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Background: The referral of patients with surgically altered bowel anatomy such as Bariatric surgery, Billroth II surgery, and Roux en Y anastomosis during liver transplants etc. for endoscopic evaluation is rising. The Double Balloon Enteroscopy (DBE) procedure has both diagnostic and therapeutic value in small bowel evaluation in these patients. Reported data on DBE in the patients with surgically altered bowel anatomy is limited.

Aim: To evaluate the success rate, diagnostic yield, and safety of DBE procedure in patients with surgically altered bowel anatomy.

Methods: We reviewed our large prospectively collected DBE database from 2006 to 2011. The patients with history of surgically altered bowel anatomy who underwent DBE were included in our study analysis. Patients’ Demographics along with DBE procedure indication, findings and complications were recorded. We used the frequency statistics to calculate the diagnostic yield of the DBE in these patients.

Results: A total of 1218 DBE procedures were performed from 2006 to 2011 at our tertiary referral center. Out of these, 64 DBEs (11 DBE-ERCP) performed in 62 patients (73% Female) with surgically altered bowel anatomy were included in our study analysis. Their mean age was 51 (26-77) years and mean BMI was 28.2 (20.3-53.6) kg/m2. Bariatric surgery was the most common 83% (n=53) type of the surgery for altered bowel anatomy. The most common indication of DBE was abdominal pain and DBE-ERCP was acute cholangitis (see table). The overall procedure success rate for adequate examination of roux limb was 92.2% (59/64). The success rate of DBE - ERCP with adequate examination of pancreato-biliary tree and required therapeutic intervention was 63.3% (n=7/11). The overall diagnostic yield (pertinent positive findings) of DBE procedure was found to be 64% (n=41). The diagnostic yield in patients with prior negative imaging and/or capsule endoscopy was found to be 47% (n=30). The diagnostic yield of small bowel biopsy (targeted or random) was 9.4 % (n=3/32), while the diagnostic yield of small bowel aspirate for bacterial overgrowth was found to be 100% (n=5/5). No complications were identified after any DBE procedure in mean follow-up period of 6 months. Mean procedure time was 89.6 (38-180) minutes and average fluoroscopy time was 173 (15-466) seconds.

Conclusion: The DBE is a safe procedure and carries very high diagnostic yield in the patients with surgically altered bowel anatomy for various indications. The diagnostic yield remains high even if there are negative radiology tests and/or capsule endoscopy prior to DBE procedure. The diagnostic yield of small bowel aspirate was very high while diagnostic yield of gastrointestinal biopsies were low. In our study, we found fair success rate of DBE with ERCP procedure in terms of adequate examination with required therapeutic intervention.

Indications of DBE without ERCP (n=53 pts)	n (%)
Persistent abdominal pain Bleeding - Overt Bleeding - Obscure Other	17 (32) 10 (19) 8 (16) 18 (33)
Indications of DBE-ERCP (n=11 pts)	n (%)
Acute cholangitis Recurrent pancreatitis Biliary Stricture Other	3 (27.3) 2 (18.2) 2 (18.2) 4 (36.3)