Thank you very much. So it's really my pleasure to introduce Mariana Avanitakis, with whom I had the privilege to work for the last 20 years. She's a full professor of medicine in our department. She is head of a clinic of pancreatology and clinical nutrition. Mariana has been very much involved in education and in research. In education, she has been in charge of the postgraduate programs of the United European Week and of the SGE. She is doing a lot of other things. And today she will speak about deep enteroscopy. So my task is to talk about deep enteroscopy in 13 minutes. So I will try to focus on some points. This is my disclosure. And so this is the agenda for this for this talk. We'll talk about indications, different modalities we have for deep enteroscopy with special focus on the motor or spiral, some technical aspects to be considered in deep enteroscopy and illustrations with some video cases. So what can we do to explore the small bowel? Initially, it was mostly pushing and not leading anywhere. And with the venue of the video capsule endoscopy, we revolutionized small bowel exploration and start identifying lesions that we wanted to treat and to to offer directed therapy. And so a lot of different deep enteroscopy techniques were developed with device assisted enteroscopy. So when do we have to explore the small bowel? Well, when we have a suspected small bowel bleeding and when gastroscopy and colonoscopy disclose no findings, whether there's a determinate iron deficiency anemia, whether suspected or known a Crohn's disease, when there's refractory celiac disease in test setting of different polyposis syndromes like Pusch-Jegers, when imaging tests are suspicious for small bowel tumor, and in some selected settings for neoplastic surveillance as lymphoma and melanoma. Typically in small bowel bleeding, after upper GI endoscopy and colonoscopy have ruled out any bleeding in these areas, we will suspect that it comes from the small bowel. What we will do next will depend if the patient is stable. In this case, we will do either video capsule endoscopy most often, either the dedicated imaging techniques for small bowel CT or MR enteroscopy. And it's important to know that capsule endoscopy still has not more than 70% diagnostic yield. And this may increase if we do the procedure near the bleeding episode, but we can still have false negatives. Regarding the results, then we will do dedicated enteroscopy according to the findings. In case of an unstable patient with a brisk bleeding, overt brisk bleeding, we may go to a CT scan, CT scan angiography, and angiography for embolization. You must also know that this, to have a positive finding, will require the active bleeding minimum 0.5 milliliters per minute. So you might have also false negatives in this case. We might need to also to go to a deep enteroscopy. Etiology will vary according to age and young patients will have mostly Crohn's or NSAID related ulcers, also polyp and tumors, and older patients, angiotensias are the primary finding issue, not forget the more rare causes. So when do you go for device assisted deep enteroscopy? If we have significant findings in capsule endoscopy, for example, telangiestasia, if we have a suspected small bowel overt bleeding to offer emersitasis, if there is a indication for biopsies, in example, Crohn's disease, or if there's a small bowel tumor, in this case, we can also do a tattoo to orient the surgeon. If there's a suspicion for submucosal mass, in case of polypectomy is required for inherited polyposis syndromes and in refractory celiac disease for biopsies to exclude lymphoma. So we can take the anterograde or the retrograde route. How do we choose between them? This study had shown that if we can use a ratio, which is the time from pylorus to the lesion on the time from the pylorus to the siccum, and if you take a threshold of 0.6, if you're lower than 0.6, you can use the anterograde route and you're for over 0.6, the retrograde and this can give you an accuracy of 100% in this study. So it is recommended to use the findings of previous investigations to guide you the choice of route. And of course, if you don't know, or if you're uncertain, or if you have an overt bleeding, you will choose the anterograde approach because you have more chances of finding the lesions, which are mostly proximal, and also because generally we progress more by the anterograde approach. Do you use CO2 or air? This meta-analysis grouping for randomized trials clearly showed that CO2 offers better progression and less post-procedural pain, so CO2 is the way to go. So how do we estimate progression? Roughly, that's for sure. With double balloon systems, we will count the net advancements. With the spiral, we'll count the folds. In any case, it is recommended to mark the deepest point of insertion with a tattoo. So what can we do? What alternatives do we have up to now? We have balloon catheter systems. These are easy to use, but they don't really obtain very deep progression rates, so they're not very widely used. On the other hand, the balloon systems, double balloon enteroscopy and simple balloon enteroscopy, are very widely spread. We have a very large experience with them. They have a very good, they're very efficient, and they have a very good safety profile. And finally, the manual spiral has also been used extensively, and it has been the base for new techniques, as we'll see later. So there's no large-scale prospective randomized trials that compare this technique, but the same Reospol comparative trials. In a nutshell, we can say that diagnostic yields are similar, around 65-70 percent. The safety profiles are similar, and the double balloon seems to be the deepest, and the one that offers the highest rate of panenteroscopy. The single balloon is the easiest to perform, and the manual spiral is the quickest. So this is the novel motorized spiral. It has taken the idea of using this over tube, but with the fins, the flexible spiral, to to advance in the bowel by pleating it, and it incorporated a motorized system that's controlled by a foot pedal. This is the first publication by Ors Newhouse in GIE that showed this system. We had the pleasure of collaborating with our friends from Düsseldorf in two trials on motorized spiral. The first one, using the anterograde approach, where we had included 140 procedures. We see that they had very good technical success, and also very good diagnosing a therapeutic yield, comparable to what we have until now with the other systems. A very good progression rate, and an acceptable safety profile. And the second trial, including also the retrograde approach, and here we saw that we could have a very high rate of total enteroscopy. Also, this study from India showed that this can also be, we have the same results in the real life setting, where also in this group of 61 patients, mostly with Crohn's disease, inflammatory lesions, we saw that we had the same rate of diagnostic yields. So, I'll finish with two video cases. So, this is one of 71-year-old woman, she has iron deficiency anemia, fatigue, and trouble breathing since one month. She has melena, and definitely has a significant loss in hemoglobin, and a low ferritin. She takes NSAIDs, but very occasionally, and upper and lower endoscopy did not really identify a significant source of bleeding. She required a transfusion and supplements in iron, and she underwent capsule endoscopy. As the algorithm indicated, she was stable. And here we see a finding, so it's a large angictasia, it's one hour after the, on the capsule timing. It's classified P2, according to Soren's classification, meaning it's highly relevant, and can explain the clinical setting. And if we do our ratio, we see that it's 0.55. So, in this case, we can decide to use the anterograde approach, which we did. And this patient underwent anterograde motorized spiral. Here I am with Dr. Newhouse, and this is the device. We see that we have a foot pedal to control the rotation. It can rotate clockwise and advance, or anticlockwise, and go backwards in the bowel. And here the patient is in, with general anesthesia. We advance very nicely, and we have this rotation of force gauge that shows us the resistances. And if we have high resistances, in this case, the machine has a safety system that stops, and we straighten the scope, we deloop, and we can advance again. Here is our target lesion. We will apply APC, but first we'll inject some saline to have a little safety cushion that will protect from the heat, and diffuse the heat, and protect from the muscle layer. And we can safely apply APC to destroy the lesion. And this patient had a very good outcome with no recurrence of bleeding. This is another case, 63-year-old woman. She has anticoagulants for permanent atrial fibrillation, and she presented in the ER with melina and hypotension, and a significant loss of hemoglobin. We see six. She had gastroscopy, but there was no bleeding. And she had CT angiography, which showed a suspicion of bleeding in the mid-judgment of arterial bleeding. So she was addressed immediately to interventional radiology, where there was no bleeding identified. And in this case, she was scheduled for anterograde endoscopy with the motorized spiral. And here we advance, and we can see, with the help of the water pump, we can identify a definite source of bleeding, arterial bleeding. This is not an aegyptasia. This is a dura for a lesion. And once we see this, we know that it will be treated better with CLIPS, not APC. So here we started putting the CLIPS. You can see that we have a very stable position with the motorized spiral to apply therapeutics. And also that we have a 3.2 operating channel, and the length is 160 centimeters. So most of our devices can be used. And here we had, finally, a good control by putting four CLIPS. As you see here, we see more clearly now there's a little bit of residual bleeding. So I'm going to put the last CLIP and finish by tattooing proximal to the lesion. As well as this patient had no further bleeding. So the story finished well. And to conclude, deep petroscopy is still a challenge, despite all the devices that we have. Depth and speed is not everything. We still need to decrease our diagnostic and therapeutic yield. I did not talk about this, but all deep endoscopies need training. And we have to start by a capsule endoscopy. Motorized spiral is promising. We still need some more data on safety on real life use in many centers. And we're very excited to also explore endoscopy-assisted ERCP in patients with altered anatomy with this technique. Thank you for attention. Thank you very much, Mariana. We have a few minutes for discussion. As we can expect, many of the questions from the audience are related with the severe adverse event, which can occur after a spiral endoscopy. Could you comment on that? There have been rare reports on perforation. Yes. So in our study, the two severe adverse events of the first trial were a perforation probably related to a resection. It was a Page-Jeggers polyp, and it was detected one day later. The patient required operation, but she went well. And the other was a bleeding in the But it's true that there have been rare reports of esophageal perforation. But this has to be still confirmed by a large trial, which is finished now. We have about 300 cases, and we have a large trial, which is finished now. We have about 300 cases in 12 centers. And up to now, there have not been any serious adverse events in this registry up to now. But up to now, we are still using a bougie before introducing a spiral endoscope, just to detect any unrecognized narrowing of the esophagus before to start the endoscopy. Yes. We use a 30 millimeter bougie to be on the safe side. But it's, for example, in Düsseldorf, I think they don't use the bougie anymore. But we still keep using it. Mariana, can you comment? In the studies, I think, that have been done thus far, patients who had had previous abdominal surgery, and I think all abdominal surgery, were excluded. Is that correct? Yes, correct. Yes. So all abdominal surgery, even colorectal surgery, especially for the second trial, which is a retrograde approach included, were excluded. Not in the study in the third registry, which we just finished now, we could include these patients with post-operative anatomy. My feeling is that there's no more complications with these patients. And we had experience also in ERCP. So we know it's feasible. Düsseldorf also has presented in the ESG days their experience with 20 patients. So this is something that's going to be more extensively studied now. So maybe one last question. So the spinal endoscopy is a little bit different from what we had before, because even without the super expert, without being the super expert in endoscopy, in the vast majority of cases, we can have the total endoscopy going from above and from below together. And the question is, if you have a patient with obvious chronic bleeding, but with a negative capsule endoscopy, would you go for a spinal endoscopy or not? So first, it depends on the patient. If it's a patient with a lot of comorbidities, who has a bit of anemia, you give him some iron supplementation is better, then I would not go for spinal endoscopy. I would just continue giving him iron. But I would probably do a CT just to be sure that he has not a tumor or something like that. Now, if the patient requires transfusion, I may go for a spiral anterograde approach. Yes.

deep enteroscopy

small bowel exploration

video capsule endoscopy

balloon catheter systems

motorized spiral