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Evidences supporting the vascular etiology of post-double balloon enteroscopy pancreatitis: Study in porcine model

World Journal of Gastroenterology 2017年第34期23卷 6201-6211页

作者： rafael latorre Octavio López-Albors Federico Soria Esther Morcillo Pilar Esteban Enrique Pérez-Cuadrado-Robles Enrique Pérez-Cuadrado-Martínez Department of Anatomy and Comparative Pathology University of Murcia Minimally Invasive Surgery Centre Jesús Usón Department of Gastroenterology Small Bowel UnitMorales Meseguer Hospital

Double balloon enteroscopy(DBE) is an endoscopic technique broadly used to diagnose and treat small bowel diseases. Among the associated complications of the oral DBE, post-procedure pancreatitis has taken the most attention due to its gravity and the thought that it might be associated to the technique itself and anatomical features of the pancreas. However, as the etiology has not been clarified yet, this paper aims to review the published literature and adds new results from a porcine animal model. Biochemical markers, histological sections and the vascular perfusion of the pancreas were monitored in the pig during DBE practice. A reduced perfusion of the pancreas and bowel, the presence of defined hypoxic areas and disseminated necrotic zones were found in the pancreatic tissue of pigs. All these evidences contribute to support a vascular distress as the most likely etiology of the post-DBE pancreatitis.

关键词： Double balloon enteroscopy Pancreas Animal model Pancreatitis Pig

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Effect of double-balloon enteroscopy on pancreas:An experimental porcine model

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World Journal of Gastroenterology 2012年第37期18卷 5181-5187页

作者： rafael latorre Federico Soria Octavio López-Albors Ricardo Sarriá Francisco Sánchez-Margallo Pilar Esteban Fernando Carballo Enrique Pérez-Cuadrado Department of Anatomy and Comparative Pathology University of MurciaCampus de Espinardo Jesús Usón Minimally Invasive Surgery Center 10071 CáceresSpain Jesús Usón Minimally Invasive Surgery Center Digestive Service Morales Meseguer Hospital Digestive Service Virgen de la Arrixaca Hospital

AIM： To evaluate the effect of double-balloon enteros- copy （DBE） on pancreas histology and levels of pancre- atic enzymes. METHODS： Conventional upper gastrointestinal endos- copy was performed on five control pigs. Oral DBE was performed with an EN-450T5 enteroscope on 20 pigs. Two experimental groups （10 pigs each） were defined according to DBE duration： 90 rain for Group 1 and 140 min for Group 2. During oral insertion, the balloons were not inflated in the descending part of the duodenum to avoid the minor duodenal papilla. Serum amy- lase, lipase and C-reactive protein （CRP） levels were monitored before the procedure and repeated every 30 min until the exploration was finished, as well as 24 h and 7 d after. After the procedure and for a total of 7 d, the pigs were observed twice a day for signs of de- creased activity, irritability, vomiting or anorexia. Gross and microscopic examination of the pancreas was per- formed on day 7. RESULTS： All animals tolerated DBE without clini- cal manifestations of acute pancreatitis. Experimental groups had higher levels of enzymes than the control group at 24 h. Throughout the exploration, the amylase levels increased significantly above the baseline 24 h after DBE, although the increase was not statistically significant and did not reach 20% of the baseline. An increase in lipase and CRP was observed at 24 h after the procedure, although by day 7, all enzymatic lev- els had returned to baseline. No differences between Groups 1 and 2 were found for any enzyme and sam- pling site during and after the procedure. Similarly, no correlation between insertion depth and enzyme levels was observed. Direct in situ and post-removal inspec- tion of the pancreas did not show any evidence of fluid collection, abscesses or hemorrhage. Histological examination of the pancreas from Groups 1 and 2 re- vealed the existence of focal areas （0.14-0.26 mm2） of ischemic necrosis in 47.4% of the animals. In the pigs with damaged pancreas, the lef

关键词： Endoscopy Pancreatitis Double-balloon en-teroscopy Experimental study Pig model

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Effect of the manipulation of the duodenal papilla during double balloon enteroscopy

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World Journal of Gastroenterology 2016年第17期22卷 4330-4337页

作者： rafael latorre Octavio López-Albors Federico Soria Eugenia Candanosa Enrique Pérez-Cuadrado Department of Anatomy and Comparative Pathology Veterinary Faculty University of Murcia Campus Universitario de Espinardo 30100 Murcia Spain Minimally Invasive Surgery Center Jesus Uson 10071 Caceres Spain Unit of Digestive Diseases Morales Meseguer University Hospital 30008 Murcia Spain

AIM: To determine the hypothesis that inflating the balloons in the duodenal papilla determines changes in the biochemical markers of ***: Four groups of pigs were used: Group papilla(GP), the overtube's balloon was inflated in the area of the papilla; GP + double balloon enteroscopy(GP + DBE), the overtube's balloon was kept inflated in the area of the papilla for 20 min before a DBE; Group DBE(GDBE), DBE was carried out after insuring the balloon's inflation far from the pancreatic papilla; and Group control(GC). Serum concentrations of amylase, lipase and C-reactive protein(CRP) were evaluated. Pancreases were processed for histopathology ***: Main changes occurred 24 h after the procedure compared with baseline levels. Amylase levels increased significantly in GP(59.2% higher) and were moderately higher in groups GP + DBE and GDBE(22.7% and 20%, respectively). Lipase increased in GP and GP + DBE, whereas it hardly changed in GDBE and in GC. CRP increased significantly in GP, GP + DBE and GDBE, while no changes were reported for GC. No statistically significant difference between groups GP and GP + DBE was found for the histopathological findings, except for vacuolization and necrosis of the pancreatic parenchyma that was higher in GP than in GP + ***: The manipulation of the duodenal papilla by the inflated overtube's balloon during DBE causes pancreatic structural damage and increased biochemical markers associated with pancreatitis.

关键词： Duodenal papilla Double balloon enteroscopy Pancreas Animal model Pancreatitis

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Role of double-balloon enteroscopy in malignant small bowel tumors

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World Journal of Gastrointestinal Endoscopy 2015年第6期7卷 652-658页

作者： Enrique Pérez-Cuadrado Robles Pilar Esteban Delgado Paloma Bebia Conesa Blanca Martínez Andrés Milivoj Franulic Guggiana Eduardo Alcaraz Mateos Mariana Fernández Caballero José Luis Rodrigo Agudo Silvia Chacón Martínez rafael latorre Federico Soria Juan Manuel Herrerías Gutiérrez Enrique Pérez-Cuadrado Martínez Department of Gastroenterology Morales Meseguer Hospital Department of Radiology Morales Meseguer Hospital Department of Pathology Morales Meseguer Hospital Department of Hematology and Oncology Morales Meseguer Hospital Department of Anatomy University of Murcia Centre Jesus Usón Hospital Universitario Virgen Macarena

AIM: To assess the double-balloon enteroscopy(DBE) role in malignant small bowel tumors(MSBT).METHODS: This is a retrospective descriptive study performed in a single center. All consecutive patients who underwent a DBE with final diagnosis of a malignant neoplasm from 2004 to 2014 in our referral center were included. Patient demographic and clinical pathological characteristics were recorded and reviewed. MSBT diagnosis was achieved either by DBE directed biopsy with multiple tissue sampling, endoscopic findings or histological analysis of surgical specimen. We have analyzed double-balloon enteroscopy impact in outcome and clinical course of these patients. RESULTS: Of 627 patients, 28(4.5%)(mean age = 60 ± 17.3 years) underwent 30 procedures(25 anterograde, 5 retrograde) and were diagnosed of a malignant tumor. Patients presented with obscure gastrointestinal bleeding(n = 19, 67.9%), occlusion syndrome(n = 7, 25%) and diarrhea(n = 1, 3.6%). They were diagnosed by DBE biopsy(n = 18, 64.3%), histological analysis of surgical specimen(n = 7, 25%) and unequivocal endoscopic findings(n = 2, 7.1%). Gastrointestinal stromal tumor(n = 8, 28.6%), adenocarcinoma(n = 7, 25%), lymphoma(n = 4, 14.3%), neuroendocrine tumor(n = 4, 14.3%), metastatic(n = 3, 10.7%) and Kaposi sarcoma(n = 1, 3.6%) were identified. DBE modified outcome in 7 cases(25%), delaying or avoiding emergency surgery(n = 3), modifying surgery approach(n = 2) and indicating emergency SB partial resection instead of elective approach(n = 2).CONCLUSION: DBE may be critical in the management of MSBT providing additional information that may be decisive in the clinical course of these patients.

关键词： Double balloon enteroscopy Malignantsmall bowel tumors Obscure gastrointestinal bleeding Gastrointestinal stromal tumor Occlusion syndrome

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