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
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 (18-20 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.
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
Note: White arrow indicates the direction of the operator’s right hand.
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
Liberal water irrigation is used in place of CO2 insufflation to allow visualization of the lumen and also enable forward passage.
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.
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.
Use water installation to open the lumen of the bend.
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.
Withdrawal after maximal insertion
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.
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.
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.
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.
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