SMALL BOWEL ENTEROSCOPY

Dr CC FooQueen Mary HospitalJoint Hospital Surgical Grand Round24-10-2009

SMALL BOWEL ENTEROSCOPY Small bowel represent the last frontier to be

explored with endoscopic means Difficulties caused by its relatively long length

and tortuosity

SMALL BOWEL ENTEROSCOPY 5% of all GI bleeding occurs between the

ligament of Treitz and ileocaecal valve

DiSario J et al. Enteroscopes - technology status evaluation report. Gastrointest Endosc 2007; 66(5): 872–80

SMALL BOWEL ENTEROSCOPY Small bowel pathologies

AngiodysplasiaMeckel’s diverticulaNSAID related enteropathyBenign or malignant tumour

SMALL BOWEL ENTEROSCOPY Push enteroscopy Double balloon enteroscopy (DBE) Single balloon enteroscopy (SBE) Spiral enteroscopy Capsule endoscopy

SMALL BOWEL ENTEROSCOPY Indications:

GI bleeding of obscure origin Chronic diarrhoea Malabsorptive syndrome Chronic abdominal pain

Therapeutic application: Foreign body removal Mucosal resection Insertion of SEMS Dilatation of stricture in Crohn’s disease ERCP after Billroth II or Roux-en-Y reconstruction or after bariatric

surgery

1807Bozzini :‘Lichtleiter’Comprised of wax candle, reflecting mirror and inspection tube

1957Hirshowitz: First flexible fiber endoscope

1970sClinical use of colonoscopy and upper endoscopy

1987Push enteroscocpy

2000Capsule endoscopy

1977Tada :Sonde enteroscope

2001Yamamoto:Double balloon enteroscopy

2006Otsuka:Single balloon enteroscopy

2007Akerman:Spiral endoscopy

ENDOSCOPY TIMELINE

SONDE ENTEROSCOPY

Described by Tada in 1977 Sonde enteroscopy Working length of 250-400cm Propelled by small bowel peristalsis Lack of working channel and prolonged

examination time

PUSH ENTEROSCOPY

Performed with a dedicated enteroscope with an overtube

Method:Overtube loaded onto the enteroscopeEnteroscope enter the proximal jejunumOvertube pushed into the 3rd part of duodenum and

held by assistantEnteroscope proceed to advance into the jejunum

Depth of insertion: 40 to 100cm past ligament of Treitz

DOUBLE BALLOON ENTEROSCOPY (DBE) Developed by Yamamoto in

2001 Manufactured by the Fujinon,

Inc, Saitama, Japan

DOUBLE BALLOON ENTEROSCOPY High resolution video

endoscope Working length of 200cm Flexible overtube Latex balloons at the tipe

of the enteroscope and on the overtube

DOUBLE BALLOON ENTEROSCOPY Serial inflation and

deflation of balloons with air by the pressure-controlled pump

Alternating pushing and pulling maneuvers

Allowing the small bowel to be threaded onto the overtube

Matsumoto et al. Am J Roentgenol 2008

DOUBLE BALLOON ENTEROSCOPY

The Wolfson Unit for EndoscopySt Mark's Hospital, UK

DOUBLE BALLOON ENTEROSCOPY Antegrade (oral) and

retrograde (anal) approach could achieve total small bowel examination

Fluoroscopy can be used as an aid

SINGLE BALLOON ENTEROSCOPY (SBE) Developed by Ohtsuka in

2007 Manufactured by Olympus,

Inc, Tokyo, Japan

Working length of 200cm Outer diamter of 9.2mm Working channel 2.8mm Overtube overall length

140cm Latex free balloon

SINGLE BALLOON ENTEROSCOPY In contrast to DBE, balloon

is not attached to the tip of the enteroscope

Stable positioning in the small bowel is achieved during withdrawal of the scope by angling the tip of the endoscope

SINGLE BALLOON ENTEROSCOPY

SPIRAL ENTEROSCOPY

Described by Dr Akerman First performed in 2006 Applies the mechanical advantage of a screw to

convert rotational force into linear one Currently more than 2000 cases have been

performed worldwide

SPIRAL ENTEROSCOPY

Device: Discovery SB overtube Spirus CorporationOverall length 118cmOuter diameter 14.5mmAccomodates endoscope

<9.4mm diameter

SPIRAL ENTEROSCOPY Method

Overtube is backloaded on the enteroscopeAdvanced slowly with gentle clockwise rotation of the

overtube Spiral passes beyond the ligament of TreitzSpiral threads engage in the jejunum and mobile small

bowel can be rapidly pleated onto the enteroscope

SPIRAL ENTEROSCOPY

Spirus Medical

COMPLICATIONS OF SMALL BOWEL ENTEROSCOPY Mucosal stripping Pancreatitis Aspirations Bleeding Gastric, duodenal and jejunal perforations

Complication rate generally <1%

EXAMINATION TIMEStudy Patient no. Mean exam

time(min)

Type

Yamamoto Japan 2004 123 123 DBE

Di Caro Europe 2005 62 160 DBE

Heine Netherland 2006 275 200 DBE

Mehdizadeh US 2006 188 197 DBE

Gross and Stark US 2008 137 197 DBE

Tsujikawa Japan 2008 41 (78 procedures) 133 SBE

Ramchandani India 2009 106 (131 procedures)

137 SBE

Akerman US 2008 101 17 Spiral

Esmail US 2009 57 28 Spiral

Morgan US 2009 148 34 Spiral

DEPTH OF INSERTIONStudy Patient no. Mean

depth Oral (cm)

Mean depthAnal (cm)

Type

Di Caro Europe 2005 62 254 180 DBE

Heine Netherland 2006 275 270 156 DBE

Mehdizadeh US 2006 188 360 183 DBE

Gross and Stark US 2008 137 220 124 DBE

Tsujikawa Japan 2008 41 (78 procedures)

270 SBE

Ramchandani India 2009 106 (131 procedures)

255 163 SBE

Akerman US 2008 75 249 Spiral

Esmail US 2009 57 246 Spiral

Morgan US 2009 148 250 Spiral

DIAGNOSTIC YIELDStudy Patient no. Yield

(%)Therap

y(%)

Type

Yamamoto Japan 2004 123 76 18 DBE

Di Caro Europe 2005 62 80 42 DBE

Heine Netherland 2006 275 73 55 DBE

Mehdizadeh US 2006 188 43 27 DBE

Gross and Stark US 2008 137 80 45 DBE

Tsujikawa Japan 2008 41 (78 procedures)

54 SBE

Ramchandani India 2009 106 (131 procedures)

61 8.4 SBE

Akerman US 2008 75 24 13 Spiral

Esmail US 2009 57 51 Spiral

COMPLETE SMALL BOWEL EXAMINATIONStudy Patient no. Complete

examination%

Type

Yamamoto Japan 2004 123 86 DBE

Di Caro Europe 2005 62 16 DBE

Heine Netherland

2006 275 42 DBE

Mehdizadeh US 2006 188 4 DBE

Gross and Stark US 2008 137 20 DBE

Tsujikawa Japan 2008 24 25 SBE

Ramchandani India 2009 20 25 SBE

CONCLUSION

Advances in small bowel enteroscopy facilitate diagnosis and management of small bowel lesions

Histological sampling and therapeutic endoscopies are made possible

Results of different enteroscopies are yet to be revealed by future clinical trials