Intraoperative Enteroscopy: A Fast and Safe Technique for Localization and Treatment of Small Bowel Lesions

Objective: Intraoperative Enteroscopy (IOE) was first described in the late 1960s and is regarded as the gold standard for complete evaluation of the small bowel. However, with the advent of deep endoscopy and video capsule endoscopy, IOE has been used less frequently. Recently we published a large series demonstrating that IOE is a valuable tool for the final diagnosis and treatment of Small Intestinal Bleeding (SIB) and non-adhesive Obstructive Small Bowel Disease (OSBD) [1]. Existing literature lacks clear guidelines on the technique of IOE; therefore, we propose safe and effective methods to guide the surgeon’s approach to IOE. Methods and Procedures: As we recently described IOE is indicated in patients with SIB that is visualized but cannot be treated via endoscopy. For OSBD, IOE is indicated when computed tomography and/or initial enteroscopy are non-diagnostic and there is a suspicion for a resectable lesion (i.e. tumor or diverticulum), or when a pathologic lesion is identified but not amenable to endoscopic therapy. The procedure begins with standard diagnostic laparoscopy and complete evaluation of the small bowel. The evaluation includes visualizing a lesion or tattoos which may have been marked endoscopically beforehand. If no small bowel lesion is visualized, a six-centimeter supra-umbilical incision is made and an Alexis® wound protector is inserted for the purpose of IOE. The small bowel is eviscerated for complete visual inspection and manual palpation. If no lesion is palpated, IOE follows via an enterotomy made in proximity to the anticipated lesion or between proximally and distally marked ink tattoos. The enteroscope is secured with a purse string suture to prevent leakage of enteric contents. The small bowel mucosa is examined both anterograde and anterograde, with the gastroenterologist controlling the enteroscope and the surgeon simultaneously advancing the scope and telescoping the bowel extracorporally over it. Carbon dioxide is ideally used for insufflation. Definitive treatment depends on the type of lesion identified, with small bowel resection being the most common procedure. Post-operative management is patient and provider dependent. Generally, nasogastric tubes and urinary indwelling catheters are removed on postoperative day one and diet advanced as tolerated. Conclusion: IOE is a safe, fast, and effective method for diagnosing and treating SIB and OSBD undiagnosed by conventional modalities. While the majority of the reports describing IOE have been published in Europe or Asia, we have proven that this technique is accurate and valuable in North America. Here we provide clear guidelines regarding the indications and appropriate technique by which to perform IOE in the United States. Amanda Fazzalari1,2, Shruthi Srinivas1, Natalie Pozzi2, Christopher Schlieve1, Jonathan Green MSCI1, Demetrius Litwin1, David Cave3 and Mitchell A Cahan1* 1Department of Surgery, University of Massachusetts Medical School, USA 2Department of Surgery, Saint Mary’s Hospital, USA 3Department of Gastroenterology, University of Massachusetts Medical School, USA