Endoscopy 2010; 42(6): 517
DOI: 10.1055/s-0029-1244084
Letters to the editor

© Georg Thieme Verlag KG Stuttgart · New York

First cases of spiral enteroscopy in the UK: let's “torque” about it!

E.  J.  Despott1 , S.  Hughes2 , P.  Marden2 , C. Fraser1
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Further Information

Publication History

Publication Date:
26 May 2010 (online)

We read with interest the paper by Buscaglia et al. entitled “The spiral enteroscopy training initiative: results of a prospective study evaluating the Discovery SB overtube device during small bowel enteroscopy” [1] and subsequent letter and reply from Riccioni et al. [2] and Akerman et al. [3], respectively.

We have also prospectively recorded our initial experience (from November 2008) of the first 22 cases of spiral enteroscopy in the UK. These were carried out at two tertiary referral centers by endoscopists who were well experienced in double-balloon enteroscopy (DBE). The first 11 procedures were done under the supervision of two visiting expert spiral enteroscopists and the subsequent 11 were performed “solo.” The mean age of patients was 58 years (range 19 – 81 years). Twelve procedures were carried out under general anesthesia and the remainder were under conscious sedation. In 13 procedures carbon dioxide was the insufflating gas and air was used in the rest. The most common indication was suspected mid-intestinal bleeding (n = 16); other indications were small-bowel polyposis in the setting of Peutz-Jeghers syndrome (PJS) (n = 5) and direct percutaneous endoscopic jejunostomy feeding tube replacement (n = 1).

We found a number of positive aspects of spiral enteroscopy.

Spiral enteroscopy was considered to be technically easier to learn compared with DBE. The mean duration of the spiral enteroscopy procedures was relatively short at 42 ± 12 minutes (insertion and withdrawal). This was more favorable than our mean time for DBE (75 ± 22 minutes), which we recently reported at Gastro 2009 (United European Gastroenterology Federation and World Gastroenterology Organization [UEGW/WCOG]) 4. Carrying out therapeutic procedures, particularly argon plasma coagulation for proximal small-bowel angioectasias, was very satisfying due to the stability of the endoscopic view provided by the overtube. Controlled withdrawal of the enteroscope through the small bowel with good visualization was possible during counter-clockwise rotation of the overtube. Trauma scores 1 were low: all cases scored 1 (edema/erythema) at the ligament of Treitz and the esophagus. Only one case scored 2 for jejunal submucosal bruising induced during insertion and the patient remained well after the procedure. Insertion distance was impressive in some cases: in one patient, when the spiral engaged the small bowel throughout, the enteroscope was advanced to the cecum, achieving unidirectional pan-enteroscopy in 65 minutes. To our knowledge, this case, which was performed at the Bristol center, is the first case of complete enteroscopy by spiral enteroscopy to be reported in the literature to date.

What are the possible current limitations of spiral enteroscopy? Despite our case of pan-enteroscopy, which is impressive and significant, deep spiral enteroscopy insertion may still be difficult to achieve because of the inability of the spiral to engage the small bowel at times. The reason for this is multifactorial and probably represents the steepest part of the learning curve. Engagement can be encouraged or prolonged by interventions such as the Cantero maneuver, the “over the scope” maneuver [1] [5] [6], and abdominal counter pressure applied by an assistant. Interestingly for two patients requiring repeat enteroscopy, spiral enteroscopy was unable to reach the small bowel tattoos placed at previous oral and rectal DBE, respectively. In another patient, spiral enteroscopy failed to reach a proximal ileal PJS polyp seen at magnetic resonance enterography, which was subsequently located and removed by oral DBE during the same session. Two of these three patients had undergone previous small-bowel surgery and it is possible that the presence of small-bowel adhesions was the limiting factor in preventing deeper enteroscopy by spiral enteroscopy.

We found estimating the insertion depth to be challenging and therefore described the final position of the enteroscope as either proximal or distal jejunum or ileum, according to a subjective element of insertion depth and small-bowel morphology. Distance estimation appears easier and fairly accurate with DBE using the May method [7].

Other questions relate to the effectiveness of spiral enteroscopy insertion via the rectal route, as at present deep insertion of the distal small bowel has not been reported. This is relevant because the ability to achieve pan-enteroscopy is increasingly useful. Dr Akerman’s demonstration during a satellite symposium at Gastro 2009 of a prototype self-propelled spiral enteroscopy is exciting and we wait with interest for news of further developments.

In conclusion, our initial UK experience with spiral enteroscopy suggests that spiral enteroscopy is easy to learn. When small-bowel engagement readily occurs, spiral enteroscopy can achieve deep small-bowel intubation in a relatively short time. Spiral enteroscopy is safe and provides a stable platform for both therapy and examination of the small bowel during withdrawal. Comparative studies of spiral enteroscopy with balloon-assisted enteroscopy are needed.

Competing interests: None

References

  • 1 Buscaglia J M, Dunbar K B, Okolo P I. et al . The spiral enteroscopy training initiative: results of a prospective study evaluating the Discovery SB overtube device during small bowel enteroscopy (with video).  Endoscopy. 2009;  41 194-199
  • 2 Riccioni M E, Cianci R, Spada C, Costamagna G. Use of spiral enteroscopy in a tertiary endoscopy center: initial experience.  Endoscopy. 2009;  41 820
  • 3 Akerman P, Cantero D. Reply to Riccioni et al.  Endoscopy. 2009;  41 820
  • 4 Despott E J, Hughes S, Deo A. et al . Expanding the international double balloon enteroscopy experience; first results from the UK multi-centre DBE registry.  Endoscopy. 2009;  41 Suppl 1 A232
  • 5 Akerman P A, Agrawal D, Cantero D, Pangtay J. Spiral enteroscopy with the new DSB overtube: a novel technique for deep peroral small-bowel intubation.  Endoscopy. 2008;  40 974-978
  • 6 Akerman P A, Cantero D. Spiral enteroscopy and push enteroscopy.  Gastrointest Endosc Clin N Am. 2009;  19 357-369
  • 7 May A, Nachbar L, Schneider M. et al . Push-and pull enteroscopy using the double-balloon technique: method of assessing depth of insertion and training of the enteroscopy technique using the Erlangen Endo-Trainer.  Endoscopy. 2005;  37 66-70

E. J. DespottMD 

The Wolfson Unit for Endoscopy
St Mark’s Hospital and Academic Institute, Imperial College London

Watford Road
London
HA1 3UJ
UK

Fax: +44-208-4233588

Email: edespott@doctors.org.uk

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