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

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

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

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

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

6. 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

7. 1807 Bozzini : ‘Lichtleiter’ Comprised of wax candle, reflecting mirror and inspection tube 1957 Hirshowitz: First flexible fiber endoscope 1970s Clinical use of colonoscopy and upper endoscopy 1987 Push enteroscocpy 2000 Capsule endoscopy 1977 Tada : Sonde enteroscope 2001 Yamamoto: Double balloon enteroscopy 2006 Otsuka: Single balloon enteroscopy 2007 Akerman: Spiral endoscopy ENDOSCOPY TIMELINE

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

9. 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 100cm past ligament of Treitz

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

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

12. 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

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

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

15. SINGLE BALLOON ENTEROSCOPY (SBE) Developed by Ohtsuka in 2007 Manufactured by Olympus, Inc, Tokyo, Japan Working length of 200cm Outer diamter of 9.2mm Working channel 2.8mm Overtube overall length 140cm Latex free balloon

16. 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

17. SINGLE BALLOON ENTEROSCOPY

18. SPIRAL ENTEROSCOPY Described by Dr Akerman First 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

19. SPIRAL ENTEROSCOPY Device: Discovery SB overtube Spirus Corporation Overall length 118cm Outer diameter 14.5mm Accomodates endoscope <9.4mm diameter

20. 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

21. SPIRAL ENTEROSCOPY Spirus Medical

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

23. EXAMINATION TIME StudyPatient no.Mean exam time (min) Type Yamamoto Japan2004 123 DBE Di Caro Europe2005 62160DBE Heine Netherland2006 275200DBE Mehdizadeh US2006 188197DBE Gross and Stark US2008 137197DBE Tsujikawa Japan2008 41 (78 procedures)133SBE Ramchandani India2009 106 (131 procedures)137SBE Akerman US2008 10117Spiral Esmail US2009 5728Spiral Morgan US2009 14834Spiral

24. DEPTH OF INSERTION StudyPatient no.Mean depth Oral (cm) Mean depth Anal (cm) Type Di Caro Europe2005 62254180DBE Heine Netherland2006 275270156DBE Mehdizadeh US2006 188360183DBE Gross and Stark US2008 137220124DBE Tsujikawa Japan2008 41 (78 procedures) 270SBE Ramchandani India2009 106 (131 procedures) 255163SBE Akerman US2008 75249Spiral Esmail US2009 57246Spiral Morgan US2009 148250Spiral

25. DIAGNOSTIC YIELD StudyPatient no.Yield (%) Therapy (%) Type Yamamoto Japan2004 1237618DBE Di Caro Europe2005 628042DBE Heine Netherland2006 2757355DBE Mehdizadeh US2006 1884327DBE Gross and Stark US2008 1378045DBE Tsujikawa Japan2008 41 (78 procedures)54SBE Ramchandani India2009 106 (131 procedures) 618.4SBE Akerman US2008 752413Spiral Esmail US2009 5751Spiral

26. COMPLETE SMALL BOWEL EXAMINATION StudyPatient no. Complete examination % Type YamamotoJapan200412386DBE Di CaroEurope20056216DBE HeineNetherland200627542DBE MehdizadehUS20061884DBE Gross and StarkUS200813720DBE TsujikawaJapan20082425SBE RamchandaniIndia20092025SBE

27. 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