By the Endoscope Removal Method Procedure

1. Instead of a fixing rubber, nylon surgical sutures (3-0 or 4-0 in size) or nylon fishing line (approximately 0.145 mm in diameter, equivalent to no. 0.8) is used to secure the endoscope balloon (Fig. 11.4.2). In this situation, a hood is not attached to the endoscope. When the hood is absolutely necessary for insertion of the endoscope, the hood is mounted (not secured with surgical tape). It should be noted that the hood must be left in the intestine when the endoscope is removed. It is retrieved endoscopically at the end of the intervention or is excreted in the feces (see section 11.4.3 for the method of collecting the hood) (Fig. 11.4.2).

Fig. 11.4.2. Securing the endoscope balloon with sutures

Four sites should be secured. The second ligature from the tip must be placed distal to the opening of the air route on the lateral side of the tip. Without the second ligature, a deflated endoscope balloon may limit the field of view during examination

2. The double-balloon endoscope is used to locate the stenotic site in the small intestine and to determine the length and number of the stenotic sites with a water-soluble contrast agent (Figs. 11.4.3, 11.4.4).

Fig. 11.4.2. Securing the endoscope balloon with sutures

Four sites should be secured. The second ligature from the tip must be placed distal to the opening of the air route on the lateral side of the tip. Without the second ligature, a deflated endoscope balloon may limit the field of view during examination

Figs. 11.4.3 to 11.4.8 are from the same patient.

Figs. 11.4.3 to 11.4.8 are from the same patient.

Fig. 11.4.4. Selective, contrast-enhanced radiograph Selective, contrast-enhanced radiograph showing a stenosis (arrows) approximately 1 cm in length together with distension of the proximal portion of the intestine (the endoscope was inserted through the anus)

3. A guidewire (0.35 mm diameter, 450 cm length) (Jagwire) is inserted through the forceps channel of the endoscope and placed beyond the stenotic site. The endoscope is then removed, leaving the guidewire and the overtube in the small intestine (Fig. 11.4.5). A hood, if attached, drops off at this point.

Fig. 11.4.5. A guidewire is placed beyond the stenotic site, and the endoscope alone is removed

4. A 150-cm plastic tube (whose preparation is described later) is inserted along the guidewire and the overtube. The tip of the plastic tube is placed just short of the tip of the overtube under fluoroscopic guidance. The plastic tube facilitates smooth insertion of a balloon dilator. The dilatation balloon with an expended diameter of 8-15 mm is inserted along the guidewire, plastic tube, and overtube to the affected region to dilate the stenotic site. An appropriate balloon is chosen based on the length of the stenotic site (Fig. 11.4.6; see also Fig.11.4.7).

Fig. 11.4.6. A balloon dilator is used to dilate the stenotic site

Fig.11.4.7. Selective, contrast-enhanced radiograph during balloon inflation

The arrowheads indicate the two ends of the balloon

5. The balloon is then deflated. The degree of dilatation is evaluated, and the balloon is inflated again as appropriate. The balloon dilator may be replaced with a different size of dilatation balloon with the plastic tube in place. If a contrast agent is injected into the proximal opening of the overtube, an additional contrast-enhanced study can be performed during the intervention (Fig. 11.4.8). After completing the dilatation, the dilatation balloon, guidewire, and plastic tube are removed through the overtube. Reinserting the endoscope into the overtube, which is placed to shorten and straighten the intestine, allows easy endoscopic evaluation of the efficacy of the dilatation immediately after intervention.

Fig. 11.4.8. Selective, contrast-enhanced radiograph after balloon dilatation

Intestinal contents retained in the proximal portion passed through (arrow) immediately after dilatation

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