Clin J Gastroenterol (2011) 4:347–350 DOI 10.1007/s12328-011-0252-7
CASE REPORT
Incomplete capsule endoscopy examinations after Roux-en-Y gastric bypass Dhavan A. Parikh • Mohit Mittal • Surinder K. Mann
Received: 1 May 2011 / Accepted: 12 July 2011 / Published online: 9 August 2011 Ó Springer 2011
Abstract Background Video capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel. Optimization of this imaging modality has focused on minimizing the rate of incomplete studies through appropriate patient selection. Recent data have shown an increased incidence of incomplete examinations in those with surgically altered gastrointestinal anatomy. Methods We present 4 consecutive cases of post Rouxen-Y gastric bypass patients undergoing video capsule endoscopy. Results Three patients were referred for obscure gastrointestinal bleeding and one for diagnosis of Crohn’s disease; all 4 patients had incomplete studies. One patient experienced capsule retention in the gastric pouch. Two patients had repeated poor small bowel preparation despite compliance with preparatory methods. The fourth patient experienced delayed gastrointestinal transit despite satisfactory small bowel preparation. Conclusion Patients with a history of Roux-en-Y surgery appear to be at increased risk for incomplete examination
D. A. Parikh S. K. Mann Department of Gastroenterology, UC Davis Medical Center, Sacramento, USA D. A. Parikh (&) Department of Internal Medicine, UC Davis Medical Center, 4150 V Street, PSSB 3116, Sacramento, CA 95817-1460, USA e-mail: [email protected] M. Mittal UC Davis School of Medicine, Sacramento, CA, USA S. K. Mann Department of Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, CA, USA
due to capsule retention and delayed gastric transit. Endoscopists may consider additional precursory testing or the use of alternative imaging methods in this population. Keywords Video capsule endoscopy Roux-en-Y Small bowel
Introduction Video capsule endoscopy (VCE) is an effective and minimally invasive tool for the evaluation of small bowel (SB) pathology. Study completion rates vary based on the indication, with the higher end approaching 80–85% [1]. Several factors such as inadequate battery life in the setting of delayed gastrointestinal (GI) transit, poor SB preparation and capsule retention have been cited as primary reasons for incomplete examinations [2–10]. On average, capsule retention as a cause of incomplete examination has been reported in 1.4% of studies according to a recent systematic review [1]. While the rate of incomplete studies secondary to capsule retention in postoperative patients has not been widely reported, this same review suggests that post-surgical stenosis may account for up to 7.4% of all capsule retentions [1]. Additional studies have shown that delivery and transport of the video capsule via the standard peroral route can be problematic in patients with a history of gastroparesis or abnormal upperGI anatomy due to prior Whipple, Billroth I/II, Nissen fundoplication and Roux-en-Y operations [11]. Here we present 4 cases that illustrate an increased risk of incomplete VCE examinations in patients with a history of Roux-en-Y gastric bypass surgery. All 4 patients underwent Roux-en-Y gastric bypass for treatment of morbid obesity. No underlying GI dysmotility was documented.
123
348
Clin J Gastroenterol (2011) 4:347–350
Methods A total of 250 VCE procedures were reviewed between December 2007 and December 2009. Of these, the medical records of 4 consecutive adult patients with a history of Roux-en-Y gastric bypass who underwent VCE at the University of California Davis Medical Center were analyzed. VCE protocol—prior to VCE patients were advised to have a 24 h full-liquid diet, followed by SB and colonic irrigation with 2 L of polyethylene glycol and a 12-h fast. Patients were then brought to the GI laboratory to be fitted with a video recorder, battery and a four-sensor array belt attached to the abdomen. Patients were then asked to swallow slurry of simethicone followed by the PillCam SB capsule (Given Imaging, Yoqneam, Israel). They were allowed a small snack 4 h after ingestion of the capsule endoscope. The video recorded for 8 h and the patients then returned to the GI laboratory to have the video recorder, battery and sensors removed. The video was then loaded onto the computer for data retrieval.
Fig. 1 Upper endoscopic examination showing both capsule endoscopes retained in the gastric pouch near the gastrojejunal anastamosis
Results
was not visualized. A kidney, ureter and bladder X-ray performed 2 weeks later confirmed passage of the capsule endoscope. A repeat VCE study performed 4 months later was again incomplete as the capsule endoscope remained in the SB obstructed by food debris.
Case 1
Case 3
A 50-year-old woman with type II diabetes mellitus and a history of Roux-en-Y gastric bypass over 5 years prior was referred to GI clinic for evaluation of obscure GI bleeding (OGIB). The first VCE study was incomplete as the capsule remained at the gastrojejunal anastomosis. The patient underwent a repeat VCE procedure 2 weeks later, and this too was incomplete as the second capsule remained at the anastomotic site (Fig. 1). Approximately 45 days postprocedure the patient successfully underwent upper endoscopy for retrieval of both capsule endoscopes. Upper endoscopic examination revealed a gastric pouch of about 4–5 cm, with significant narrowing of the outlet into the SB (Fig. 2). The patient tolerated the procedure well without further complications.
A 42-year-old man with type II diabetes mellitus and a history of Roux-en-Y gastric bypass 3 years prior was referred for investigation of OGIB. The patient initially presented to the emergency department with a 3 week history of progressive dyspnea on exertion. He was found to have a hemoglobin count of 2.2 g/dL and mean corpuscular volume of 58.1 fL. After appropriate resuscitation, an EGD and colonoscopy only showed a single non-bleeding arteriovenous malformation at the hepatic flexure. The patient then underwent VCE for further evaluation, but this study was noted to be incomplete due to large amount of food debris.
Case 2 A 60-year-old woman with type II diabetes mellitus and a history of Roux-en-Y gastric bypass 8 years prior was referred for VCE for diagnosis of Crohn’s disease after an esophagogastroduodenoscopy (EGD) and colonoscopy failed to show conclusive evidence of inflammatory bowel disease. On examination, the capsule endoscope was seen entering the SB shortly after swallowing with evidence in support of the patient’s surgical history. One hour into the study the capsule remained in the SB along with a large amount of food debris obscuring visualization. The cecum
123
Case 4 A 54-year-old woman with type II diabetes mellitus and a history of Roux-en-Y gastric bypass 16 years prior was referred for evaluation of OGIB. Initial VCE was incomplete as the capsule was delayed in the gastric pouch for approximately 7 h. The SB was unable to be visualized in its entirety. The study was repeated by endoscopic deployment, and resulted in a complete study without obvious lesions.
Discussion VCE has been widely accepted as an efficacious procedure for evaluation of SB pathology. From December 2007 to
Clin J Gastroenterol (2011) 4:347–350
349
Fig. 2 a Narrowing of the gastric outlet, b gastric pouch with distal narrowing, c capsule endoscope retained in gastric pouch, d removal of capsule endoscope with flower basket
Table 1 Characteristics of the four patients with a history of Roux-en-Y gastric bypass surgery who underwent VCE
Patient
Age/sex
Indication
Reason for incomplete examination
1
50/F
OGIB
Capsule retention at gastrojejunostomy
2
60/F
Suspicion of Crohn’s Disease
Poor small bowel preparation limiting visualization
3
42/M
OGIB
Poor small bowel preparation limiting visualization
4
54/F
OGIB
Delayed GI transit
December 2009, 4 patients with a history of Roux-en-Y gastric bypass underwent VCE at our institution, accounting for 1.6% of all capsule studies performed during this time. Although overall study completion rates were high, patients with a history of Roux-en-Y surgery seemed at increased risk for incomplete studies. Here the incomplete examination rate was 100% among patients with Roux-enY, with all 4 patients having incomplete examinations due to either capsule retention, poor preparation limiting SB visualization, or delayed GI transit (Table 1). There was no significant difference in completion rates seen in patients with other abdominal surgeries. Case 1 suggests that incomplete examination may be attributed to inherent alteration of the upper GI tract anatomy after a Roux-en-Y procedure. The gastrojejunostomy created during a Roux-en-Y procedure generally
measures 1–2 cm in diameter [12] while the capsule endoscope (Given Imaging) measures 1.1 cm 9 2.6 cm [13, 14]. Depending on the size of the anastomosis created by the surgeon, it is possible that the orifice of this anastomotic site may not accommodate the capsule endoscope. Holden et al. [11] recognized this fact, and described the utility of endoscopically placing the capsule endoscope in order to avoid retention at the narrowed gastric outlet. Further structuring as a post-operative complication may additionally limit the orifice at the anastomotic site. Additionally, the degree of obstruction secondary to stricture formation can also be increased by co-existent local inflammation and edema [12]. Cases 2, 3 and 4 illustrate the role of impaired GI transit leading to incomplete studies in patients with a history of Roux-en-Y surgery. In cases 2 and 3, both patients
123
350
Clin J Gastroenterol (2011) 4:347–350
satisfactorily completed the required 2 L polythelyene glycol purge, but ultimately had poor SB preparation. The patient in case 4 had a satisfactory SB preparation, but the capsule endoscope still failed to pass through the GI tract in the standard time. While the true cause of poor SB preparation in cases 2 and 3 is unclear, as is the cause of the incomplete study in case 4, an intriguing explanation may involve impaired GI motility due to post-operative hormonal changes. It has been shown that the Roux-en-Y procedure itself often leads to specific hormonal changes that aid in facilitating weight loss [15, 16]. Glucagon-like peptide and peptide YY, which are believed to positively regulate satiety, have been shown to be elevated in Rouxen-Y recipients [17]. Conversely, hormones that stimulate appetite such as ghrelin have been shown to be decreased in these patients. The net effect of these hormonal changes is believed to lead to decreased GI motility and delayed gastric emptying [17]. Patients with a history of Roux-en-Y gastric bypass may be at increased risk for incomplete VCE examination, primarily due to capsule retention and regional transit abnormalities. Additional interventions may be necessary to circumvent these risks and improve study completion rates in this population. Complications such as capsule retention can potentially be avoided by endoscopic deployment of the capsule endoscope as performed in case 4 of this series. Use of the patency capsule may be of benefit in those unable to tolerate endoscopic capsule placement. Balloon enteroscopy should also be considered given its demonstrated utility in accessing the afferent limb in patients with Roux-en-Y surgery [18, 19]. It is important for endoscopists to be aware of such complications in this population as bariatric surgery gains popularity among a growing population suffering from morbid obesity. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small bowel capsule endoscopy: a systematic review. Gastrointest Endosc. 2010;71:280–6. 2. Carlo JT, DeMarco D, Smith BA, Livingston S, Wiser K, Kuhn JA, et al. The utility of capsule endoscopy and its role for diagnosing pathology in the gastrointestinal tract. Am J Surg. 2005;190:886–90.
123
3. Sidhu R, Sanders DS, Kapur K, Hurlstone DP, McAlindon ME. Capsule endoscopy changes patient management in routine clinical practice. Dig Dis Sci. 2007;52:1382–6. 4. Cheon JH, Kim YS, Lee IS, Chang DK, Ryu JK, Lee KJ, et al. Can we predict spontaneous capsule passage after retention? A nationwide study to evaluate the incidence and clinical outcomes of capsule retention. Endoscopy. 2007;39:1046–52. 5. Sturniolo GC, Di Leo V, Vettorato MG, De Boni M, Lamboglia F, De Bona M, et al. Small bowel exploration by wireless capsule endoscopy: results from 314 procedures. Am J Med. 2006;119:341–7. 6. Knopp TC, Mardini HE, Pen˜a LR. Wireless capsule endoscopy indication as a predictor of study quality. Dig Dis Sci. 2008;53:1898–901. 7. Matas JL, Asteinza M, Loscos JM, Ferna´ndez S, Ramı´rez-Armengol JA, Dı´az-Rubio M. Diagnostic yield and safety of capsule endoscopy. Rev Esp Enferm Dig. 2006;98:666–73. 8. Rondonotti E, Herrerias JM, Pennazio M, Caunedo A, Mascarenhas-Saraiva M, de Franchis R. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc. 2005;62:712–6. 9. Viazis N, Papaxoinis K, Vlachogiannakos J, Efthymiou A, Theodoropoulos I, Karamanolis DG. Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test? Gastrointest Endosc. 2009;69:850–6. 10. Knopp TC, Mardini HE, Pen˜a LR. Wireless capsule endoscopy indication as a predictor of study quality. Dig Dis Sci. 2008;53:1898–901. 11. Holden JP, Dureja P, Pfau PR, Schwartz DC, Reichelderfer M, Judd RH, et al. Endoscopic placement of the small-bowel video capsule by using a capsule endoscope delivery device. Gastrointest Endosc. 2007;65:842–7. 12. Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and outcomes. Gastroenterology. 2007;132:2253–71. 13. Kornbluth A, Legnani P, Lewis BS. Video capsule endoscopy in inflammatory bowel disease: past, present, and future. Inflamm Bowel Dis. 2004;10:278–85. 14. Mishkin DS, Chuttani R, Croffie J, Disario J, Liu J, Shah R, et al. Technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc. 2002;56:621–4. 15. Borg CM, le Roux CW, Ghatei MA, Bloom SR, Patel AG, Aylwin SJ. Progressive rise in gut hormone levels after Roux-enY gastric bypass suggests gut adaptation and explains altered satiety. Br J Surg. 2006;93:210–5. 16. Holdstock C, Zethelius B, Sundbom M, Karlsson FA, Ede´n Engstro¨m B. Postprandial changes in gut regulatory peptides in gastric bypass patients. Int J Obes (Lond). 2008;32:1640–6. 17. Beckman LM, Beckman TR, Earthman CP. Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass procedure: a review. J Am Diet Assoc. 2010;110:571–84. 18. Fahndrich M, Sandmann M, Heike M. A facilitated method for endoscopic interventions at the bile duct after Roux-en-Y reconstruction using double balloon enteroscopy. Z Gastroenterol. 2008;46:335–8. 19. Layec S, D’Halluin PN, Pagenault M, Sulpice L, Meunier B, Bretagne JF. Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: a new role for double-balloon enteroscopy. Gastrointest Endosc. 2010;72:449–51.
CASE REPORT
Incomplete capsule endoscopy examinations after Roux-en-Y gastric bypass Dhavan A. Parikh • Mohit Mittal • Surinder K. Mann
Received: 1 May 2011 / Accepted: 12 July 2011 / Published online: 9 August 2011 Ó Springer 2011
Abstract Background Video capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel. Optimization of this imaging modality has focused on minimizing the rate of incomplete studies through appropriate patient selection. Recent data have shown an increased incidence of incomplete examinations in those with surgically altered gastrointestinal anatomy. Methods We present 4 consecutive cases of post Rouxen-Y gastric bypass patients undergoing video capsule endoscopy. Results Three patients were referred for obscure gastrointestinal bleeding and one for diagnosis of Crohn’s disease; all 4 patients had incomplete studies. One patient experienced capsule retention in the gastric pouch. Two patients had repeated poor small bowel preparation despite compliance with preparatory methods. The fourth patient experienced delayed gastrointestinal transit despite satisfactory small bowel preparation. Conclusion Patients with a history of Roux-en-Y surgery appear to be at increased risk for incomplete examination
D. A. Parikh S. K. Mann Department of Gastroenterology, UC Davis Medical Center, Sacramento, USA D. A. Parikh (&) Department of Internal Medicine, UC Davis Medical Center, 4150 V Street, PSSB 3116, Sacramento, CA 95817-1460, USA e-mail: [email protected] M. Mittal UC Davis School of Medicine, Sacramento, CA, USA S. K. Mann Department of Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, CA, USA
due to capsule retention and delayed gastric transit. Endoscopists may consider additional precursory testing or the use of alternative imaging methods in this population. Keywords Video capsule endoscopy Roux-en-Y Small bowel
Introduction Video capsule endoscopy (VCE) is an effective and minimally invasive tool for the evaluation of small bowel (SB) pathology. Study completion rates vary based on the indication, with the higher end approaching 80–85% [1]. Several factors such as inadequate battery life in the setting of delayed gastrointestinal (GI) transit, poor SB preparation and capsule retention have been cited as primary reasons for incomplete examinations [2–10]. On average, capsule retention as a cause of incomplete examination has been reported in 1.4% of studies according to a recent systematic review [1]. While the rate of incomplete studies secondary to capsule retention in postoperative patients has not been widely reported, this same review suggests that post-surgical stenosis may account for up to 7.4% of all capsule retentions [1]. Additional studies have shown that delivery and transport of the video capsule via the standard peroral route can be problematic in patients with a history of gastroparesis or abnormal upperGI anatomy due to prior Whipple, Billroth I/II, Nissen fundoplication and Roux-en-Y operations [11]. Here we present 4 cases that illustrate an increased risk of incomplete VCE examinations in patients with a history of Roux-en-Y gastric bypass surgery. All 4 patients underwent Roux-en-Y gastric bypass for treatment of morbid obesity. No underlying GI dysmotility was documented.
123
348
Clin J Gastroenterol (2011) 4:347–350
Methods A total of 250 VCE procedures were reviewed between December 2007 and December 2009. Of these, the medical records of 4 consecutive adult patients with a history of Roux-en-Y gastric bypass who underwent VCE at the University of California Davis Medical Center were analyzed. VCE protocol—prior to VCE patients were advised to have a 24 h full-liquid diet, followed by SB and colonic irrigation with 2 L of polyethylene glycol and a 12-h fast. Patients were then brought to the GI laboratory to be fitted with a video recorder, battery and a four-sensor array belt attached to the abdomen. Patients were then asked to swallow slurry of simethicone followed by the PillCam SB capsule (Given Imaging, Yoqneam, Israel). They were allowed a small snack 4 h after ingestion of the capsule endoscope. The video recorded for 8 h and the patients then returned to the GI laboratory to have the video recorder, battery and sensors removed. The video was then loaded onto the computer for data retrieval.
Fig. 1 Upper endoscopic examination showing both capsule endoscopes retained in the gastric pouch near the gastrojejunal anastamosis
Results
was not visualized. A kidney, ureter and bladder X-ray performed 2 weeks later confirmed passage of the capsule endoscope. A repeat VCE study performed 4 months later was again incomplete as the capsule endoscope remained in the SB obstructed by food debris.
Case 1
Case 3
A 50-year-old woman with type II diabetes mellitus and a history of Roux-en-Y gastric bypass over 5 years prior was referred to GI clinic for evaluation of obscure GI bleeding (OGIB). The first VCE study was incomplete as the capsule remained at the gastrojejunal anastomosis. The patient underwent a repeat VCE procedure 2 weeks later, and this too was incomplete as the second capsule remained at the anastomotic site (Fig. 1). Approximately 45 days postprocedure the patient successfully underwent upper endoscopy for retrieval of both capsule endoscopes. Upper endoscopic examination revealed a gastric pouch of about 4–5 cm, with significant narrowing of the outlet into the SB (Fig. 2). The patient tolerated the procedure well without further complications.
A 42-year-old man with type II diabetes mellitus and a history of Roux-en-Y gastric bypass 3 years prior was referred for investigation of OGIB. The patient initially presented to the emergency department with a 3 week history of progressive dyspnea on exertion. He was found to have a hemoglobin count of 2.2 g/dL and mean corpuscular volume of 58.1 fL. After appropriate resuscitation, an EGD and colonoscopy only showed a single non-bleeding arteriovenous malformation at the hepatic flexure. The patient then underwent VCE for further evaluation, but this study was noted to be incomplete due to large amount of food debris.
Case 2 A 60-year-old woman with type II diabetes mellitus and a history of Roux-en-Y gastric bypass 8 years prior was referred for VCE for diagnosis of Crohn’s disease after an esophagogastroduodenoscopy (EGD) and colonoscopy failed to show conclusive evidence of inflammatory bowel disease. On examination, the capsule endoscope was seen entering the SB shortly after swallowing with evidence in support of the patient’s surgical history. One hour into the study the capsule remained in the SB along with a large amount of food debris obscuring visualization. The cecum
123
Case 4 A 54-year-old woman with type II diabetes mellitus and a history of Roux-en-Y gastric bypass 16 years prior was referred for evaluation of OGIB. Initial VCE was incomplete as the capsule was delayed in the gastric pouch for approximately 7 h. The SB was unable to be visualized in its entirety. The study was repeated by endoscopic deployment, and resulted in a complete study without obvious lesions.
Discussion VCE has been widely accepted as an efficacious procedure for evaluation of SB pathology. From December 2007 to
Clin J Gastroenterol (2011) 4:347–350
349
Fig. 2 a Narrowing of the gastric outlet, b gastric pouch with distal narrowing, c capsule endoscope retained in gastric pouch, d removal of capsule endoscope with flower basket
Table 1 Characteristics of the four patients with a history of Roux-en-Y gastric bypass surgery who underwent VCE
Patient
Age/sex
Indication
Reason for incomplete examination
1
50/F
OGIB
Capsule retention at gastrojejunostomy
2
60/F
Suspicion of Crohn’s Disease
Poor small bowel preparation limiting visualization
3
42/M
OGIB
Poor small bowel preparation limiting visualization
4
54/F
OGIB
Delayed GI transit
December 2009, 4 patients with a history of Roux-en-Y gastric bypass underwent VCE at our institution, accounting for 1.6% of all capsule studies performed during this time. Although overall study completion rates were high, patients with a history of Roux-en-Y surgery seemed at increased risk for incomplete studies. Here the incomplete examination rate was 100% among patients with Roux-enY, with all 4 patients having incomplete examinations due to either capsule retention, poor preparation limiting SB visualization, or delayed GI transit (Table 1). There was no significant difference in completion rates seen in patients with other abdominal surgeries. Case 1 suggests that incomplete examination may be attributed to inherent alteration of the upper GI tract anatomy after a Roux-en-Y procedure. The gastrojejunostomy created during a Roux-en-Y procedure generally
measures 1–2 cm in diameter [12] while the capsule endoscope (Given Imaging) measures 1.1 cm 9 2.6 cm [13, 14]. Depending on the size of the anastomosis created by the surgeon, it is possible that the orifice of this anastomotic site may not accommodate the capsule endoscope. Holden et al. [11] recognized this fact, and described the utility of endoscopically placing the capsule endoscope in order to avoid retention at the narrowed gastric outlet. Further structuring as a post-operative complication may additionally limit the orifice at the anastomotic site. Additionally, the degree of obstruction secondary to stricture formation can also be increased by co-existent local inflammation and edema [12]. Cases 2, 3 and 4 illustrate the role of impaired GI transit leading to incomplete studies in patients with a history of Roux-en-Y surgery. In cases 2 and 3, both patients
123
350
Clin J Gastroenterol (2011) 4:347–350
satisfactorily completed the required 2 L polythelyene glycol purge, but ultimately had poor SB preparation. The patient in case 4 had a satisfactory SB preparation, but the capsule endoscope still failed to pass through the GI tract in the standard time. While the true cause of poor SB preparation in cases 2 and 3 is unclear, as is the cause of the incomplete study in case 4, an intriguing explanation may involve impaired GI motility due to post-operative hormonal changes. It has been shown that the Roux-en-Y procedure itself often leads to specific hormonal changes that aid in facilitating weight loss [15, 16]. Glucagon-like peptide and peptide YY, which are believed to positively regulate satiety, have been shown to be elevated in Rouxen-Y recipients [17]. Conversely, hormones that stimulate appetite such as ghrelin have been shown to be decreased in these patients. The net effect of these hormonal changes is believed to lead to decreased GI motility and delayed gastric emptying [17]. Patients with a history of Roux-en-Y gastric bypass may be at increased risk for incomplete VCE examination, primarily due to capsule retention and regional transit abnormalities. Additional interventions may be necessary to circumvent these risks and improve study completion rates in this population. Complications such as capsule retention can potentially be avoided by endoscopic deployment of the capsule endoscope as performed in case 4 of this series. Use of the patency capsule may be of benefit in those unable to tolerate endoscopic capsule placement. Balloon enteroscopy should also be considered given its demonstrated utility in accessing the afferent limb in patients with Roux-en-Y surgery [18, 19]. It is important for endoscopists to be aware of such complications in this population as bariatric surgery gains popularity among a growing population suffering from morbid obesity. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small bowel capsule endoscopy: a systematic review. Gastrointest Endosc. 2010;71:280–6. 2. Carlo JT, DeMarco D, Smith BA, Livingston S, Wiser K, Kuhn JA, et al. The utility of capsule endoscopy and its role for diagnosing pathology in the gastrointestinal tract. Am J Surg. 2005;190:886–90.
123
3. Sidhu R, Sanders DS, Kapur K, Hurlstone DP, McAlindon ME. Capsule endoscopy changes patient management in routine clinical practice. Dig Dis Sci. 2007;52:1382–6. 4. Cheon JH, Kim YS, Lee IS, Chang DK, Ryu JK, Lee KJ, et al. Can we predict spontaneous capsule passage after retention? A nationwide study to evaluate the incidence and clinical outcomes of capsule retention. Endoscopy. 2007;39:1046–52. 5. Sturniolo GC, Di Leo V, Vettorato MG, De Boni M, Lamboglia F, De Bona M, et al. Small bowel exploration by wireless capsule endoscopy: results from 314 procedures. Am J Med. 2006;119:341–7. 6. Knopp TC, Mardini HE, Pen˜a LR. Wireless capsule endoscopy indication as a predictor of study quality. Dig Dis Sci. 2008;53:1898–901. 7. Matas JL, Asteinza M, Loscos JM, Ferna´ndez S, Ramı´rez-Armengol JA, Dı´az-Rubio M. Diagnostic yield and safety of capsule endoscopy. Rev Esp Enferm Dig. 2006;98:666–73. 8. Rondonotti E, Herrerias JM, Pennazio M, Caunedo A, Mascarenhas-Saraiva M, de Franchis R. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc. 2005;62:712–6. 9. Viazis N, Papaxoinis K, Vlachogiannakos J, Efthymiou A, Theodoropoulos I, Karamanolis DG. Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test? Gastrointest Endosc. 2009;69:850–6. 10. Knopp TC, Mardini HE, Pen˜a LR. Wireless capsule endoscopy indication as a predictor of study quality. Dig Dis Sci. 2008;53:1898–901. 11. Holden JP, Dureja P, Pfau PR, Schwartz DC, Reichelderfer M, Judd RH, et al. Endoscopic placement of the small-bowel video capsule by using a capsule endoscope delivery device. Gastrointest Endosc. 2007;65:842–7. 12. Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and outcomes. Gastroenterology. 2007;132:2253–71. 13. Kornbluth A, Legnani P, Lewis BS. Video capsule endoscopy in inflammatory bowel disease: past, present, and future. Inflamm Bowel Dis. 2004;10:278–85. 14. Mishkin DS, Chuttani R, Croffie J, Disario J, Liu J, Shah R, et al. Technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc. 2002;56:621–4. 15. Borg CM, le Roux CW, Ghatei MA, Bloom SR, Patel AG, Aylwin SJ. Progressive rise in gut hormone levels after Roux-enY gastric bypass suggests gut adaptation and explains altered satiety. Br J Surg. 2006;93:210–5. 16. Holdstock C, Zethelius B, Sundbom M, Karlsson FA, Ede´n Engstro¨m B. Postprandial changes in gut regulatory peptides in gastric bypass patients. Int J Obes (Lond). 2008;32:1640–6. 17. Beckman LM, Beckman TR, Earthman CP. Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass procedure: a review. J Am Diet Assoc. 2010;110:571–84. 18. Fahndrich M, Sandmann M, Heike M. A facilitated method for endoscopic interventions at the bile duct after Roux-en-Y reconstruction using double balloon enteroscopy. Z Gastroenterol. 2008;46:335–8. 19. Layec S, D’Halluin PN, Pagenault M, Sulpice L, Meunier B, Bretagne JF. Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: a new role for double-balloon enteroscopy. Gastrointest Endosc. 2010;72:449–51.
