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Mid-gut exploration: video-capsule endoscopy cannot always determine the insertion route of device-assisted enteroscopy

Open AccessPublished:September 15, 2022DOI:https://doi.org/10.1016/j.vgie.2022.08.013

      Video

      (mp4, (115.37 MB)

      Difficult choice between anterograde versus retrograde motorized spiral enteroscopy based on video-capsule endoscopy findings to target a lesion illustrated in a clinical case.

      Abbreviations:

      DAE (device-assisted enteroscopy), MSE (motorized spiral enteroscopy), VCE (video-capsule endoscopy)
      Mid-gut exploration is achieved with video-capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), including motorized spiral enteroscopy (MSE).
      • Rondonotti E.
      • Spada C.
      • Adler S.
      • et al.
      Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) technical review.
      VCE and DAE are complementary procedures
      • Micic D.
      • Semrad C.E.
      Role of video capsule endoscopy as a prelude to deep enteroscopy.
      ; whereas VCE can be used as first-step noninvasive diagnostic procedure, DAE requires deep sedation or general anesthesia, time, and expertise.
      • Spada C.
      • McNamara D.
      • Despott E.J.
      • et al.
      Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.
      Despite previous studies proposing a time index based on VCE landmarks to guide the choice of route (anterograde vs retrograde), this decision can be challenging.
      • Gay G.
      • Delvaux M.
      • Fassler I.
      Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy.
      ,
      • Li X.
      • Chen H.
      • Dai J.
      • et al.
      Predictive role of capsule endoscopy on the insertion route of double-balloon enteroscopy.
      Several guidelines also highlighted the important role of small-bowel cross-sectional imaging such as dynamic contrast enhanced CT, computed tomography enterography, or magnetic resonance enterography in the management of small bowel bleeding and masses.
      • Ohmiya N.
      Management of obscure gastrointestinal bleeding: comparison of guidelines between Japan and other countries.
      • Yamamoto H.
      • Ogata H.
      • Matsumoto T.
      • et al.
      Clinical practice guideline for enteroscopy.
      • Gerson L.
      • Fidler J.
      • Cave D.
      • et al.
      ACG clinical guideline: diagnosis and management of small bowel bleeding.
      We illustrated this issue with a clinical case: a 49-year-old patient with a kidney transplant underwent VCE for melena and anemia after normal esogastroduodenoscopy and colonoscopy. Cross-sectional modalities were not used because of chronic renal failure impeding administration of intravenous contrast. An actively bleeding obstructive lesion was identified in the supposed proximal part of the ileum (Fig. 1A). Using the time-index, we performed anterograde MSE (Fig. 1B). Despite good progression (400 cm), the lesion was not reached. The deepest point of insertion was tattooed. Consequently, we performed a retrograde MSE in a second session, where the tumor (lymphoma) was reached at 70 cm above the ileocecal valve (Fig. 1C). In conclusion, VCE time-index is an estimation and cannot always determine accurately the preferred approach before MSE, especially when the lesion is obstructive. Although cross-sectional modalities were not used in this particular case, they should be considered in managing small-bowel bleeding and masses. Motorized spiral has shown an acceptable safety profile, but caution is recommended during insertion, progression, and retrieval (Video 1, available online at www.giejournal.org).
      • Beyna T.
      • Moreels T.
      • Arvanitakis M.
      • et al.
      Motorized spiral enteroscopy: results of an international multicenter prospective observational clinical study in patients with normal and altered gastrointestinal anatomy.
      ,
      • Beyna T.
      • Arvanitakis M.
      • Schneider M.
      • et al.
      Total motorized spiral enteroscopy: first prospective clinical feasibility trial.
      Figure thumbnail gr1
      Figure 1A, Actively bleeding obstructive lesion visualized through the video-capsule endoscopy in the ileum. B, The lesion's time-index location is calculated as the ratio of the transit time from the pylorus to the lesion and the transit time from the pylorus to the cecum, suggesting an anterograde approach. (Adapted from: Li X, Chen H, Dai J, et al. Predictive role of capsule endoscopy on the insertion route of double-balloon enteroscopy. Endoscopy 2009;41:762-6.) C, Hemi-circumferential lesion localized 70 cm above the ileocecal valve identified during the retrograde motorized spiral enteroscopy.

      Disclosure

      All authors disclosed no financial relationships.

      Supplementary data

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