General Considerations for Endoscopy

The double-balloon endoscope can be inserted through the mouth and the anus. Before insertion procedures specific for individual approaches are detailed, considerations common to both approaches are described.

It is essential to provide the patient with adequate information on the examination and obtain informed consent before endoscopy. To relieve anxiety, the physician should inform the patient immediately before the examination that it takes more time than routine endoscopy but causes little or no pain—and that the physician is ready to treat any discomfort of which the patient complains. To monitor the patient's condition during the examination, monitors such as electrocardiography, a pulse oximeter, and an automated sphygmo-manometer should be ready for use, and an intravenous line should be established to administer additional doses of sedatives.

Devices should be arranged to ensure that a fluoroscopic monitor and an endoscopic monitor can be seen simultaneously because some manipulations during the examination require simultaneous monitoring of fluoroscopic and endoscopic views. The floor preferably is covered with a water-absorbing sheet because intestinal fluids may come out of the rear end of the overtube.

A total of five buttons are used to operate the pump that controls balloons at the endoscope tip and the overtube. Air supply and withdrawal buttons, pause buttons for individual balloons and an alarm stop button are available. The pump that controls the balloons at the endoscope tip and the overtube continuously monitors the balloon pressure and automatically maintains the internal pressure of inflated balloons at a set pressure of 6 kPa (45 mm Hg). It is designed to activate an alarm when the balloon pressure exceeds the limit or fails to reach the set pressure after a certain amount of time on the air supply. Whenever an alarm sounds during the examination, its cause should be identified and the pump temporarily stopped as needed. When the balloon is inflated at a site with a large internal diameter, even a large amount of air supplied may fail to elevate the balloon pressure to a set pressure, and an alarm is activated because of an excessive amount of air supplied. Caution must be exercised because the balloon may be damaged if the problem is not addressed. Pressing the pause button is recommended to prevent balloon damage when the cause of the alarm cannot be quickly determined.

All devices should be ready for use, as described in Chapter 7. Balloons should be carefully tested to ensure that they have no air leaks and to avoid reinsertion because of balloon defects found during the examination.

Smooth insertion of the double-balloon endoscope requires techniques for advancing the endoscope tip with a minimum of force. That is because endoscope insertion is based on a point supported by the overtube balloon, and the support by the balloon is kept to a minimum to ensure safety. Forcible insertion does not advance the endoscope tip but only with

draws the overtube. This is required to ensure safety, and only the allowable range of insertion force should be applied to advance the endoscope tip smoothly.

Specifically, forcible insertion of a sharply angled endoscope should be avoided. The operator should insert the endoscope while reducing the angle as much as possible and swinging the tip so the endoscope forms a large arc.

Air insufflation during insertion should be kept to a minimum. This is important for keeping the patient's discomfort to a minimum and for pleating the intestine over the overtube. To keep air insufflation to a minimum and negotiate bends using a slalom technique during insertion, we usually insert the endoscope with a hood attached to its tip. This hood prevents "red-out" and facilitates insertion by the slalom technique with a minimum of air insufflation.

Because insertion of the double-balloon endoscope is based on the grip of the intestine by the balloon, the operator advances the endoscope or the overtube only after confirming that the balloon is adequately inflated or deflated. A balloon is considered to be inflated enough to have a good grip when the pressure gauge of the pump indicates a stable level of 6 kPa. A balloon is considered to be adequately deflated when the pump stops making an air-withdrawal sound.

In principle, the double-balloon endoscope is inserted with concomitant monitoring of the shape of the endoscope and the condition of the balloon with a fluoroscope as needed; however, experienced physicians do not need frequent use of a fluoroscope. The duration of fluoroscopy should be minimized to keep the extent of exposure to a minimum.

Both balloons (at the endoscope tip and the overtube) are initially deflated; and the overtube is placed at the rear end of the endoscope so the portion of the endoscope beyond the tip of the overtube is as long as possible. The operator should hold the endoscope tip for insertion without the aid of an assistant. When the overtube is inserted, the assistant stands between the operator and the patient to hold the overtube straight and insert it along the endoscope. The inner and outer surface of the overtube is coated with hydrophilic material, and lubricity between the overtube and the endoscope is improved by injecting water into the overtube. Thus, the assistant injects water as needed.

A 155-cm marking on the endoscope can be used as a guide, and the overtube is inserted until its rear end reaches the marking. When the rear end reaches that position, the tip of the overtube reaches the proximity of the balloon attached to the endoscope tip. During the examination, bear in mind that further insertion may cause interference of the tip of the overtube with the balloon at the endoscope tip, dislocation of the balloon, or damage to the balloon. Although the clearance between the tip of the overtube and the endoscope is kept to a minimum, the intestinal wall could become entangled in the clearance when the intestine is sharply angled. When abnormal resistance occurs during insertion of the overtube, the cause should be determined fluoroscopically instead of by forcible insertion. Any sharp bend should be reduced by withdrawing the endoscope and reinserting the overtube. Because the overtube is inserted without fluoroscopic guidance, it is important to insert the overtube gently to prevent it from catching the intestinal mucosa. When insertion of the overtube is difficult, a jiggling technique may facilitate insertion.

After inserting the overtube, the assistant holds the overtube on the portion outside of the body with both hands: The overtube close to the insertion site of the patient (mouth or anus) is held with the left hand, and the rear end of the overtube is held with the right hand, with the result that the overtube is held in a straightened position between the two hands. The operator manipulates the endoscope as he or she inserts it into the rear end of the overtube, so the assistant should hold the rear end of the overtube securely (Fig. 8.1). For double-balloon endoscopy, not only the operator but also the assistant should be familiar with the principle of insertion and notable complications.

Fig. 8.1. Operator, assistant, and patient

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