours prior to the procedure. In DBE with an malformation, or varix); (2) mucosal lesions (e.g., CD, ery- anal approach, patients were prepared similar to that for a thema, erosion, or ulcer); (3) tumor (benign or malignant); colonoscopy with a 2 or 4 L polyethylene glycol-electrolyte (4) others; and (5) no specific findings. These factors were lavage solution the day before the procedure. The approach compared between the elderly and younger groups. was determined by the endoscopist based on the suspected location of target lesions, clinical judgment, capsule en- 4. Statistical Analysis doscopy (CE) findings, and/or radiologic imaging. All DBE procedures were performed under conscious sedation with Statistical analysis was performed using SPSS software, midazolam and/or pethidine. Procedures were routinely version 15.0 for Windows (SPSS Inc., Chicago, IL, USA). Con- 314 www.irjournal.org http://dx.doi.org/10.5217/ir.2014.12.4.313 • Intest Res 2014;12(4):313-319 tinuous data are expressed as means and SDs. All continu- er group. The mean age was 71.4 years (range, 65−88) in the ous variables were compared using a two-tailed Student’s elderly group and 39.5 years (range, 16−64) in the younger t-test. All categorical variables were compared using Fisher’s group. Co-morbidities were present in 67.6% of elderly pa- exact test. A P-value less than 0.05 was considered statisti- tients and 33.9% of younger patients; the difference in the cally significant. number of patients with co-morbidities between groups was statistically significant (P=0.001). The elderly group RESULTS contained a significantly higher percentage of ASA class III patients (20.6% vs. 2.4%; P=0.001). A history of NSAID, anti- 1. Baseline Characteristics coagulant, or antiplatelet agent use was significantly more common in the elderly group than in the younger group Table 2 summarizes the baseline characteristics of the (29.4% vs. 11.3%; P=0.015). The most common imaging mo- study patients. A total of 218 DBEs (n=158) were performed: dality used prior to DBE was abdominal CT (66%) followed 41 (n=34) in the elderly group and 177 (n=124) in the young- by CE (35%).

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