Antegrade enteroscopy had a significantly greater diagnostic and therapeutic yield in small bowel disease, compared with retrograde enteroscopy, reported Dr. Madhusudhan R. Sanaka and colleagues in the August issue of Clinical Gastroenterology and Hepatology.
Moreover, antegrade enteroscopy had a significantly shorter mean duration, with a greater mean depth of maximal insertion, the authors added.
In what the researchers called "the first study ... to compare the efficacy of all three available enteroscopy systems between antegrade and retrograde approach" in small bowel disease, Dr. Sanaka, of the Digestive Disease Institute at the Cleveland Clinic, studied 250 such procedures performed at that institution between January 2008 and August 2009.
A total of 182 procedures were antegrade (91 with a single-balloon enteroscope, 52 with a double-balloon enteroscope, and 39 with a spiral enteroscope), and 68 were retrograde (23 with a single balloon, 37 with a double balloon, and 8 with a spiral enteroscope).
The mean age of all participants was 61.5 years, and the antegrade and retrograde groups did not differ significantly on any of the demographic factors or history of prior capsule endoscopies.
Although obscure gastrointestinal bleeding was the most common indication in both groups, "abdominal pain or suspected Crohn’s disease was a much more common indication for antegrade enteroscopy when compared to retrograde (18.7% vs. 4.4%, P less than .001)," wrote the authors.
Overall, the diagnostic yield of antegrade enteroscopy was significantly greater, at 63.7%, than the yield of the retrograde procedures (39.7%), with P less than .001 (Clin. Gastroenterol. Hepatol. 2012 [doi: 10.1016/j.cgh.2012.04.020]).
The investigators then looked at the therapeutic yield of the two procedures. "With the antegrade approach, in 59 procedures (32.4%), a therapeutic intervention was performed," including argon plasma coagulation in 52 cases (28.6%), dilatation in 1 (0.6%), and polypectomy in 4 cases (2.2%).
With the retrograde approach, therapies were initiated in just 14.7% of cases, which was significantly lower than the percentage for the antegrade approach (P less than .001).
The authors also compared the technical aspects of the different procedure types. In this study, antegrade enteroscopies lasted 44.3 minutes on average, versus 58.9 minutes for the retrograde procedures (P less than .001).
Antegrade procedures also achieved a significantly greater depth of maximal insertion on average, at 231.8 cm, compared with 103.4 cm for retrograde procedures (P less than .001).
The authors conceded that the study had several limitations. Not only was it retrospective, they wrote, "there was no randomization and hence there could have been a significant bias in patient selection and use of a particular enteroscopy approach in individual cases, particularly in patients in whom the source of small bowel disorder was not known."
Nevertheless, "our findings of higher diagnostic and therapeutic yields with antegrade enteroscopy compared to retrograde enteroscopy support the expert opinion to consider antegrade enteroscopy as a default initial approach for suspected small bowel disease," the authors concluded.
"Retrograde enteroscopy may be considered when the antegrade enteroscopy is either nondiagnostic or if the abnormalities identified are unlikely to account for the patient’s symptoms," or when capsule endoscopy or radiologic imaging studies indicate that distal small bowel disease is likely, such as in suspected Crohn’s disease.
One of the authors, Dr. John Vargo, declared that he is a consultant for Olympus America, maker of enteroscopes and other devices. The authors stated that there was no outside funding.
