title: Changes in efficiency and resource utilization after increasing experience with double balloon enteroscopy.
abstract: OBJECTIVE
  To investigate changes in efficiency and resource utilization as a single endoscopist's experience increased with each subsequent 100 double balloon enteroscopy (DBE) procedures.
  
  
  METHODS
  We reviewed consecutive DBE procedures performed by a single endoscopist at our center over 4 years. DBE was employed when the clinician deemed the procedure was needed for disease management. The approach (oral, anal or both) was chosen based on suspected location of the target lesion. All DBE was performed in a standard endoscopy room with a portable fluoroscopy unit. Fluoroscopy was used to aid in shortening the small intestine and reducing bowel loops. For oral DBE, measurements were taken from the incisors. For anal DBE, measurements were taken from the anal verge. Enteroscopy continued until the target lesion was reached, until the entire small intestine was examined, or until no further progress was deemed possible. The length of small intestine examined (cm), procedure duration (min), and fluoroscopy time (s) were analyzed for sequential groups of 100 DBE. Sub-groups of diagnostic and therapeutic procedures were analyzed using multivariable linear regression.
  
  
  RESULTS
  802 consecutive DBE procedures were analyzed. For oral DBE, median [interquartile range (IQR)] length of small bowel examined was 230.8 cm (range: 210-248 cm) and for anal DBE was 143.5 cm (range: 100-180 cm). No significant increase in length examined was noted for either the oral or anal approach with advancing position in series. In terms of duration of procedure, the median (IQR) for oral DBE was 86 min (range: 71-105 min) and for anal DBE was 81.3 min (range: 67-105 min). When comparing by the position in series, there was a significant (P value < 0.001) decrease in procedure duration for both upper and lower procedures with increasing experience. Median (IQR) time of exposure to fluoroscopy for oral DBE was 190 s (114-275) compared to anal DBE which was 196.4 s (312-128). This represented a significant (P value < 0.001) decrease in the amount of fluoroscopy used with increasing position in series. For both oral and anal DBE, fluoroscopy time was reduced by greater than 50% over the course of 802 total procedures performed. Sub-group analysis was conducted on therapeutic and diagnostic groups. Out of 802 procedures, a total of 434 were considered therapeutic. Argon plasma coagulation was by far the most common therapeutic intervention performed. There was no evidence of a difference in length examined or fluoroscopy exposure among oral DBE for diagnostic and therapeutic procedures, P = 0.91 and P = 0.32 respectively. The median (IQR) for length was 235 cm (range: 178-280 cm) for diagnostic vs 230 cm (range: 180-275 cm) for therapeutic procedures; additionally, fluoroscopy time median (IQR) was 180 s (range: 110-295 s) and 162 s (range: 102-263 s) for no intervention and intervention. However, there was a significant difference in procedure duration among oral DBE (P < 0.001). The median (IQR) was 80 min (range: 60-97 min) and 94 min (range: 77-110 min) for diagnostic and therapeutic interventions respectively.
  
  
  CONCLUSIONS
  For a single endoscopist, increased DBE experience with number of performed procedures is associated with increased efficiency and decreased resource utilization.
authors.affiliation: Neal C Patel, Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ 85259, United States.
authors.forename: Neal C
authors.initials: NC
authors.lastname: Patel
authors.forename: William C
authors.initials: WC
authors.lastname: Palmer
authors.forename: Kanwar R
authors.initials: KR
authors.lastname: Gill
authors.forename: David
authors.initials: D
authors.lastname: Cangemi
authors.forename: Nancy
authors.initials: N
authors.lastname: Diehl
authors.forename: Mark E
authors.initials: ME
authors.lastname: Stark
keywords: Double balloon enteroscopy; Obscure gastrointestinal bleed