Initial Application of the ShapeLock™ Endoscopic Guide for Small Bowel Enteroscopy

Abstract

Background: Currently small bowel enteroscopy (SBE) is limited by loss of vector forces and curling of scope within the stomach. Attempts to overcome these limitations have led to widespread application of capsule endoscopy (CE), development of double-balloon enteroscopy (DBE), and use of conventional overtubes. CE is limited by inability to undertake endotherapy. DBE requires a significant capital expenditure. Conventional overtubes prove difficult to get through the pylorus and have been associated with inadvertent strip mucosectomy and even procedural pancreatitis from damage to the papilla. A shape-locking guide, developed for difficult colonoscopy, (USGI Medical, San Clemente, CA) was adapted for SBE and utilized clinically in patients with small bowel disorders in whom no diagnosis/treatment was noted with capsule and/or conventional SBE. Materials and Methods: A 54 Fr. ShapeLock™ (SL) device, 80 or 100 cm was used investigationally in conjunction with an Olympus pediatric colonoscope (2 patients) or SB enteroscope (6 patients), respectively. Conscious sedation was achieved with Demerol/Fentanyl and Versed. After initial scope passage into the ligament of Trietz, the SL was passed under fluoroscopic control through the pylorus and locked in place within the C-loop to prevent scope looping. Subsequent scope and SL passage to definable pathology or the limits of the scope length were undertaken using push and pull maneuvers with and without unlocking and advancement of the SL. Results: The SL was placed beyond the pylorus in 5/8 patients aged 32-85 years. Two of the three remaining patients had surgically altered anatomy eliminating the pylorus. The enteroscope/pediatric colonoscope could be advanced into the terminal ileum in 1 patient, mid to distal jejunum in 5 patients, and proximal to mid-jejunum in another two. Bleeding sites were found in 4/6 patients (3 subsequently treated with heater probe), an anastomotic stenosis in 1, and inactive IBD in another. An SL related proximal esophageal abrasion was seen in 3 patients, a non-significant cricopharyngeal tear in 1, and minor pyloric abrasions in 2 patients. An asymptomatic Mallory-Weiss tear was seen in another patient. Conclusions: 1) A ShapeLock™ Endoscopic Guide has been developed that precludes scope looping in the stomach and appears to facilitate SB enteroscopy. 2) Further studies are required to define safety of the ShapeLock™ and its role relative to CE and DBE. Background: Currently small bowel enteroscopy (SBE) is limited by loss of vector forces and curling of scope within the stomach. Attempts to overcome these limitations have led to widespread application of capsule endoscopy (CE), development of double-balloon enteroscopy (DBE), and use of conventional overtubes. CE is limited by inability to undertake endotherapy. DBE requires a significant capital expenditure. Conventional overtubes prove difficult to get through the pylorus and have been associated with inadvertent strip mucosectomy and even procedural pancreatitis from damage to the papilla. A shape-locking guide, developed for difficult colonoscopy, (USGI Medical, San Clemente, CA) was adapted for SBE and utilized clinically in patients with small bowel disorders in whom no diagnosis/treatment was noted with capsule and/or conventional SBE. Materials and Methods: A 54 Fr. ShapeLock™ (SL) device, 80 or 100 cm was used investigationally in conjunction with an Olympus pediatric colonoscope (2 patients) or SB enteroscope (6 patients), respectively. Conscious sedation was achieved with Demerol/Fentanyl and Versed. After initial scope passage into the ligament of Trietz, the SL was passed under fluoroscopic control through the pylorus and locked in place within the C-loop to prevent scope looping. Subsequent scope and SL passage to definable pathology or the limits of the scope length were undertaken using push and pull maneuvers with and without unlocking and advancement of the SL. Results: The SL was placed beyond the pylorus in 5/8 patients aged 32-85 years. Two of the three remaining patients had surgically altered anatomy eliminating the pylorus. The enteroscope/pediatric colonoscope could be advanced into the terminal ileum in 1 patient, mid to distal jejunum in 5 patients, and proximal to mid-jejunum in another two. Bleeding sites were found in 4/6 patients (3 subsequently treated with heater probe), an anastomotic stenosis in 1, and inactive IBD in another. An SL related proximal esophageal abrasion was seen in 3 patients, a non-significant cricopharyngeal tear in 1, and minor pyloric abrasions in 2 patients. An asymptomatic Mallory-Weiss tear was seen in another patient. Conclusions: 1) A ShapeLock™ Endoscopic Guide has been developed that precludes scope looping in the stomach and appears to facilitate SB enteroscopy. 2) Further studies are required to define safety of the ShapeLock™ and its role relative to CE and DBE.