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Emergency Withdrawal

Unexpected clinical events may necessitate prompt extraction of the enteroscope. If the procedure has been performed under monitored anesthesia care, the patient in an unexpected life threatening emergency situation may require endotracheal intubation. In this circumstance, the enteroscope may be left in place until tracheal intubation is accomplished. Withdrawal can then follow. Please note that emergency withdrawal will inherently require extra time to perform if the enteroscope is well advanced into the small bowel and pleated onto the scope. Removal efforts are directed at freeing the pleated bowel. If this is not accomplished, there is risk of intussusception. The first step is to insufflate the lumen with CO2 and water. The water will provide lubrication. Backward rotation is maintained as the enteroscope is slowly pulled out. Tip deflection in all directions may enable unpleating of the bowel and the withdrawal. The same precautions must be taken when the 80 cm mark is noted at the mouthpiece. Withdrawal must be interrupted at this point. With active backward rotation maintained, the tip of the enteroscope must be seen to first exit the duodenum and pass through the pylorus into the antrum before resuming withdrawal with backward rotation into and through the esophagus. The patient’s neck should be straightened to ease passage through the esophagopharyngeal segment.

Equipment Failure

Loss of power or other major equipment failure such as a cable break or motor failure will stop the spiral segment from rotating. Similar to emergency withdrawal, removal of the enteroscope will take extra-time to accomplish. It is important to insufflate the bowel in order to release the pleated portions from the scope. This is accomplished by instilling CO2 or air as well as water for lubrication directly through the scope channel. Tubing may be connected via luer lock to the working channel or syringes may be used. Once insufflation is apparent, the scope is slowly withdrawn. Fluoroscopy may be used to monitor effective insufflation and avoid excessive insufflation. Tip deflection in all directions may facilitate unpleating of the bowel. If there is resistance to withdrawal, pulling should halt followed by a pause, additional insufflation or instillation of water performed, followed by forward pushing 5-10 cm before gentle pulling withdrawal is re-initiated. When the 80 cm mark is noted exiting the mouthpiece, extra effort at tip deflection to release the scope from the duodenum and pylorus is performed before the final pull through the esophagus. Neck straightening is needed to aid esophagopharyngeal passage.

Detachment with loss of the spiral tube

If the spiral tube becomes released from the scope attachment rotational activity within the lumen will cease. Pull the enteroscope until the spiral tube has completely separated from the scope and obtain an optimum field of view. The pleated bowel must be released by using gas insufflation and water as the scope is withdrawn. If the spiral tube becomes completely separated from the scope and free within the lumen, retrieval efforts are made similar to extraction of a foreign body using forceps or inflated balloon at the distal end of the spiral tube. The enteroscope with captured spiral tube are slowly withdrawn. Failure to retrieve the spiral tube may require surgical removal.

Note


Do not, under any circumstances, forcefully withdraw the enteroscope. Instead, allow the pleated bowl to be unraveled off of the spiral segment through backward rotation.