Endoscopy 2009; 41(9): 820
DOI: 10.1055/s-0029-1215013
Letters to the editor

© Georg Thieme Verlag KG Stuttgart · New York

Reply to Riccioni et al.

P.  A.  Akerman, D.  Cantero
Further Information

Publication History

Publication Date:
10 September 2009 (online)

We thank Dr. Riccioni et al. for their letter regarding their experience with spiral enteroscopy and comparing this with our results previously published in this journal [1]. Spiral enteroscopy is a new technique for deep small-bowel visualization [2]. The technique is unique in endoscopy because it converts rotational forces into linear advancement through the small bowel. When the spiral is rotated in the mobile small bowel, the small bowel is pleated on the overtube and enteroscope. For the experienced endoscopist familiar with enteroscopy and overtubes, learning to use the spiral technology is the major hurdle to mastering spiral enteroscopy.

In our hands-on seminars, we have trained over 60 physicians. Physicians are trained in a two-person technique in four or five cases over 2 days. During the last two or three cases, they typically perform the procedure with minimal guidance. In our experience and in this study, proficiency is achieved by four or five cases under these circumstances. We would respectfully disagree with the statement that “five examinations are not enough to obtain deep enteroscope insertion past the ligament of Treitz, using the spiral technique.”

We agree that positioning the spirals on the overtube past the ligament of Treitz (LOT) is the most challenging aspect of learning the technique of spiral enteroscopy. A recently published abstract by Morgan et al. published the results of a 10-site multicenter USA trial with 148 patients [3]. It took an average of 7 minutes to position the spirals past the LOT and initiate spiral enteroscopy. To position the spirals past the LOT two techniques were used. The first is the Cantero maneuver. This maneuver is used when the overtube is advanced deeply into the upper gastrointestinal tract. The overtube is pulled back slowly and rotated clockwise. As the stomach loop is reduced, paradoxical motion causes the overtube to advance into the small bowel and often (about 50 % of the time) spiral pleating can be achieved. We agree that the Cantero maneuver is an advanced procedure but believe it is not difficult in concept or performance. Secondly, we use an over-the-enteroscope technique. After straightening the overtube in the upper gastrointestinal tract, the enteroscope is advanced into the proximal small bowel. The overtube is then advanced over the enteroscope into the small bowel past the LOT. Once past the LOT, spiral pleating can be begun.

We were gratified to hear that Dr. Riccioni et al. found the withdrawal to be quite stable, controlled, and superior to other push-and-pull systems. Dr. Riccioni’s team also found only mild mucosal trauma and no complications in their small series. This is in concurrence with other publications [3] [4] [5].

In summary, recent studies have demonstrated the effectiveness and efficiency of spiral enteroscopy [1] [2] [3] [4] [5] [6]. There is an indisputable learning curve to the technique of spiral enteroscopy. We believe that proficiency and safety in performing the procedure can be achieved in five cases in our training sessions. Outside of these training sessions the exact number of cases needed to achieve proficiency is less well known. We have trained many physicians outside of our training sessions with apparent success. Analysis of the successful training of these physicians is currently underway. Proficiency can be achieved more rapidly with experienced supervision, and fluoroscopy can be quite helpful early in the learning curve and even late in the learning curve in challenging cases. We are developing an inflatable spiral which may simplify the learning curve for spiral enteroscopy [7].

Spiral enteroscopy is safe and effective for deep small-bowel intubation. We agree with Dr. Riccioni et al. that the Discovery SB has subjectively superior controlled withdrawal over push-and-pull enteroscopy techniques. In addition, although Dr. Riccioni’s first cases showed no decreased time of procedure, currently published studies suggest spiral enteroscopy may have a significant time savings [1] [2] [3] [4] with similar depth of insertion and diagnostic yield to push-and-pull enteroscopy. Future comparative studies will be needed.

Competing interests: Dr. Akerman has an equity interest in Spirus Corporation.

References

  • 1 Buscaglia J, Dunbar K, Okolo P. et al . The Spiral enteroscopy training initiative: results of a prospective study evaluation the Discovery SB overtube device during small bowel enteroscopy (with video).  Endoscopy. 2009;  41 194-199
  • 2 Akerman P, Agrawal D, Cantero D. et al . Spiral enteroscopy with the new DSB overtube: a novel technique for deep peroral small-bowel intubation.  Endoscopy. 2008;  40 974-978
  • 3 Morgan D R, Upchurch B R, Draganov P V. et al . Spiral enteroscopy: prospective multicenter US trial in patients with small bowel disorders.  Gastrointestinal Endoscopy. 2009;  69 AB127-AB128
  • 4 Esmail S, Odstrcil E A, Mallat D. et al . A single center retrospective review of spiral enterosocpy.  Gastrointestinal Endoscopy. 2009;  69 AB197
  • 5 Schembre D, Ross A. Spiral enteroscopy: a new twist on overtube-assisted endoscopy.  Gastrointest. Endosc ;  69 333-336
  • 6 Akerman P, Cantero D. Severe complications of spiral enteroscopy in the first 1750 patients.  Gastrointestinal Endoscopy. 2009;  69 AB127
  • 7 Akerman P, Cantero D, Pangtay J. Development of a new inflatable spiral is a potentially important advancement in spiral enteroscopy.   Gastrointestinal Endoscopy. 2009;  69 AB190

P. A. AkermanMD 

Rhode Island Hospital – University Gastroenterology

33 Staniford Street
Providence
RI 02905
USA

Fax: +1-401-421-2492

Email: pakerman@lifespan.org

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