Specific Tips for Insertion in Patients with a Postoperative Intestine

tube insertion, one of the tips for abdominal maneuvering is to apply pressure on regions so a redundant loop of the endoscope is reduced. The abdominal wall around the endoscope tip may be pressed or tapped, which allows the endoscope tip to advance.

When a guidewire is used, care should be taken to avoid intestinal perforation by the guidewire. Thus, a soft-tipped guidewire is inserted and advanced through the forceps channel, followed by endoscope insertion. If the direction of the lumen is unclear during insertion of the guidewire, inflating the balloon at the endoscope tip and injecting a contrast agent into the forceps channel allows selective contrast enhancement of the lumen ahead, which helps with guidewire insertion.

Insertion into a bypassed intestine requires identification of the anastomotic site. Because of insertion with minimal air insufflation, the anastomotic site may be missed during insertion of the endoscope and identified only during its withdrawal. To reduce the examination time, it is necessary to collect detailed information and approximate the location of the anastomotic site before examination.

To identify the anastomotic site, attention should be paid to discontinuity and fusion of Kerckring's folds, luminal dilatation, direction of peristalsis, and quantity of bile. With a Roux-en-Y anastomosis, bile flows into the intestinal tract from the afferent loop; therefore, the amount of bile increases when the endoscope advances beyond the anastomotic site. In addition, the intestinal tract dilates and Kerckring's folds fuse at the anastomotic site, points that are useful for identification. Peristalsis in the efferent loop and antiperistalsis in the afferent loop help determine the position of the endoscope.

The secret for successful insertion into the bypassed intestine beyond the anastomotic site is to reduce the angle at the anastomotic site as much as possible. The angle can be reduced by pulling or pushing the endoscope, depending on the patient (Fig. 12.2.1). Even when the endoscope tip is advanced beyond the anastomotic site, it is often difficult to manipulate the endoscope reliably until the balloon at the tip of the overtube is secured in a place beyond the anastomotic site. When insertion is difficult, it is strongly recommended that the balloon at the endoscope tip be inflated and secured to advance the tip of the overtube beyond the anastomotic site.

Fig. 12.2.1. Procedure to reduce the angle at the anastomotic site

When the endoscope is advanced into the afferent loop of a Billroth II reconstruction or a Roux-en-Y reconstruction for endoscopic intervention, instruments should be inserted through the forceps channel for manipulation. The double-balloon endoscopes EN-450P5 and EN-450T5, available as of the end of 2005, have forceps channel diameters of 2.2 and 2.8 mm, respectively. The use of therapeutic devices is limited by the forceps channel diameter and the working length, which is as long as 200 cm. To address the limitation, the double-balloon endoscope inserted into a region of interest may be replaced with another endoscope that has a larger forceps channel diameter and shorter working length while the overtube is securely anchored with the balloon. The use of a shorter overtube instead of the 145-cm standard balloon-attached overtube allows the use of an endoscope with a shorter working length so long as it is thin enough to pass through the overtube, thereby offering a wide choice of endoscopes and therapeutic devices for use during endoscopic interventions.

As an example, we present a case of endoscopic mucosal resection (EMR) of duodenal cancer in the afferent duodenal loop after Roux-en-Y reconstruction. At that time, the EN-450T5 was not commercially available, and the EN-450P5 with a forceps channel diameter of 2.2 mm was used. First, the overtube with a balloon attached, TS-12140, was modified to have a shorter length of 70 cm, and the double-balloon endoscope was inserted into the blind end of the afferent duodenal loop. Then the tip of the overtube with a balloon attached was advanced into the afferent duodenal loop, and the balloon at the tip of the overtube was inflated to secure the overtube. The endoscope was removed with the balloon-attached overtube left in place, and the endoscope GIF-XQ240 (outer diameter 9.0 mm, forceps channel diameter 2.8 mm) (Olympus) was inserted to perform EMR (Fig. 12.2.2) (see section 11.3.5).

Balloon Dilation Intestine
Fig. 12.2.2. Endoscopic mucosal resection in the afferent duodenal loop

A similar method may be used to perform ERCP, endoscopic papillary balloon dilation (EPBD), lithotripsy, or tube stent placement for the treatment of choledocholithiasis after Roux-en-Y reconstruction. The procedure is applicable in other clinical settings as well.

In patients without a duodenal papilla after choledochojejunostomy, cholangiography can be performed by injecting a contrast agent into the forceps channel with the balloon at the double-balloon endoscope tip inflated (Fig. 12.2.3).

Adhesive intestinal obstruction may occur in patients with previous abdominal surgery. Contrast-enhanced studies with a long decompression tube, computed tomography, and magnetic resonance imaging may allow estimation of the site responsible for bowel obstruction but not tattooing. The use of the double-balloon endoscope enables exact identification of the region responsible for bowel obstruction and tattooing at the site. Tattooing facilitates laparoscopic identification of adhesions responsible for bowel obstruction and allows minimally invasive laparoscopic division of the adhesions. Laparoscopic visibility is increased by placing tattoos on the opposite sides of the lumen.

In patients with bowel obstruction undergoing decompression with a long decompression tube, inserting the overtube with a balloon attached, with a long decompression tube as a guide, facilitates insertion of the endoscope to the region at which the tip of a long decompression tube is placed (a long decompression tube-guiding method). Specifically, a long decompression tube (up to 16F) inserted through the nostril is cut at the proximal connector and withdrawn through the mouth. During this procedure it is desirable to keep the balloon at the tip of a long decompression tube inflated. After a guidewire is inserted through a long decompression tube to reduce loops, the balloon-attached overtube for double-balloon

Fig. 12.2.3. Cholangiography in a patient with previous choledochoje-junostomy
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