Initial Experience Using a Rotational Overtube System (ROS) in the Retrograde Examination of the Small Bowel

Abstract

Purpose: Direct examination of the distal small bowel is limited with conventional colonoscopy and antegrade enteroscopy techniques. We report our experience using a rotational overtube system (ROS) for examination of the distal small bowel using the retrograde approach. Methods: Patients in need of direct visualization of the distal small bowel underwent retrograde examination following a standard colonoscopy prep using the Spirus Endo-Ease Vista® ROS (Spirus Medical, Stoughton, MA), a 90 cm overtube with a raised spiral on the distal end, with either a pediatric colonoscope or a standard enteroscope. The system was introduced per rectum and intubation of the terminal ileum was attempted once in the cecum. The ROS was then used to splint and advance the endoscope per manufacturer recommendations. Results: Between 6/09 and 7/10, 8 patients (4F, mean age 48±16y) underwent 9 retrograde small bowel exams using the ROS. Indications included obscure-overt GI bleeding (n=4, 44%), suspected small bowel tumor (n=3, 33%), foreign body (n=1, 11%) small bowel stricture/obstruction (n=2, 22%). Some patients had multiple indications. Prior evaluation included CT scan (n=4, 44%), capsule endoscopy (n=3, 33%), antegrade overtube-assisted enteroscopy (n=6, 67%), colonoscopy (n=7, 78%), barium enema (n=1, 11%). Retrograde enteroscopy was performed immediately following antegrade enteroscopy in the same session in 4 (44%). Cecal intubation was achieved in 100%. Intubation of the terminal ileum was achieved in 8/9 procedures (89%). In one patient with GI bleeding, large cecal angiodysplasia was seen; repeated attempts at ileal intubation were not performed. Endoscopes used included a pediatric colonoscope (n=3, 33%) or a 260 cm enteroscope (n=6, 67%). Median length of examined ileum was 70 cm (range 0-100 cm). Findings included cecal angiodysplasia (n=1, 11%), small bowel angiodysplasia (n=1, 11%), ileal stricture (n=2, 22%), normal (n=4, 44%), foreign body not reached (n=1, 11%), ileal ulceration and edema (n=1, 11%). Colonic diverticulosis was found in one patient with obscure-overt bleeding which could represent the bleeding source. Therapeutic interventions performed included argon-plasma coagulation of angiodysplasia (n=2, 22%), balloon dilation of ileal stricture (n=2, 22%), and forceps biopsy (n=1, 11%). One minor complication of transient post-procedure hypoxia (not requiring intubation) occurred. Conclusion: 1. Retrograde enteroscopy using a rotational overtube system is safe and technically successful in the majority of patients in this initial experience. 2. Ileal intubation was achieved in most examinations. 3. In this small experience, the utility of retrograde enteroscopy for obscure GI bleeding was limited. 4. Larger experience is needed.