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Antegrade Approach

The spiral segment is less flexible than the remaining enteroscope. As a result, per oral antegrade passage of the PowerSpiral Enteroscope requires extra steps for safe and successful intubation of the esophagus.

Insertion through the Pharynx and Esophagus

1. The patient’s neck should be extended to ease passage through the pharynx, upper esophageal sphincter and cervical esophagus.

2. Slow forward rotation is engaged using the foot switch as the upper sphincter is entered.

3. Gentle pressure is used to advance the enteroscope through the esophagus maintaining slow forward rotation of the spiral segment.

4. Once the spiral segment has completely passed through the upper esophageal sphincter, there will be a drop in the resistance and torque. At this point, the patient’s neck may be returned to a neutral position.
Note

Patients with suspected esophageal pathology including strictures, varices or dysphagia should undergo an EGD first. Patency of the esophagus should be proven by gentle passage of a 54-60 Fr (17-20 mm) dilator and confirmed with EGD. This is important because the tip of the scope where the image is generated is smaller in caliber than the rotary spiral section.

What maneuvers are needed when resistance is encountered and rotation ceases during intubation?
A

First, deflate the endotracheal tube cuff. Then, using backward rotation, withdraw the enteroscope and inspect the mucosa. If there is no injury present, repeat intubation modulating forward rotation and pushing force. Rotation may be used intermittently.

Insertion through the Stomach and Duodenum

1. Gastric passage begins with aspirating residual contents and collapsing the lumen.

2. Forward pressure is maintained on the enteroscope, with the spiral segment rotating as the pylorus is approached and intubated.

3. Forward pressure during intubation of the pylorus will generate a gastric loop which must be reduced by straightening the enteroscope.

4. Forward motion of the spiral segment is maintained as the straightened enteroscope is advanced.

Note: White arrow indicates the direction of the operator’s right hand. 

Tips

Straightening by pulling and re-advancement by pushing may need to be repeated until the enteroscope and spiral segment have passed through the pylorus and duodenal bulb and are within the post-bulbar duodenum.

Insertion through the Small Bowel

1. The first major anatomic location to pass during intubation of the small bowel is the fixed ligament of Treitz.

2. Once this has been accomplished, the PowerSpiral Enteroscope can be more readily advanced.

3. Deep passage into the small bowel is made possible by keeping the lumen decompressed.

4. Passage through the small bowel is accomplished by using forward rotation of the spiral segment and gentle forward pressure on the enteroscope.
Tips

Liberal water irrigation is used in place of CO2 insufflation to allow visualization of the lumen and also enable forward passage.

How can I keep the lumen decompressed when the lumen may not been seen?
A

At times when the lumen may not be visible, the mucosa should still be able to slide by the tip of the enteroscope. An overly inflated lumen will prevent the spiral segment from engaging the small bowel and the necessary pleating of the small bowel behind the spiral segment (cephalad) will not occur. 
What maneuvers are useful when sharply angled bends are encountered?
A1

First, stop the spiral segment along with any forward pressure on the enteroscope. Decompress the bowel. Slowly withdraw the enteroscope, using intermittent rotation as needed, to straighten the involved segments of small bowel on either side of the sharp turn.

A2

Use water installation to open the lumen of the bend.
A3

Apply manual abdominal pressure with a massage action over the area and restart the spiral segment followed by gentle forward pressure on the enteroscope. This sequence of actions can be repeated if not successful after the first try.

Reaching the Terminal Ileum

The following images will provide indication of reaching the terminal ileum.

The ileum becomes apparent with less prominent villi and prominent lymphoid follicles.

The procedure should be terminated if the cecum is encountered.

Fluoroscopic Image

The pleated bowl will form large, hoop-like loops.

Withdrawal after maximal insertion

Note

Maximal insertion will be noticed either by passage through the ileocecal valve or the inability to advance the PowerSpiral Enteroscope any further despite straightening, decompression, and advancement with forward pressure on the enteroscope with active rotation of the spiral segment.

1. At the point of maximal or complete passage, stop rotation as soon as the cecum is seen to prevent the spiral segment from crossing the ileocecal valve.

2. Press the backward foot switch pedal and allow sufficient time for the unpleating of the bowel to start.

3. The enteroscope is allowed to passively withdraw as the pleated bowel releases itself over the enteroscope tip.

4. Controlling the speed of backward spiral rotation will modulate the rate the pleated bowel is released into view for examination.

5. The tip is „wiggled“ using the directional controls randomly in all directions to facilitate unraveling of the bowel.

6. Prudent CO2 insufflation may be used during the withdrawal phase of the examination.

7. As the spiral segment re-engages the pylorus, there may be resistance noted. Once this passes, the spiral segment has re-entered the stomach.

8. Once the 80 cm mark on the enteroscope is seen, this indicates the spiral segment will be engaging the lower esophageal sphincter.

9. The enteroscope is withdrawn through the esophagus with backward rotation of the spiral segment maintained.

10. The patient’s neck is extended once again to ease withdrawal from the cervical esophagus and upper esophageal sphincter.
Note

It is important to be sure that the spiral segment has passed completely out of the duodenum not to engage the esophagus. This is evident by seeing the pylorus from within the antrum. Exiting the duodenum is accomplished by stopping withdrawal of the enteroscope when the 80 cm mark is at the incisors and allowing 10-15 seconds of backward spiral rotation. With the pylorus in view, withdrawal into the esophagus is begun.

Patients with altered GI anatomy

The safety of this endoscope has not been established in patients with altered GI anatomy. Perform endoscopy and endoscopic treatment in these patients only when its potential benefits are greater than its risks.

Recommendation of PowerSpiral experts

In the absence of studies confirming the safety of PowerSpiral in patients with altered anatomy, when considering its use, one should consider alternative techniques and conclude that the potential benefit of PowerSpiral outweighs the potential risks.
At least 10 cases experiences (per physician) and at least 20 cases experiences (per center) of deep enteroscopy with PowerSpiral is recommended before treating patients with altered GI anatomy.

What action is required when resistance is increased?
A

Increased resistance is an indicator of remaining pleated bowel on the spiral segment. This requires advancement of the scope holding position and then resuming backward rotation.
What action should be taken if a lesion is encountered?
A

If a lesion is encountered, rotation of the spiral segment is stopped. Forward pressure on the enteroscope is maintained in order to keep the position of the enteroscope and visualization of the lesion for biopsy or therapy. Both the forward and backward rotation may be used to obtain accurate positioning of the enteroscope tip relative to a lesion.
General Techniques Retrograde Approach
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