SMALL BOWEL ENTEROSCOPY Dr CC Foo Queen Mary

SMALL BOWEL ENTEROSCOPY Dr CC Foo Queen Mary Hospital Joint Hospital Surgical Grand Round 24 -10 -2009

SMALL BOWEL ENTEROSCOPY Small bowel represent the last frontier to be explored with endoscopic means Difficulties caused by its relatively long length and tortuosity

SMALL BOWEL ENTEROSCOPY 5% of all GI bleeding occurs between the ligament of Treitz and ileocaecal valve Di. Sario J et al. Enteroscopes - technology status evaluation report. Gastrointest Endosc 2007; 66(5): 872– 80

SMALL BOWEL ENTEROSCOPY Small bowel pathologies Angiodysplasia Meckel’s diverticula NSAID related enteropathy Benign or malignant tumour

SMALL BOWEL ENTEROSCOPY Push enteroscopy Double balloon enteroscopy (DBE) Single balloon enteroscopy (SBE) Spiral enteroscopy Capsule endoscopy

SMALL BOWEL ENTEROSCOPY Indications: GI bleeding of obscure origin Chronic diarrhoea Malabsorptive syndrome Chronic abdominal pain Therapeutic application: Foreign body removal Mucosal resection Insertion of SEMS Dilatation of stricture in Crohn’s disease ERCP after Billroth II or Roux-en-Y reconstruction or after bariatric surgery

ENDOSCOPY TIMELINE 1807 Bozzini : ‘Lichtleiter’ Comprised of wax candle, reflecting mirror and inspection tube 2000 Capsule endoscopy 1970 s Clinical use of colonoscopy and upper endoscopy 1957 Hirshowitz: First flexible fiber endoscope 1987 Push enteroscocpy 1977 Tada : Sonde enteroscope 2006 Otsuka: Single balloon enteroscopy 2001 Yamamoto: Double balloon enteroscopy 2007 Akerman: Spiral endoscopy

SONDE ENTEROSCOPY Described Sonde enteroscopy Working length of 250 -400 cm Propelled Lack by Tada in 1977 by small bowel peristalsis of working channel and prolonged examination time

PUSH ENTEROSCOPY Performed with a dedicated enteroscope with an overtube Method: Overtube loaded onto the enteroscope Enteroscope enter the proximal jejunum Overtube pushed into the 3 rd part of duodenum and held by assistant Enteroscope proceed to advance into the jejunum Depth of insertion: 40 to 100 cm past ligament of Treitz

DOUBLE BALLOON ENTEROSCOPY (DBE) Developed 2001 by Yamamoto in Manufactured by the Fujinon, Inc, Saitama, Japan

DOUBLE BALLOON ENTEROSCOPY High resolution video endoscope Working Flexible Latex length of 200 cm overtube balloons at the tipe of the enteroscope and on the overtube

DOUBLE BALLOON ENTEROSCOPY Serial inflation and deflation of balloons with air by the pressure-controlled pump Alternating pushing and pulling maneuvers Allowing the small bowel to be threaded onto the overtube Matsumoto et al. Am J Roentgenol 2008

DOUBLE BALLOON ENTEROSCOPY The Wolfson Unit for Endoscopy St Mark's Hospital, UK

DOUBLE BALLOON ENTEROSCOPY Antegrade (oral) and retrograde (anal) approach could achieve total small bowel examination Fluoroscopy as an aid can be used

SINGLE BALLOON ENTEROSCOPY (SBE) Developed by Ohtsuka in 2007 Manufactured by Olympus, Inc, Tokyo, Japan Working length of 200 cm Outer diamter of 9. 2 mm Working channel 2. 8 mm Overtube overall length 140 cm Latex free balloon

SINGLE BALLOON ENTEROSCOPY In contrast to DBE, balloon is not attached to the tip of the enteroscope Stable positioning in the small bowel is achieved during withdrawal of the scope by angling the tip of the endoscope

SINGLE BALLOON ENTEROSCOPY

SPIRAL ENTEROSCOPY Described First by Dr Akerman performed in 2006 Applies the mechanical advantage of a screw to convert rotational force into linear one Currently more than 2000 cases have been performed worldwide

SPIRAL ENTEROSCOPY Device: Discovery SB overtube Spirus Corporation Overall length 118 cm Outer diameter 14. 5 mm Accomodates endoscope <9. 4 mm diameter

SPIRAL ENTEROSCOPY Method Overtube is backloaded on the enteroscope Advanced slowly with gentle clockwise rotation of the overtube Spiral passes beyond the ligament of Treitz Spiral threads engage in the jejunum and mobile small bowel can be rapidly pleated onto the enteroscope

SPIRAL ENTEROSCOPY Spirus Medical

COMPLICATIONS OF SMALL BOWEL ENTEROSCOPY Mucosal stripping Pancreatitis Aspirations Bleeding Gastric, duodenal and jejunal perforations Complication rate generally <1%

EXAMINATION TIME Study Patient no. Mean exam time (min) Type Yamamoto Japan 2004 123 DBE Di Caro Europe 2005 62 160 DBE Heine Netherland 2006 275 200 DBE Mehdizadeh US 2006 188 197 DBE Gross and Stark US 2008 137 197 DBE Tsujikawa Japan 2008 41 (78 procedures) 133 SBE Ramchandani India 2009 106 (131 procedures) 137 SBE Akerman US 2008 101 17 Spiral Esmail US 2009 57 28 Spiral Morgan US 2009 148 34 Spiral

DEPTH OF INSERTION Study Patient no. Mean depth Oral (cm) Mean depth Anal (cm) Type Di Caro Europe 2005 62 254 180 DBE Heine Netherland 2006 275 270 156 DBE Mehdizadeh US 2006 188 360 183 DBE Gross and Stark US 2008 137 220 124 DBE Tsujikawa Japan 2008 41 (78 procedures) 270 Ramchandani India 2009 106 (131 procedures) 255 Akerman US 2008 75 249 Spiral Esmail US 2009 57 246 Spiral Morgan US 2009 148 250 Spiral SBE 163 SBE

DIAGNOSTIC YIELD Study Patient no. Yield (%) Therapy (%) Type Yamamoto Japan 2004 123 76 18 DBE Di Caro Europe 2005 62 80 42 DBE Heine Netherland 2006 275 73 55 DBE Mehdizadeh US 2006 188 43 27 DBE Gross and Stark US 2008 137 80 45 DBE Tsujikawa Japan 2008 41 (78 procedures) 54 Ramchandani India 2009 106 (131 procedures) 61 8. 4 SBE Akerman US 2008 75 24 13 Spiral Esmail US 2009 57 51 SBE Spiral

COMPLETE SMALL BOWEL EXAMINATION Study Patient no. Complete examination Type % Yamamoto Japan 2004 123 86 DBE Di Caro Europe 2005 62 16 DBE Heine Netherland 2006 275 42 DBE Mehdizadeh US 2006 188 4 DBE Gross and Stark US 2008 137 20 DBE Tsujikawa Japan 2008 24 25 SBE Ramchandani India 2009 20 25 SBE

CONCLUSION Advances in small bowel enteroscopy facilitate diagnosis and management of small bowel lesions Histological sampling and therapeutic endoscopies are made possible Results of different enteroscopies are yet to be revealed by future clinical trials