Preparation of instruments and accessories needed for push and pull enteroscopy.
The prototype of the single balloon enteroscopy system (Olympus Tokyo Japan) consists of a high resolution enteroscope long 2 meters with a 2.8 mm accessory channel, and a extremely flexible transparent overtube with a latex balloon attached on its distal part.
Before positioning the enteroscope into the overtube, this has to be entirely lubrificated with approximately 30 cc of a saline solution, so the enteroscope can slide easily inside.
After the enteroscope has been placed into the overtube, a balloon pump controller is then connected to the overtube. At this point we have to check if inflation and deflation of the balloon are functioning correctly.
Now, we are ready to start the enteroscopy.
Our first case is a 64 years old woman with a mesenteric vein thrombosis and referred small bowel bleeding.
The procedure was done under general anesthesia and oro-tracheal intubation. We inserted the enteroscope and overtube through the mouth and passed in conventional fashion into the duodenum. The balloon is than inflated anchoring the overtube to the intestinal wall. Following this, the enteroscope advances ahead.
Now we are at the first jejunal loops, where capillary hemangioma-angiomatosis can be seen.
At this point, after having visualized approximately 40 cm of the small bowel, we have to anchor the distal tip of the enteroscope (which is very easy due to its extremely flexibility) to the small bowel wall, so we can start withdrawing and straightening the enteroscope, under radiological vision.
Now we deflate the balloon, so the overtube can slide over the enteroscope until it stops. Than the overtube is blocked by inflating the balloon.
After having freed the anchored tip of the enteroscope we can proceed with pushing it towards into the bowel, always under radiological vision.
This different phases of the procedure are repeated over and over again, and each time about 40 cm of bowel are covered. With this procedure, entering trough the mouth, the entire small bowel can be explored.
At the end of the procedure, after we have deflated the balloon and liberated the tip of the enteroscope, so the instrument can be retrieved.
Our second case is a 26 year-old woman with Peutz-Jeghers Syndrome and diagnosis of multiple jejunal poliposis seen by VCE.
In this patient we performed:
Endoscopic piecemeal resection of a large semipeduncolated polyp (4 cm of diameter);
Endoscopic mucosectomy of a sessile 1 cm polyp after submucosal infiltration of saline solution (2 cc);
“En bloc” snare polipectomy of a peduncolated polyp (2 cm of diameter);
“En bloc” snare polipectomy of a semipeduncolated polyp (3 cm of diameter).
Histologic examination confirmed the amartomatosic nature of the lesion.
Marilena E. Riccioni, MD, Catholic University, Rome
Enrico C. Nista, MD, Catholic University, Rome
Riccardo Urgesi, MD, Catholic University, Rome
Cristiano Spada, MD, Catholic University, Rome
Pietro Familiari, MD, Catholic University, Rome
Guido Costamagna, MD, Catholic University, Rome