Spiral Enteroscopy: A Novel Tool to Investigate Lesions in the Small Bowel

Abstract

SymbolIntroduction: Lesions originating from the small bowel are difficult to evaluate and treat. The advent of VCE (video capsule endoscopy) has allowed for more efficient evaluation, but an effective treatment modality is still under investigation. We describe a case of a 75-yearold patient who presented with anemia and recurrent melenotic stools and had a negative EGD/colonoscopy. A VCE was placed, showing AVM’s in the small bowel. So he underwent a spiral enteroscopy, which showed one bleeding angioectasia in the small bowel that was successfully treated with argon plasma coagulation (APC). The patient was discharged home safely after he had no further episodes of melenotic stools and his hematocrit remained stable.SymbolMethods: Spiral enteroscopy uses a flexible over-tube threaded with a flexible plastic spiral to help grip the small bowel. Rotational torque is applied to help pull the small bowel over the overtube as the enteroscope advances. To begin, the lubricated overtube is inserted over the enteroscope until the end of the overtube is 25 cm from the tip of the enteroscope. Once locked at the proximal end, the overtube and enteroscope may be inserted by rotation into the esophagus while the patient is under anesthesia and in the lateral decubitus position. One operator steers, while the other applies rotational torque. Rotation is continued to advance the enteroscope into the duodenum to ‘engage’ the small bowel mucosa. Once the enteroscope is past the ligament of Treitz, rotation can be used to help pleat the small bowel over the enteroscope by using gentle rotational torque. This is continued as long the overtube rotates smoothly. If resistance is encountered, the apparatus can be unlocked and the enteroscope may be advanced forward without rotation. When ready for overtube withdrawl and small bowel inspection, slow counter clockwise rotation is used. Conclusion: Small bowel lesions are notoriously difficult to diagnose and treat. Spiral enteroscopy allows for efficient management of these lesions. The combination of a flexible distal end and rigid proximal end allows for effective transition of rotational motion into linear motion, and thus safe and accurate inspection of the small bowel. The spiraling technique has advantages over other enteroscopy techniques in terms of speed of small bowel intubation but still with similar diagnostic yields. It allows for easier operator control on insertion and upon withdrawal, and provides a stable platform for therapeutics. This allows for effective therapeutic maneuvers such as biopsy, APC, stent placement, foreign body removal, and piece-meal polypectomy. Overall, spiral enteroscopy is a safe procedure with complications occurring only in 0.3-4% of cases Disclosure - Dr Cave- Consultant for Olympus Corporation.