Total enteroscopy with a nonsurgical steerable double-balloon method

BACKGROUND: Deep insertion of an enteroscope by use of a push technique is difficult. A new method of enteroscopy was developed, a double-balloon method, to improve the access to the small intestine. METHODS: The new method uses 2 balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. By using these balloons to grip the intestinal wall, the endoscope can be inserted further without forming redundant loops in the small intestine. This method was tried with a standard upper endoscope in 3 patients and with a longer enteroscope in 1 patient. RESULTS: Despite its short length the upper endoscope was successfully inserted as far as 30 to 50 cm beyond the ligament of Treitz in the 3 patients. In the fourth patient the longer enteroscope was successfully inserted beyond the ileo-cecal valve. CONCLUSIONS: The double-balloon method facilitates endoscopic access to the small intestine.     

Diagnostic yield of routine push enteroscopy with a graded-stiffness enteroscope without overtube

BACKGROUND: Push enteroscopy has become a standard procedure for evaluation of small intestinal disorders. Its diagnostic yield and acceptability, however, has been hampered by the use of an overtube, which is both inconvenient and potentially hazardous. This study assessed the clinical value of enteroscopy with a graded-stiffness videoenteroscope without an overtube. METHODS: A total of 121 consecutive patients (mean age 59 years, range 12-89 years) underwent diagnostic enteroscopy. All procedures (n = 126) were performed with a push-type graded-stiffness videoenteroscope without an overtube. Indications were the following: unexplained iron deficiency anemia (45%), GI bleeding (29%), abdominal pain (6%), malabsorption (5.5%), imaging abnormality (5.5%), diarrhea (4%), intestinal obstruction (3%), and vomiting (2%). RESULTS: The mean depth of instrument insertion distal to the pylorus was 121 cm. A diagnosis was made in 40% of all procedures. The findings included ulcerations or erosions in 43%, angioectasia in 35%, inflammation in 14%, tumors in 6%, and varices in 2%. In all cases of a positive enteroscopic diagnosis, therapeutic maneuvers were performed, and no patient needed a further diagnostic procedure. Patient comfort was good. No complications were observed. CONCLUSIONS: Routine enteroscopy with a graded-stiffness enteroscope without an overtube is safe and comfortable for the patient and the endoscopist, and has a clinical efficacy comparable with that reported for enteroscopy with use of an overtube. A prospective, randomized study is warranted to assess the exact role of this form of enteroscopy in patient care.     

Small Bowel Push-type Fiberoptic Enteroscopy for Patients with Occult Gastrointestinal Bleeding or Suspected Small Bowel Pathology

Objectives: Endoscopic investigation of the small intestine remains the last frontier for gastroendoscopists. We evaluated the diagnostic efficacy and safety of two different push-type, fiberoptic enteroscopes in the investigation of patients with occult gastrointestinal bleeding or suspected small howel pathology. Methods: Sixty-six patients (28 men, 38 women; mean age, 68) underwent push-type enteroscopy with either the SIF 10.5L (n = 17; scope length, 2495 mm) or the SIF 3000 (n = 49; length, 2995 mm) enteroscopes (Olympus America, Inc, Lake Success, New York), All patients enrolled had an indication of either occult gastrointestinal bleeding (n = 55) or suspected small bowel pathology (n = 11), Push-type enteroscopy was performed with an overtube and fluo-roscopic guidance to better estimate the degree of insertion. Assessments of mucosal visualization, tip deflection, procedure tolerance, and complications were noted. Results: Visualization of the small bowel mucosa and tip deflection was rated excellent in all patients. The mean length of insertion past the ligament of Treitz for the SIF 10.5L was 90 cm and 113 cm for the SIF 3000. Only one complication, a pharyngeal tear, occurred with the SIF 3000. Lesions that may explain the occult GI bleeding were found in 35 out of 55 patients (64%). Twenty-one of these 35 patients (60%) had lesions proximal to the ligament of Treitz, and 14 patients (40%) had lesions distal to the ligament of Treitz. If only distal lesions were considered, the diagnostic yield was 25% (14/55) for occult GI bleeding and 73% (8/11) for suspected small bowel pathology. The most common lesions were arteriovenous malformations (34%), which were successfully cauterized. Conclusion: With a relatively high diagnostic yield and therapeutic capability, push-type enteroscopy should play an important role in the investigation and treatment of lesions causing occult GI bleeding and small bowel pathology.     

双气囊内镜检查深度估测新方法初步探讨

目的 初步评估通过计算外套管向体内的回缩距离以判断双气囊内镜插入深度的准确性.方法 入选对象均为双气囊内镜榆出小肠病灶并经手术证实的患者.在双气囊内镜操作过程中通过累计每次推拉内镜过程中镜身在肠腔中的前行长度或通过计算外套管向体内的回缩距离分别判断双气囊内镜插入深度.最终以手术结果评判两种方法的准确性.结果 通过41例经口和10例经肛检查,双气囊内镜在51例患者中检出病灶并经手术证实.根据传统的镜身前行长度判断法,在经口检查者中发现从屈氏韧带-病灶的平均距离为151（30～310）cm,在经肛检查者中自回盲瓣-病灶的平均距离为100（10～180）cm;而根据外套管向体内的回缩距离判断法,则分别为143（30～320）cm和98（10～200）cm.无论进镜方式如何,上述两种方法判断内镜插入深度与手术结果的平均差别分别为19（0～50）cm和17（0～60）cm,差异无统计学意义（P＞0.05）.结论 与传统方法相比,通过外套管向体内的回缩距离判断双气囊内镜插入深度的方法同样准确而更为简便,适合临床推广应用.     

Spiral enteroscopy: a preliminary experience in Asian population

Background and Aim: In spite of recent developments in the field of enteroscopy the small bowel remains the challenging organ to access. The spiral enteroscopy is a novel technique using a special over‐tube (Endo‐Ease Discovery SB) system for deep intubation of the small bowel. The aim of the present study was to evaluate the efficacy of spiral enteroscopy with an Olympus enteroscope (SIF Q 180) in an Asian subset of patients. Methods: Between January and March 2010, 11 patients underwent spiral enteroscopies. The indication for the procedure was obscure gastrointestinal bleeding in five patients, Crohn's disease in two, malabsorbtion syndrome in two, Peutz‐Jeghers syndrome in one and Osler Weber Rendu disease in one patient. Results: Eleven patients (five male and six female) mean age 41.6 years (range 21–62 years) underwent spiral enteroscopy. Spiral enteroscopy advancement was successful in all patients. The average depth of insertion was 249 cm (range 120–400 cm) past the ligament of Treitz, and the average time for the procedure was 27.8 min (range 20–32 min). The findings included ulcers (n = 3), polyps (n = 1), arteriovenous malformation (n = 2), ulcer with stricture (n = 1), and lymphangiectasia (n = 1). No major complications were observed. Conclusion: In conclusion, our initial experience with spiral enteroscopy shows that it is easy to perform, takes less time than balloon assisted enteroscopy and is relatively safe.     

Performance of antegrade double-balloon enteroscopy: comparison with push enteroscopy

BACKGROUND: Double-balloon enteroscopy (DBE) is a novel procedure for the diagnosis of small-bowel pathology. The aim of this retrospective study was to compare the performance and the diagnostic value of antegrade DBE with those of push enteroscopy (PE). METHODS: We reviewed endoscopic and histologic findings in 118 patients examined by PE or antegrade DBE during a period 1980 to 2004. The maximal length of insertion under plain radiograph was compared between patients examined by PE and those examined by antegrade DBE. Diagnostic yield was compared among patients stratified by indication for enteroscopy and the duodenal pathology. RESULTS: Ninety-one patients were examined by PE and 27 patients by antegrade DBE. Length of insertion from the ligament of Treitz was significantly greater in antegrade DBE (median, 92 cm; range, 40-144 cm) than in PE (median, 22 cm; range, 0-98 cm; p < 0.0001). In 90 nonbleeding patients with inflammatory or miscellaneous diseases or polyposis, the diagnostic yield was not different between PE and antegrade DBE (64% vs. 82%, p = 0.13). However, it was higher in antegrade DBE (79%) than in PE (31%, p = 0.012) in nonbleeding patients without duodenal pathology. In bleeding patients, the diagnostic yield was 40% in antegrade DBE and 36% in PE (p = 0.61). CONCLUSIONS: Antegrade DBE is superior to PE in exploration of the small intestine and in diagnostic yield for small-intestinal pathology.     

A case of primary jejunal adenocarcinoma diagnosed by enteroscopy using pediatric colonoscope]

A 39-year-old man presented with dizziness and melena for 2 months. Abdominal CT scan showed constrictive wall thickening with enhancement and proximal loop dilatation of the jejunum. On endoscopic examination, there was large amount of bile stained fluid in duodenum. Enteroscopy using pediatric colonoscope demonstrated an encircling mass with obstruction approximately 20 cm distal to the ligament of Treitz. Endoscopic jejunal biopsy showed moderately differentiated adenocarcinoma. Small intestinal adenocarcinoma is uncommonly encountered in clinical practice. Because small intestine is relatively inaccessible via routine endoscopy, diagnosis of small intestinal neoplasm is often delayed for several months after the onset of symptoms. Most of the patients are diagnosed in advanced stage. Therefore, when a small bowel neoplasm is suspected, enteroscopy is the most useful study. If enteroscope is not available, enteroscopy using pediatric colonoscope may permit earlier preoperative diagnosis. We report a case of primary jejunal adenocarcinoma diagnosed by endoscopic biopsy using pediatric colonoscope.     

Push and Sonde Enteroscopy for the Diagnosis of Obsccre Gastrointestinal Bleeding

Objective: The combination of push and sonde enteroseopy permits endoscopic evaluation to extend the distal small bowel. Our objective was to determine the yields of both push and sonde enteroscopy in patients with obscure GI bleeding. Methods: We retrospectively reviewed 553 small bowel examinations performed with an orally passed 135-cm pediatric colonoscope in combination with a 2750-cm per nasal sonde enteroscope to investigate the small bowel for sources of gastrointestinal bleeding of obscure origin. Results: The examination reached the distal Jejunum or beyond in over 90% of patients undergoing both push and sonde enteroscopy. The yield of these combined studies was 58% for identifying a possible source of gastrointestinal blood loss. In 40% of the examinations, the abnormality was found distal to tbe limits of routine upper gastrointestinal en-doscopy. In 26% of all examinations, the lesion was detectable only by sonde enteroscopy. The most common small bowel findings were mucosal vascular lesions (31% of all exams) and tumors (6%). No major endoscopic complications occurred, and patients tolerated the procedures well. Conclusions: The combination of push and sonde enteroscopy is a valuable tool in the evaluation of obscure gastrointestinal bleeding and may provide useful information necessary to formulate treatment plans aimed at cessation of bleeding.     

EXPERIENCES OF BILIARY INTERVENTIONS USING SHORT DOUBLE‐BALLOON ENTEROSCOPY IN PATIENTS WITH ROUX‐EN‐Y ANASTOMOSIS OR HEPATICOJEJUNOSTOMY

Background: The efficacy of double‐balloon enteroscopy (DBE) for biliary interventions has been shown in patients with surgical anatomy. However, the use of available endoscopic retrograde cholangiography accessories during this procedure is limited because of the length of the conventional instrument (200 cm). The aim of this study was to evaluate the feasibility of short DBE for managing biliary disorders in patients with a Roux‐en‐Y gastrectomy or hepaticojejunostomy (HJ). Patients and Methods: Using a short enteroscope (152 cm) and commercially available endoscopic retrograde cholangiography accessories, biliary interventions were performed in six patients with Roux‐en‐Y reconstruction or HJ anastomosis. Results: A total of 12 biliary interventions were performed; balloon dilations of the HJ anastomosis or intrahepatic ducts (four patients), nasobiliary drainages (three patients), bile duct stone removal after endoscopic papillary large balloon dilation with or without small sphincterotomy (two patients), and a biliary stent placement (one patient). One patient showed retroperitoneal air following endoscopic papillary large balloon dilation, but recovered conservatively. Conclusions: Biliary interventions via DBE using a short enteroscope are feasible in patients with surgical anatomy.     

Endoscopic evaluation of the defunctionalized stomach by using ShapeLock technology (with video)

BACKGROUND: Patients with Roux-en-Y gastric bypass (RYGB) present a unique problem if they require diagnostic or therapeutic interventions for which the pancreatobiliary limb or the defunctionalized stomach must be accessed. Novel shape-locking guides have been reported in the literature to reduce looping during colonoscopy, and a new guide is now available to assist with enteroscopy. OBJECTIVE: To use ShapeLock technology to permit evaluation of the defunctionalized stomach. DESIGN: Observational case series. SETTING: Tertiary-care center. PATIENTS: Nine patients with a history of RYGB referred for repeat endoscopic evaluation after initial enteroscopy failed to reach the excluded stomach. INTERVENTIONS: After achieving appropriate levels of sedation, a standard enteroscope was back-loaded with the ShapeLock enteroscopy guide and was inserted through the mouth. The device was moved through the gastrojejunal (GJ) anastomosis, along the Roux limb, and into the distal pancreatobiliary limb. The device was then locked, which allowed the enteroscope to be advanced to the defunctionalized stomach. RESULTS: The ShapeLock guide was able to be advanced to the excluded stomach and perform a thorough examination of the pancreatobiliary limb in 8 of 9 patients, without complications. In 1 patient, the diameter of the GJ anastomosis prevented passage of the device. CONCLUSIONS: The ShapeLock enteroscopy guide can allow access to the upper-GI tract in patients after RYGB, provided the GJ anastomosis is of adequate diameter. This study suggested that the technique is safe and has the potential to allow therapeutic interventions in the defunctionalized stomach and duodenum, including ERCP.     

Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding

BACKGROUND: The development of wireless capsule endoscopy allows painless imaging of the small intestine. Its clinical use is not yet defined. The aim of this study was to compare the clinical efficacy and technical performance of capsule endoscopy and push enteroscopy in a series of 50 patients with colonoscopy and gastroscopy negative gastrointestinal bleeding. METHODS: A wireless capsule endoscope was used containing a CMOS colour video imager, transmitter, and batteries. Approximately 50,000 transmitted images are received by eight abdominal aerials and stored on a portable solid state recorder, which is carried on a belt. Push enteroscopy was performed using a 240 cm Olympus video enteroscope. RESULTS: Studies in 14 healthy volunteers gave information on normal anatomical appearances and preparation. In 50 patients with gastrointestinal bleeding and negative colonoscopy and gastroscopy, push enteroscopy was compared with capsule endoscopy. A bleeding source was discovered in the small intestine in 34 of 50 patients (68%). These included angiodysplasia (16), focal fresh bleeding (eight), apthous ulceration suggestive of Crohn's disease (three), tumour (two), Meckel's diverticulum (two), ileal ulcer (one), jejunitis (one), and ulcer due to intussusception (one). One additional intestinal diagnosis was made by enteroscopy. The yield of push enteroscopy in evaluating obscure bleeding was 32% (16/50). The capsule identified significantly more small intestinal bleeding sources than push enteroscopy (p<0.05). Patients preferred capsule endoscopy to push enteroscopy (p<0.001). CONCLUSIONS: In this study capsule endoscopy was superior to push enteroscopy in the diagnosis of recurrent bleeding in patients who had a negative gastroscopy and colonoscopy. It was safe and well tolerated.     

Overview of upcoming advances in colonoscopy

Although colonoscopy is a very commonly carried out procedure, it is not without its problems, including a risk of perforation and significant patient discomfort, especially associated with looping formation. Furthermore, looping formation may prevent a complete colonoscopy from being carried out in certain patients. The conventional colonoscope has not changed very much since its original introduction. We review promising technologies that are being promoted as a way to address the problems with current colonoscopy. There are some methods to prevent looping formation, including overtube, variable stiffness, computer-guided scopes, Aer-O-Scope, magnetic endoscopic imaging and the capsule endoscope. In recent years, with the progress of microelectromechanical and microelectronic technologies, many biomedical and robotic researchers are developing autonomous endoscopes with miniaturization of size and integration functionality that represent state of the art of the micro-robotic endoscope. The initial results by using aforementioned methods seem promising; however, there are some conflicting reports of clinical trials with the overtube colonoscope, the computer-guided scope and the variable stiffness colonoscope. There are also some limitations in the use of the Aer-o-scope and the capsule endoscope. The autonomous endoscope is based on a self-propelling property that is able to avoid looping completely. This novel technology could potentially become the next generation endoscope; however, there are still critical techniques to be approached in order to develop the effective and efficient novel endoscope.     

Diagnostic value of push-type enteroscopy: a report from India

OBJECTIVE: We sought to assess the diagnostic value of push-type enteroscopy in relation to indications. METHODS: Ninety-nine consecutive patients (mean age, 42+/-15 yr; 65 men) with suspected small bowel disorders underwent push enteroscopy. The indications were chronic diarrhea (n = 54), obscure gastrointestinal (GI) bleeding (n = 21), abdominal pain (n = 10), abnormal radiological studies of small bowel (n = 5), iron deficiency anemia (n = 5), and others (n = 4). Push enteroscopy was performed using the Olympus SIF-10 (160-cm) enteroscope. RESULTS: Endoscopic examination of the jejunum was successful in all the patients, except one with a distal duodenal stricture. The length of the jejunum examined ranged from 10 to 70 cm. The time taken to complete the procedure varied from 2 to 30 min. Lesions were found in nine (42.8%) patients with obscure GI bleeding; six (28.5%) had worms (Ascaris lumbricoides [n = 3], Ankylostoma duodenale [n = 3]) in the jejunum, producing multiple erosions and bleeding points. In the chronic diarrhea group, a diagnosis was made in 13 (24%) patients on enteroscopic visualization and jejunal histology: celiac disease (n = 6), tropical sprue (n = 3), Crohn's disease (n = 1), secondary lymphangiectasia (n = 1), strongyloidiasis (n = 1), and nodular lymphoid hyperplasia with giardiasis (n = 1). In patients with abdominal pain, enteroscopy provided a diagnosis in one (10%) patient. No positive diagnosis could be made on enteroscopy in patients with iron deficiency anemia and abnormal radiological studies of small bowel. CONCLUSION: Push-type enteroscopy is a useful test in the evaluation of patients with obscure GI bleeding and chronic diarrhea. In developing countries, in patients with obscure GI bleeding, the presence of worms in the jejunum is an important finding on enteroscopy. Tropical sprue, giardiasis, and strongyloidiasis are distinct findings in patients with chronic diarrhea in the present series.     

双气囊电子小肠镜临床应用初探

目的探讨小肠疾病检查新方法——双气囊电子小肠镜的操作、诊断效果、适应证等问题。方法应用双气囊电子小肠镜对13例疑诊小肠疾病的患者进行双气囊小肠镜检查。分别从口侧或肛侧进镜，利用外套管、内镜前端的双气囊交替充气、放气和交替滑进，推进小肠镜进入小肠检查。记录检查范围、时间、耐受性及病变等。结果13例患者共行小肠镜检查19例次(11例次接受了口侧进镜，8例次接受了肛侧进镜)，每侧进镜术程平均80min。从口侧进镜均达第3～6组小肠，从肛侧进镜达4～6组小肠。发现空肠良性问质瘤1例、空肠淋巴瘤1例、回肠溃疡狭窄及憩室2例、空肠息肉2例、空肠糜烂2例。口侧进镜患者，术中多数出现恶心、消化液自口及外滑管口溢出，偶尔出现一过性轻微腹痛；肛侧进镜患者无明显不适及反应；未出现出血、穿孔等并发症。结论双气囊小肠镜是一种新型小肠疾病检查手段，平均2～3h可检查完所有小肠，进镜迅速。于操作直视下观察病变，通过活检对病变进行定性检查。病变检出率明显优于小肠钡剂造影，具有安全、可控性、直视、图像清晰等优点，适用于无肠粘连及严重脏器功能不全的小肠疾病患者。     

Push enteroscopy in the era of capsule endoscopy

GOALS: To evaluate the diagnostic yield of push enteroscopy in relation to indication and compare the yield in patients who had capsule endoscopy followed by push enteroscopy against capsule endoscopy naive patients. BACKGROUND: With the advent of capsule endoscopy the role of push enteroscopy needs to be reevaluated. STUDY: Patients who underwent push enteroscopy from January 2002 to May 2006 were included. RESULTS: One hundred fifty-five patients underwent push enteroscopy: 93 females, average age 55 years. There were 74 cases where both push enteroscopy (PE) and capsule endoscopy (CE) were performed. Indications for PE were iron deficiency anemia (n=51), overt bleeding (n=31), suspected celiac disease (n=32), refractory celiac disease (n=19), assessment for Crohn's disease (n=10), and miscellaneous (n=12). In 148 patients, an average length of 70 cm of small bowel was examined (range 30 to 130 cm). PE was unsuccessful in 7 patients due to anatomic strictures or patient distress. The overall diagnostic yield was 30% with the highest yield in overt bleeding when compared with other subgroups (P<0.001). Nine percent of lesions were within the reach of a standard endoscope. Comparison of the diagnostic yield in patients who had CE followed by PE against CE naive patients was 41% versus 47%, respectively (P<1). There were no cases where push enteroscopy recognized a lesion that had not been already detected by capsule endoscopy. CONCLUSIONS: Push enteroscopy has the greatest diagnostic yield in patients with overt bleeding when compared with other referral indications. PE should be used as an adjuvant to CE for therapeutic intervention.     

Small bowel enteroscopy

For the examination of the small bowel in patients with suspected small bowel bleeding, endoscopic tools to perform deep enteroscopy have become essential. Double balloon enteroscopy has gained worldwide acceptance as an endoscopic technique that can be used safely and effectively to provide complete examination of the small bowel, offer therapeutic intervention, and favorably affect clinical outcomes. Single balloon enteroscopy seems to have utility similar to that of the double balloon system. Preliminary experience with a novel overtube device using either the single or double balloon enteroscope has suggested that this may be a very viable approach to deep enteroscopy. Collectively, these are remarkable innovations that allow access to portions of the small bowel that were previously only available by intraoperative enteroscopy or laparotomy. On the basis of the available data, each of these procedures seems to have unique merits, is generally safe and well tolerated, and is highly likely to be clinically beneficial.     

Factors associated with reduced insertion depth at double balloon enteroscopy: A retrospective,multivariate analysis

Background

Deep small bowel insertion during double balloon enteroscopy can be difficult to achieve.

Aims

To determine the factors influencing depth of insertion during double balloon enteroscopy.

Methods

History of abdomino-pelvic surgery, route of insertion, type of enteroscope, age, sedation or general anaesthesia used and gender were considered as potential influencing factors; procedures were categorised accordingly and maximal depth of insertion calculated.

Results

At multivariate analysis, maximal depth of insertion was significantly associated with history of abdominal-pelvic surgery (P < 0.001), rectal approach (P = 0.011), gender (P = 0.02) and use of the therapeutic enteroscope (P = 0.047). Mean maximal depth of insertion was 266 ± 12 cm, 255 ± 9 cm (P = 0.50), 197 ± 10 cm (P < 0.0001), 160 ± 12 cm (P < 0.01) and 103 ± 33 cm (P < 0.15) when 0, 1, 2, 3 and 4 influencing factors were present, respectively.

Conclusion

Maximal depth of insertion was significantly influenced by history of abdomino-pelvic surgery, insertion route, gender and type of enteroscope used.     

Hyperamylasemia and pancreatitis following spiral enteroscopy

BACKGROUND

Acute pancreatitis is a significant potential complication with double-balloon enteroscopy. Hyperamylasemia is frequently observed after both double-balloon enteroscopy and single-balloon enteroscopy but often without associated pancreatitis. Whether the same phenomenon occurs with spiral enteroscopy is currently unknown.

AIMS:

To determine the incidence of pancreatitis and hyperamylasemia following spiral enteroscopy.

METHODS:

A prospective cohort study of consecutive patients undergoing proximal spiral enteroscopy was conducted. Serum amylase levels were measured immediately before and following the procedure, combined with observation for clinical signs of pancreatitis.

RESULTS:

A total of 32 patients underwent proximal spiral enteroscopy, with a mean total procedure time of 51 min (range 30 min to 100 min) and mean depth of insertion of 240 cm (range 50 cm to 350 cm). The diagnostic yield was 50%, with 31% of all procedures being therapeutic. While no patients exhibited signs that raised suspicion of pancreatitis, hyperamylasemia was common (20%). Hyperamylasemia was not significantly associated with procedure duration or depth of insertion but was linked to patients with Peutz-Jeghers syndrome and with the use of propofol sedation, suggesting that it may be more common in difficult cases.

CONCLUSIONS:

Postprocedural hyperamylasemia occurred frequently with proximal spiral enteroscopy, while no associated pancreatitis was observed. This finding suggests that hyperamylasemia may not necessarily reflect pancreatic injury nor portend a risk for pancreatitis.     

Spiral enteroscopy for therapeutic ERCP in patients with surgically altered anatomy: actual technique and review of the literature

Background

Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures are difficult to perform in patients with surgically altered anatomy. Recently, balloon enteroscopy (BE) has made it easier to perform ERCP in these patients. However, BE-assisted ERCP is often technically demanding and time consuming.

Methods

Spiral enteroscopy (SE), which has recently been developed, is a novel method of using a rotating overtube to pleat small bowel onto the enteroscope, thus advancing it through the lumen. We review the mechanism and efficacy of SE, especially in ERCP of patients with surgically altered anatomy, and report on the first patient to undergo ERCP using SE in Japan.

Results

Spiral enteroscopy-assisted ERCP seems to be feasible and safe in patients with surgically altered anatomy. Additionally, SE-assisted ERCP appears to be easier to perform than other methods previously described and allows stable positioning of the enteroscope in order to perform delicate therapeutic maneuvers.

Conclusions

SE for ERCP is expected to be at least as useful as balloon enteroscopy in patients with surgically altered anatomy.     

Enteroscopy

Wireless capsule endoscopy and double-balloon endoscopy are new methods of enteroscopy that have been introduced in recent years. Wireless capsule endoscopy is an epoch-making examination method that makes possible an endoscopic imaging examination of the entire small intestine without discomfort and without confining patients to a medical facility. Although it is expected to be useful as an initial examination for finding diseases of the small intestine, it cannot be used for biopsy or treatment. One risk associated with the capsule endoscopy technique is entrapment by strictures. Double-balloon endoscopy is based on a new insertion technique in which two balloons, one at the distal end of the endoscope and the other at the distal end of an overtube, are operated in combination, and the endoscope is inserted while simultaneously shortening the intestine. It can be inserted through either the mouth or the anus, allowing the observation of the entire gastrointestinal tract. It features excellent maneuverability even in the distal small intestine, and enables back-and-forth observation, biopsy, and endoscopic treatment at any given site. These two new enteroscopy techniques are expected to lead to innovations in how diseases of the small intestine are approached.