Intra-operative fibreoptic enteroscopy for bleeding lesions in the small intestine

Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations

BACKGROUND

Double-balloon enteroscopy (DBE) is a new endoscopic tool that not only allows diagnostic workup of small bowel diseases, but also makes it possible to carry out therapeutic interventions. However, for a variety of reasons, endoscopic therapy appears to be more difficult to carry out deep in the small bowel than in the upper or lower gastrointestinal tract.

AIM

The purpose of this study was to evaluate the acute technical success and acute complication rate of DBE.

PATIENTS

Between June 2003 and July 2006, 353 patients (152 women, 201 men; mean age 60.3 +/- 17.1 yr) with suspected or known small bowel disease underwent 635 consecutive DBE procedures. The majority of the patients were suffering from midgastrointestinal bleeding (N = 210, 60%). The overall diagnostic yield was 75% (265/353) for relevant lesions in the small bowel. The overall therapeutic yield was 67% (236/353).

METHODS

Endoscopic therapy was performed in 59% of these patients (139/236). All therapeutic interventions were done in an inpatient manner. The majority of the procedures were carried out with the patients under conscious sedation (N = 130, 73%); sedation with propofol was administered in 37 (20.8%) and with a combination of propofol and meperidine in 11 (6.2%) investigations.

RESULTS

A total of 178 therapeutic procedures was carried out. A median of 270 cm of the small bowel was visualized using the oral route and a median of 150 cm using the anal route. The investigation time averaged 78 +/- 30 minutes. The endoscopic treatments included argon plasma coagulation (APC, 102 treatment sessions), injection therapy (N = 2), a combination of APC and injection (N = 6), polypectomies (N = 46), dilation therapy (N = 18), and foreign-body extraction (N = 3). In 6/178 cases (3.4%), polypectomy (N = 2), dilation (N = 3), and implantation of a self-expanding metal stent (N = 1) could not be performed successfully for technical or anatomical reasons. Severe treatment-associated complications occurred in six of the 178 therapeutic procedures (3.4%) and 4/139 patients (2.9%), consisting of bleeding (N = 2) and perforation (N = 3) during and after polypectomy of large polyps (>3 cm in size), as well as one case of segmental enteritis after APC.

CONCLUSIONS

Endoscopic therapeutic interventions can be performed safely even in the more difficult conditions of the small bowel in the majority of patients. Polypectomy of large polyps appears to be the procedure associated with the highest risk.

Prospective comparison of push enteroscopy and push-and-pull enteroscopy in patients with suspected small-bowel bleeding

BACKGROUND AND AIMS

The management of patients with suspected mid-gastrointestinal bleeding has in the past been difficult, as push enteroscopy (PE) only allows limited endoscopic access for diagnosis and treatment. Recently published uncontrolled data on push-and-pull enteroscopy (PPE) using the double-balloon technique suggest that this new method has a high diagnostic yield and therapeutic efficacy. A prospective controlled study was therefore carried out to compare PPE with PE as the common nonsurgical gold standard method.

METHODS

The diagnostic yield, complications, and various examination parameters were compared in 52 consecutive patients with suspected mid-gastrointestinal bleeding who were evaluated with both enteroscopy methods.

RESULTS

No relevant complications were observed with either method. Sedoanalgesia, examination times, and X-ray exposure were lower with PE. The insertion depth was significantly greater with PPE than with PE (230 cm vs 80 cm, p < 0.0001). The overall diagnostic yield with PPE (38 of 52 patients, 73%) and the results of oral PPE only (33 of 52 patients, 63%) were superior to those with PE (23 of 52 patients, 44%; p < 0.0001). PPE identified additional lesions in deeper parts of the small bowel in PE-positive patients in 78% of cases (18 of 23 patients).

CONCLUSIONS

For endoscopic examination of the small bowel in patients with suspected mid-gastrointestinal bleeding, PPE is superior to PE with regard to the length of small bowel visualized, as well as the diagnostic yield. As the method also allows endoscopic treatment to be carried out, PPE should always be considered before open surgery and intraoperative endoscopy in patients with mid-gastrointestinal bleeding.

Intestinal intussusception and occlusion caused by small bowel polyps in the Peutz-Jeghers syndrome. Management by combined intraoperative enteroscopy and resection through minimal enterostomy: case report

The Peutz-Jeghers syndrome is a hereditary disease that requires frequent endoscopic and surgical intervention, leading to secondary complications such as short bowel syndrome.

CASE REPORT

This paper reports on a 15-year-old male patient with a family history of the disease, who underwent surgery for treatment of an intestinal occlusion due to a small intestine intussusception.

DISCUSSION

An intra-operative fiberscopic procedure was included for the detection and treatment of numerous polyps distributed along the small intestine. Enterotomy was performed to treat only the larger polyps, therefore limiting the intestinal resection to smaller segments. The postoperative follow-up was uneventful.

CONCLUSION

We point out the importance of conservative treatment for patients with this syndrome, especially those who will undergo repeated surgical interventions because of clinical manifestation while they are still young.

AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics committee. The paper was approved by the committee on May 16, 1999, and by the AGA governing board on July 18, 1999.

The role of angiography in the investigation of acute or chronic gastrointestinal haemorrhage

We have reviewed the clinical details and radiology of all patients with non-variceal gastrointestinal haemorrhage referred for angiography during an 8 year period. Forty-six patients with a history of overt bleeding had 49 technically satisfactory angiograms of which 29 were true positives but 16 were false negatives (sensitivity 64%, accuracy 63%). The accuracy of angiography in this group was much higher (92%) in those patients referred within 24 h of admission. Nine patients who had a history of iron-deficiency anaemia due to sub-acute blood loss had 9 angiograms. Five studies in this group were correct (two true negatives and three true positives) but there were four false positive studies. Angiography is an effective means of diagnosis in patients with acute gastrointestinal haemorrhage who have a negative endoscopy but best results will only be achieved when the study is performed with minimal delay following negative endoscopy. Angiography should also be considered in patients with continuing subacute blood loss when other investigations are negative.

Intra-operative enteroscopy in the management of bleeding small bowel lesions

This paper reviews the use of intra-operative enteroscopy at St Vincent's Hospital, Melbourne between 1982 and 1990 in the management of presumed small bowel bleeding. Intra-operative enteroscopy was found to be a moderately technically demanding procedure. The diagnostic yield in this small series of nine patients was 100%. When solitary small bowel lesions are identified, resultant directed therapy should prevent further bleeding. When multiple widespread angiodysplastic lesions are identified as occurred in three cases, the bleeding is difficult to cure.

Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding

The role and effectiveness of intraoperative enteroscopy in the evaluation of gastrointestinal (GI) bleeding of obscure origin is not clearly defined. Our aim was to determine if intraoperative enteroscopy is effective in identifying a source, which would lead to therapy and prevent recurrent gastrointestinal hemorrhage. Forty-four patients (median age: 64 years) underwent intraoperative enteroscopy. Median number of preoperative blood transfusions, duration of bleeding (months), and prior hospitalizations for GI hemorrhage were 19, 15, and 2, respectively. Many patients had risk factors associated with bleeding. All had undergone an extensive preoperative evaluation. Intraoperative enteroscopy was completely negative in 13 (30%). A site-specific source was seen in the small bowel in 31 patients (70%); 27 patients had lesions amenable to segmental resection with or without other means of definitive management. Only 6 of 31 patients (19%) had lesions that were actively bleeding. Twenty-three (52%) patients have had recurrent bleeding requiring transfusion (median follow-up: 21 months). Although intraoperative enteroscopy identified specific mucosal abnormalities in 70% of patients, the therapeutic efficacy in preventing recurrent hemorrhage was only 41%. Intraoperative enteroscopy is an effective tool in selected patients with occult GI bleeding and correctly identifies a treatable source and prevents recurrent bleeding in 41% of patients.

Detection of duodenal gastrinomas by operative endoscopic transillumination. A prospective study

The ability of operative endoscopic transillumination of the bowel wall to detect duodenal gastrinoma was evaluated prospectively in 26 patients with the Zollinger-Ellison syndrome. The results were assessed by exploratory laparotomy and compared with the results of other localization techniques. Twelve duodenal gastrinomas were resected from 10 patients. Operative endoscopic transillumination detected 10 of the 12 gastrinomas, a sensitivity of 83%, which was significantly greater (P less than 0.05) than that for either preoperative imaging (25%) or intraoperative ultrasonography and palpation (42%). The sensitivity of operative endoscopic transillumination was a result of the ability to detect focal areas that did not transilluminate on the serosal side of the duodenum, and not the mucosal appearances seen through the endoscope, which were not helpful. Operative endoscopic transillumination detected gastrinomas less than 1 cm in diameter throughout the duodenum. Of the patients in this study, 39% had duodenal gastrinomas, a greater frequency than previously reported. These results indicate that operative endoscopic transillumination is the most sensitive technique yet described for detecting duodenal gastrinomas and should be performed routinely in all patients with the Zollinger-Ellison syndrome who undergo exploratory laparotomy for cure.

Intraoperative enteroscopy--indications and limitations

Over the past 9 years we were called upon to operate on 47 patients because of bleeding lesions of the small intestine. The procedure of intraoperative endoscopy was selected for 17 of these patients. One or more of the following indications for intraoperative endoscopy pertained: to detect otherwise occult lesions (nine patients), to define the location of multiple small lesions (six patients), to confirm bleeding from known lesions (two patients), to exclude the presence of lesions suspected of bleeding (two patients), and to aid in determining the length of required resection (two patients). Fourteen of these 17 patients survived the immediate post-operative period, and in a median follow-up of 37 months bleeding has not recurred. No complication of intraoperative enteroscopy was encountered in this series.

Endoscopy of the small intestine

For the patient and the clinician, it is well that small-bowel diseases are unusual, as our ability to access this area remains limited. Frequently, all of the diagnostic and therapeutic modalities of radiology, endoscopy, and surgery are required for successful resolution of a given problem. Because management of bleeding from a small-bowel source usually will involve the surgeon at some point, it is mandatory that the best "road map" be obtained prior to exploration. If a small-bowel source is suspected after a negative endoscopic evaluation of the esophagus, stomach, duodenum, and colon, then the clinician must decide which radiographic and endoscopic examination is most appropriate. If bleeding is slow or intermittent, push-type enteroscopy to evaluate the proximal jejunum will have an expected diagnostic discovery rate of about 30 per cent. A stiffening over-tube or internal cable should result in deeper passage of the instrument and a potentially greater yield. Retrograde ileoscopy should be a part of every colonoscopy done for occult bleeding. If endoscopy does not identify a bleeding source, then a detailed barium study of the small bowel using an enteroclysis double-contrast technique will discover more pathology than a standard small-bowel-follow-through. Because sonde-type enteroscopes are not readily available, the clinician must decide at this point whether to refer the patient to an enteroscopist or consider surgery and intraoperative endoscopy. If a bleeding source has been found, then intraoperative endoscopy can localize lesions for specific resection. If the pathology remains obscure, intraoperative endoscopy will have a discovery rate of about 70 per cent. For more active hemorrhage, a bleeding scan with 99mTc-labeled red blood cells can confirm that blood loss is continuing and also will guide the angiographer toward a more directed study, thus decreasing the contrast material load for the patient. If a bleeding source can be identified angiographically, a short course of vasopressin infusion to convert the need for surgical intervention to a more elective situation would be beneficial to the patient. Intraoperative endoscopy under urgent conditions is more difficult, because luminal blood must be lavaged or cleared for a proper examination. Many times, however, intraoperative endoscopy can "surround" a segment of intestine by identifying areas that are clearly normal.

Intraoperative endoscopy of the gastrointestinal tract: clinical necessity or lack of preoperative preparation?

Intraoperative gastrointestinal endoscopy is an evolving technique that has received limited attention in the literature through case and small series reports. This literature does contain some papers in which the method was employed instead of conventional endoscopy, but, in general, intraoperative endoscopy has been effectively used as an aid to the surgeon to locate pathology not otherwise detectable and to enhance diagnosis and therapy at laparotomy. The procedure will not be required often, but when used, has the potential to be of as much service to the surgeon as a scalpel or retractor. As more surgeons are being trained in gastrointestinal endoscopy, the indications and uses will surely expand.

Intra-operative localization of bleeding small intestinal lesions

We prospectively studied 12 patients to compare fibreoptic enteroscopy and methylene blue injection through superselectively prepositioned angiographic catheters in intra-operative localization of bleeding small intestinal lesions. Four patients were excluded because the lesions were easily detected by gross examination. Eight patients were subjected to study by these two methods. As methylene blue injection required a positive angiography, it was possible only in five patients. In two of these five patients, non-bleeding lesions were present outside the intestinal segments localized by this method. Enteroscopy was simple, accurate and reliable in seven patients. Complete enteroscopy was impossible in one patient with advanced lymphoma because the intestine and its mesentery were matted together. Fortunately, the bleeding ulcers were still within the reach of the endoscope. Enteroscopy localized bleeding small intestinal lesions more exactly than methylene blue injection so that the length of gut resection could be shorter. We, therefore, conclude that enteroscopy is the better intra-operative localization procedure.

Preoperative and intraoperative localisation of gastrointestinal bleeding of obscure origin

In the past six years, 37 patients with gastrointestinal bleeding of obscure origin had their bleeding sites localised preoperatively or intraoperatively. Preoperative investigations followed a regime consisting of endoscopy, barium meal and follow through, small bowel enema, 99mTc pertechnetate scan, 99mTc-labelled red blood cell scan and selective coeliac and mesenteric angiography. Bleeding lesions were localised preoperatively in 36 patients. In one patient, diagnostic laparotomy had to be carried out immediately before any investigation because the bleeding was severe. At operation, angiosarcoma of ileum was found. Unless preoperative investigations showed the lesions to be in anatomically fixed organs like the duodenum or colon, the lesions had still to be found at operation. Palpation and transillumination detected the lesion intraoperatively in 21 patients while only some lesions were found in three patients with multiple lesions. Sigmoidoscopy through enterotomies was required in one patient. Intraoperative enteroscopy was done for small lesions not found grossly at operation in nine patients, to detect additional lesions in three patients or to rule out suspicious lesion shown on preoperative tests in one patient. In another patient with diffuse lymphoma of small bowel with bleeding from only a small segment of jejunum, injection of methylene blue intraoperatively through a previously placed angiographic catheter stained the bleeding segment of jejunum blue. This segment was identified easily and resected. These preoperative and intraoperative localisation procedures were simple and effective and we recommend them to be used more freely.