Long-Term Outcomes According to a Device-Assisted Enteroscopy Strategy after Capsule Endoscopy in Patients with Small Bowel Bleeding: A Nationwide Population-Based Cohort Study

Background/Aims: Although the use of device-assisted enteroscopy (DAE) has increased, few large-scale studies have examined long-term outcomes focused on small bowel (SB) bleeding. We analyzed National Health Insurance Service data to evaluate the clinical utility of DAE in patients with SB bleeding who underwent capsule endoscopy. Methods: We included a cohort of 11,690 patients who underwent capsule endoscopy for SB bleeding (identified using ICD-10 codes) between 2014 and 2022. Patients were categorized into three groups: no DAE, diagnostic DAE, and therapeutic DAE. We assessed four major outcomes, including the probability and factors associated with SB rebleeding, severe SB rebleeding, rebleeding-related mortality, and all-cause mortality. Results: Of 11,690 patients, 5,211 were included in the analysis (no DAE, n=4,960; diagnostic DAE, n=173; therapeutic DAE, n=78). The probability of SB rebleeding and severe SB rebleeding was highest in the therapeutic DAE group, followed by the diagnostic DAE and no DAE groups (p<0.001), with 7-year rebleeding probabilities of 19.8%, 15.8%, and 5.0%, respectively. Rebleeding-related and all-cause mortality were also highest in the therapeutic DAE group, followed by the diagnostic DAE and no DAE groups (p<0.001 for both), with 7-year rebleeding-related mortality probabilities of 9.3%, 5.9%, and 2.7%, respectively. Risk factors for both rebleeding-related and all-cause mortality included age, male sex, liver cirrhosis, and malignancy. Conclusions: Patients who require therapeutic DAE for SB bleeding remain at increased long-term risk of rebleeding and mortality. These findings likely reflect their greater underlying disease burden and highlight the need for individualized long-term surveillance and careful management of comorbidities, even after therapeutic intervention.