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The return of the helix: an evaluation of motorized spiral enteroscopy in actual daily clinical practice; a few points to “torque” about and ponder upon…Referring to Al-Toma A et al. pp. 1034–1042
Although Akerman et al. first reported on the concept of motorized spiral enteroscopy (MSE) over a decade ago , it has only recently been introduced into actual clinical practice  and our understanding of its safety and performance is still being fine-tuned. In this issue of Endoscopy, Al-Toma et al., from the Netherlands, report on their multicenter prospective uncontrolled study in a “real-world” setting, with a focus on performance and safety in “all-comers,” including patients with a previous history of surgery and altered anatomy . Their study included 170 patients, with a median age of 64 years. The primary end points were the diagnostic and therapeutic yields (in patients with suspected small-bowel pathology on pre-enteroscopy imaging) and overall safety, as measured by adverse events. The diagnostic and therapeutic yields were 64.1 % and 53.5 %, respectively. Median procedure durations were 45 and 40 minutes for antegrade and retrograde MSE procedures, respectively. Panenteroscopy was achieved in 70.3 % of patients in whom it was attempted, warranting a bidirectional approach in 42.1 %. Of the whole cohort, 34 patients had post-surgical altered small-bowel anatomy (20 %). Altered anatomy was present in 11 of the 45 patients (24.4 %) in whom panenteroscopy was achieved. There were no differences in any of the outcomes in the nonsurgical and surgical subgroups. The authors reported that no major adverse events (defined as perforation, bleeding warranting transfusion, pancreatitis, and unplanned hospital admission) occurred within 30 days of follow-up. Minor adverse events (defined as mucosal abrasion, superficial lacerations, self-limiting pharyngitis, abdominal discomfort, nausea, and vomiting) occurred in 15.8 %.
“Further large prospective comparative multicenter international studies are required to further evaluate the effectiveness and, especially, the safety of this novel technology to better understand its potential and respective role vis-à-vis the more established BAE in both academic and nonacademic centers.”
Despite this study’s recognized limitations, the authors are to be commended for their multicentric effort to commence the much required data collection process regarding the performance and safety of this newly introduced technology in actual day-to-day clinical practice, as well as in patients with a history of previous small-bowel surgery.
Although there is yet to be a direct comparison of MSE with the widely established balloon-assisted enteroscopy (BAE), which has been in daily clinical use for > 20 years, data from this paper and other studies on MSE   suggest that this may provide a more rapid, single-operator alternative to deep enteroscopy, with impressive panenteroscopy rates. The favorable safety profile of BAE is well recognized and is backed up by > 1400 peer-reviewed publications to date. In reflection of this, the European Society for Gastrointestinal Endoscopy (ESGE) benchmarks the acceptable adverse event rate at ≤ 1 % for purely diagnostic BAE, and ≤ 5 % for BAE with endotherapy .
With regards to MSE, the rates of adverse events, particularly those occurring in everyday clinical practice, are still being studied and understood. This subject is of particular importance, given the unique, unprecedented, motor-controlled spiral moiety that, through rotation, actively advances or withdraws the enteroscope through the lumen of the gastrointestinal (GI) tract. As has also been shown in multiple publications relating to manual spiral enteroscopy (MSE’s predecessor) that the process of “engagement” of the GI mucosa with the rotating spiral moiety (essential for advancement or withdrawal) may in itself frequently result in trauma   , the degree of which may be graded by the dedicated 5-point Buscaglia score (0, no trauma; 1, edema/erythema; 2, superficial hematoma/erosion; 3, superficial laceration; 4, deep laceration; 5, perforation), which is, in recognition of this frequent occurrence, specific to spiral enteroscopy .
Such spiral-related trauma, particular for this type of procedure, is also shown in the data presented by Al-Toma et al. . Although they did not grade it using the dedicated Buscaglia score, the authors reported small-bowel injury in 12 patients (deep mucosal tears [n = 4], submucosal hematoma [n = 2], and superficial mucosal abrasions [n = 6]). Perhaps a bit surprisingly, these four deep tears (Buscaglia 4) were not classified as serious adverse events by the authors, despite their definition of “minor adverse events” including only mucosal tears that were of just a superficial nature. The more recently published, very similar multicenter international prospective study by Beyna et al. , relating to 298 patients (all-comers in daily clinical practice), also reported a case of deep “mucosal and submucosal injury” (Buscaglia 4) of the esophagus, which warranted “prolonged” hospitalization, as well as a case of small-bowel perforation (Buscaglia 5) that required surgery.
Another crucial and important point that should be borne in mind, which is specific to antegrade MSE, relates to the interaction of the raised spiral-moiety with the patient’s upper esophageal sphincter and esophagus. In their series, Al-Toma et al.  elected not to predilate the upper esophageal sphincter with a bougie (as previously described  ), but alternatively avoided esophageal injury by aborting procedures where excessive resistance was encountered on insertion through the upper esophageal sphincter (n = 2). However, deep esophageal laceration (Buscaglia 4) from impaction of the spiral overtube in the upper esophagus on withdrawal (despite no resistance on insertion) has also been reported , and clinicians should be alerted to this potential risk. Although Al-Toma et al. showed no differences in adverse events among patients who had undergone previous surgery, when compared with those who had not, clinicians should also be aware of the theoretical risk of similar spiral-impaction issues occurring in the context of stenotic areas of the small bowel (e. g. as caused by post-surgical adhesions).
Again, Al-Toma et al. are to be commended for initiating this important data collection on the performance and safety of MSE in routine daily clinical practice. Further large prospective comparative multicenter international studies are required to further evaluate the effectiveness and, especially, the safety of this novel technology to better understand its potential and respective role vis-à-vis the more established BAE in both academic and nonacademic centers.
Article published online:
08 July 2022
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