Failure of Capsule Transportation Due to Gastroparesis after Gastric Truncal Vagotomy

We read with interest the paper by Hollerbach et al. on ”Endoscopically assisted capsule endoscopy of the small bowel in patients with functional gastric outlet obstruction” [1].

We carried out a capsule endoscopy (CE) in a 66-year-old man with recurrent gastrointestinal bleeding, which in recent years had repeatedly led to a need for transfusions of several units of packed red cells. Thirty years previously, the patient had undergone several abdominal operations, including fundoplication and gastric truncal vagotomy, to treat severe reflux esophagitis and recurrent gastric and duodenal ulcers. Since that time, the patient had only been able to eat small amounts of food, probably due to delayed gastric emptying. Before CE, the patient underwent gastroscopy, enteroscopy, colonoscopy, and small-bowel magnetic resonance imaging; all of these investigations yielded negative results. CE was well tolerated. Surprisingly, the capsule video record showed a static picture of gastric folds for the entire recording period of 7 h 30 min (Figure [1] a). In addition, the patient did not excrete the capsule with 96 h after swallowing it. An abdominal radiograph showed that the capsule was still in the stomach area (Figure [1] b).

Figure 1 a Static capsule-endoscopic view of a gastric fold. b An abdominal radiograph showed that the capsule was still in the stomach region 96 h after the start of the examination.

The patient subsequently underwent gastroscopy; the capsule was found in the gastric antrum and captured with a polyp retrieval net (Figure [2]). Delayed gastric emptying and chronic gastroparesis are well-known postoperative complications associated with gastric truncal vagotomy. So far as we are aware, this is the first report of a capsule failing to pass beyond the stomach due to gastroparesis after gastric truncal vagotomy.

Figure 2 In the subsequent gastroscopy, the capsule was found in the gastric antrum and captured with a polyp retrieval net.

In general, the contraindications to capsule endoscopy include known or suspected gastrointestinal obstructions, strictures, and fistulas [2]. However, we would suggest that gastric vagotomy and suspected diabetic gastroparesis should be included as a relative contraindication to performing capsule endoscopy. To carry out a second CE in the same patient, we used a polypectomy snare to transport the capsule endoscope through the pylorus, as previously described by Hollerbach et al. [1]. Another potential approach has been described by Carey et al., who used an overtube and a net to guide the capsule into the duodenum [3]. This is a practicable technique to avoid aspiration of the capsule in patients with dysphagia [4] [5].

References

• 1 Hollerbach S, Kraus K, Willert J. et al . Endoscopically assisted video capsule endoscopy of the small bowel in patients with functional gastric outlet obstruction.  Endoscopy. 2003;  35 226-229
• 2 Barkin J S, O'Loughlin C. Capsule endoscopy contraindications: complications and how to avoid their occurrence.  Gastrointest Endosc Clin N Am. 2004;  14 61-65
• 3 Carey E J, Heigh R I, Fleischer D E. Endoscopic capsule endoscope delivery for patients with dysphagia, anatomical abnormalities, or gastroparesis.  Gastrointest Endosc. 2004;  59 423-426
• 4 Sinn I, Neef B, Andus T. Aspiration of a capsule endoscope.  Gastrointest Endosc. 2004;  59 926-927
• 5 Fleischer D E, Heigh R I, Nguyen C C. et al . Video capsule impaction at the cricopharyngeus: a first report of this complication and its successful resolution.  Gastrointest Endosc. 2003;  57 427-428