Keywords
motorized spiral enteroscope - power spiral enteroscopy - spiral overtube - rotational
movements - depth of maximum insertion - total enteroscopy
Introduction
Historically, endoscopic evaluation of deep small bowel started in 1971 using ropeway
and “sonde” enteroscopes. But did not achieve wide acceptance as they were cumbersome,
time consuming, and technically challenging. Later for the next three decades, the
push enteroscope using long endoscopes was used for the evaluation of the upper jejunum
only leaving the deeper small bowel uninvestigated. An intraoperative enteroscope
was also put into practice but it was invasive involving abdominal incision and enterotomy
and, thus, remained a less acceptable choice. In 2000, a wireless capsule endoscope
was introduced as a novel noninvasive method for the evaluation of small bowel mucosa,
and since then, we have witnessed an enhanced capability in the diagnosis of small
bowel diseases.[1]
In 2001, Yamamoto et al[2] introduced the double-balloon enteroscope which offers a detailed evaluation of
deep small bowel. Within a decade, this was quickly followed by the introduction of
a single-balloon enteroscope[3] and a spiral enteroscope[4] and later a novel through-the-scope balloon was also described for the same purpose.[5] These device-assisted enteroscopes (DAEs) not only allow detailed evaluation of
the small bowel mucosa but also allow us to carry out various therapeutic procedures
including tissue sampling, clip application, polypectomy, argon plasma coagulation,
foreign body removal, stricture dilatation, biliary interventions in surgically altered
anatomy, etc.[6] Additionally, total enteroscopy also became a reality with the introduction of these
techniques into our practice.[7] Despite a significant advancement, the above-described techniques still remain complex,
time-consuming, labor-intensive, cumbersome, and require refined endoscopic skills.
Also, long-length accessories might be required to pass through these long enteroscopes
to carry out various therapeutic interventions. These above challenges warrant further
refinement of the enteroscope which could offer us a faster, safer, and deeper evaluation
of small bowel on a more stable platform using a shorter length scope.
A novel motorized spiral enteroscope (MSE) was introduced in 2015 by Neuhaus et al,[8] and initial evidence indicates that MSE has tried to address these shortcomings
of the currently available DAE. In this review, we present the details of the equipment
and its specifications, procedure technique, indications and contraindications, current
evidence on this technology, and future improvements.
Device, Equipment, and Specifications
Device, Equipment, and Specifications
MSE was introduced as a power spiral enteroscope (PSE) in November 2015. It is a 168-cm-long
flexible reusable endoscope. The PSE carries a rotating coupler at around 40 cm from
the tip of the scope and an integrated motor just below the wheels on the enteroscope
([Fig. 1A, B]). It is fully compatible with the EVIS EXERA III and the latest EVIS X1 CV-1500
endoscopy systems (Olympus medical systems corporation, Tokyo) for usage. The device
specifications of PSE in comparison with other available enteroscopes are detailed
in [Table 1]. Additionally, the PSE unit comes along with other essential equipment such as (1)
control unit, (2) foot pedal, (3) force gauze, (4) disposable 24-cm-long spiral overtube,
(5) Bite block, (6) lubricating jelly specific for the enteroscope and spiral overtube,
and (7) connecting cables ([Fig. 2A–F]). To perform the procedure, additionally, we need a water flush pump, CO2 pump, 18-mm and 20-mm bougie dilators, tattooing ink, and fluoroscopy in our endoscopy
unit.
Fig. 1 (A) Power spiral enteroscopy with (B) integrated motor available below the wheels on the enteroscope.
Fig. 2 (A) Control unit, (B) foot pedal, (C) force gauze, (D) disposable 24-cm-long spiral overtube, (E) mouth piece, and (F) lubricating jelly.
Table 1
Device specifications of various enteroscopes
|
DAE system type
|
Single-balloon enteroscope
|
Double-balloon enteroscope
|
Balloon-guided enteroscope
|
Spiral enteroscope
|
PowerSpiral enteroscopy
|
|
Company
|
Olympus Tokyo, Japan
|
Fujifilm Corporation Tokyo, Japan
|
SmartMedical Systems Raanana, Israel
|
Spirus Medical Stoughton, Massachusetts, United States
|
Olympus Tokyo, Japan
|
|
Endoscope model
|
SIF-Q 180
|
EN-580T
|
No specific scope
|
No specific scope
|
PSF-1
|
|
Outer diameter distal end of endoscope
|
9.2 mm
|
9.4 mm
|
|
|
11.2 mm
|
|
Instrument channel
inner diameter
|
2.8 mm
|
3.2 mm
|
|
|
3.2 mm
|
|
Outer diameter of
Overtube
|
13.2 mm
|
13.2 mm
|
|
14.5 mm
|
18.1 and 31.1 mm
(with spiral)
|
|
Total length
|
2,345 mm
|
2,300 mm
|
|
|
2,015 mm
|
|
Working length
|
2,000 mm
|
2,000 mm
|
|
|
1,680 mm
|
|
Virtual
chromoendoscopy
|
Yes
|
Yes
|
Depend on
endoscope used
|
Depend on
endoscope used
|
Yes
|
Abbreviations: DAE, device-assisted enteroscope; PSE, power spiral enteroscope.
Setting Up the Equipment
The enteroscope needs to be liberally lubricated using the jelly provided by the manufacturer
(EndoLan) from the tip of the enteroscope to the rotational segment. The disposable
spiral overtube is 24-cm-long, 18-mm-wide overtube with pliable silicone spiral attached
on the outer surface of it making it altogether around 31 mm wide. The inner surface
of the spiral overtube has grooves. The spiral overtube is loaded onto the enteroscope
with a connector pointing toward the rotational segment of the enteroscope, and it
has to be adjusted gently such that the ridges on the rotational segment align with
the grooves of the spiral overtube. Further advancement locks the overtube in place
with a click. The lock collar on the overtube is further advanced onto the connector
to lock the assembly completely that is confirmed by the nonvisualization of the yellow
mark on the spiral overtube ([Fig. 3]).
Fig. 3 Power spiral enteroscopy after loading with spiral overtube and device specifications
and measurements.
The next step would be a system check. System check is done after the control unit
is turned on or the enteroscope has been replaced. As soon as the inspection mode
is turned on, the backward light starts blinking first on the force gauge and the
backward pedal has to be pressed to rotate the spiral overtube in a counter-clockwise
direction. While maintaining the anticlockwise rotation, the overtube is bent gradually,
and on the force gauge display, the changing forces can be appreciated. A manual squeezing
pressure in the middle of the overtube would increase the forces indicated on the
display and a continuous increase in squeeze pressure would activate the limit function,
and the rotational movement is automatically halted by the built-in safety function.
The same maneuver is repeated by pressing the forward pedal during clockwise rotation
of the spiral overtube. Pressing the backward pedal and forward pedal would cause
anticlockwise and clockwise movements of the spiral overtube, respectively. This would
be transmitted as backward or forward propulsion of the enteroscope in the small bowel.
Detailed information about the system assembly and setting up the equipment is available
on the manufacturer website (www. https://www.olympusprofed.com/gi/powerspiral/).
Indications
Patients with (1) suspected small bowel bleeding, (2) positive stool occult blood
with unrevealing upper endoscopic and colonoscopic study, (3) unexplained iron deficiency
anemia, (4) chronic diarrhea, (5) malabsorption and protein-losing enteropathy, (6)
foreign body obstruction, (7) radiologic imaging suggestive of mucosal thickening,
luminal narrowing, tumor, ulcer, bleeding, (8) unexplained pain abdomen, etc., in
the small bowel need enteroscopy for various diagnostic and therapeutic purposes,
and PSE can be considered in such cases.
Contraindications
While choosing PSE, a number of patient-related factors, underlying other gastrointestinal
diseases, and various miscellaneous factors are needed to be considered.
Patient-related factors like (1) severe comorbid illness causing medical instability,
(2) contraindication to general anesthesia, (3) contraindication to endotracheal intubation,
and (4) uncontrolled coagulopathy; underlying other gastrointestinal diseases like
(1) known intestinal perforation, (2) recent feeding jejunostomy tube placement (<2
weeks), (3) esophagogastric tumors/varices, (4) tumors/stenosis/metal stent prosthesis
in the esophagogastric/colonic location, (5) eosinophilic esophagitis, (6) severe
colitis, (7) surgically altered anatomy, and (8) radiation-induced mucosal changes;
and other miscellaneous factors like (1) children especially infants and toddlers,
(2) pregnancy, (3) failure to provide consent, and (4) inability to accept the mouth
piece are needed to be considered and any contraindications should be explored at.
Patient Preparation
The procedure is done under general anesthesia with preferably nasotracheal intubation.
The mouth piece is 35 mm wide and so adequate jaw opening and proper dental alignment
have to be checked before considering for PSE. All indications and contraindications
should be checked and a prior laboratory workup and anesthetic checkup should be completed
before the procedure. A thorough history including the use of anticoagulants should
be obtained. Overnight fasting is required for antegrade PSE, and an additional bowel
lavage preparation is required for retrograde PSE. The procedure is done with the
patient in the left lateral decubitus position or supine position. Gentle neck extension
is needed in antegrade PSE to allow smooth negotiation of the enteroscope loaded with
a spiral overtube. Findings of previously done investigations like upper endoscopy,
colonoscopy, radiologic imaging, capsule endoscopy were noted. This would pick up
any unnoticed contraindication, would guide the route of PSE, and also plan appropriate
therapeutic intervention if needed.
Technique of Power Spiral Enteroscope
Technique of Power Spiral Enteroscope
Prior esophageal bougie dilation over the guidewire up to 18 to 20 mm is encouraged
for all antegrade PSE procedures to facilitate the smooth passage of the enteroscope.
The technique of PSE grossly remains the same for antegrade and retrograde routes
of PSE.[9]
[10]
PSE is introduced via the mouth into the oral cavity and gently negotiated into the
upper esophagus. A forward foot pedal is activated as soon as the distal portion of
the spiral overtube reaches the incisors. This activates the clockwise spiral movements
of the overtube and aids in forward propulsion of the enteroscope. Maneuvers like
transient deflation of the cuff of the endotracheal tube and gentle extension of the
neck to straighten the pathway might be needed for smooth negotiation of the entire
overtube deep into the esophagus and stomach. A gentle forward push is maintained
while the forward pedal is activated to propel the enteroscope forward. When the double
marker at the 80-cm location of the enteroscope reaches incisors, it confirms that
the entire overtube has crossed the esophagogastric junction (EGJ). During the entire
procedure, we should remember that the scope tip is 16 cm ahead of the tip of the
spiral overtube as this is important while negotiating any stricture segment. CO2 insufflation would cause more distension and bloating up of the small bowel leading
to an ineffective procedure. So, as soon as the scope tip reaches the duodenum, CO2 is switched off and the small bowel is distended with intermittent water instillation.
This would allow better lubrication between the overtube and small bowel mucosa leading
to better scope-bowel engagement. PSE is propelled distally by continuous activation
of the forward pedal, gentle push onto the scope, intermittent water instillation,
gentle massage-like movements on the anterior abdominal wall, and also sometimes by
position change of patient. Through the procedure, the operator should be vigilant
of the signal on the force gauze that appears on the monitor in the picture-in-picture
mode. Whenever excessive pressure is sensed on the overtube while negotiating a stricture
or flexure or bend or a loop, the limit function gets active and the rotation ceases.
The operator may follow the above-described maneuvers in various combinations to overcome
these challenges and continue to perform the enteroscope. Appropriate therapeutic
intervention is performed whenever needed during the procedure. The procedure is continued
till the area of interest or till the maximum insertion point is reached. The operator
may stop the procedure at the maximal insertion point whenever it is perceived that
further advancement of PSE is not possible in the deep small bowel despite normal-looking
lumen. If a total enteroscopy or retrograde enteroscopy is warranted, then this area
is marked either with a clip or tattooing ink and this point is tried to reach via
the retrograde route in the same session or on a different day ([Fig. 4A,B]). During scope withdrawal, the backward pedal is activated which causes anticlockwise
rotation of the spiral overtube. Additional application of gentle backward traction
on the scope, CO2 insufflation into the small bowel, and gentle wiggling movements of the scope tip
using the wheels would allow smooth withdrawal of the scope. The small bowel is examined
during both insertion and withdrawal of the enteroscope and appropriate interventions
may be performed. For monitoring of end-tidal CO2, body temperature is necessary during the procedure. Fluoroscopy may be used whenever
deemed necessary to estimate the depth of insertion ([Fig. 5]), negotiating small bowel in surgically altered anatomy, presence of any bend or
any complication like perforation, etc. As the scope is nearing the 80-cm mark at
the incisors, care should be taken to ensure that the scope is entirely in the stomach
as this would avoid simultaneous engagement of the spiral overtube at the pylorus
and EGJ which would lead to difficult withdrawal of scope. Maneuvers like neck extension
and cuff deflation might be required during withdrawal of the scope also. Similar
steps might be applied while performing retrograde route of PSE as well except the
need to watch for the 80-cm mark. Standard length accessories like clips, injection
needles, balloon dilators, snares, forceps, coagulation probe, etc., can be passed
through the working channel of PSE to perform appropriate therapeutic interventions
wherever necessary. Any adverse events like mucosal abrasions, lacerations, tears,
perforation, etc., need to be identified and tackled, if necessary, in the same session.
The patient is observed in the recovery room for few hours and started on an oral
diet and discharged as per the clinical condition.
Fig. 4 Total enteroscopy: (A) marking clip placed during retrograde enteroscopy and (B) visualization of the same marking clip during antegrade enteroscopy.
Fig. 5 Use of fluoroscopy +/− contrast instillation to note the whorls and confirm the position
and direction of the scope and its tip.
Power Spiral Enteroscope versus Balloon-Assisted Enteroscope: Important Technical
Differences in Procedure
Power Spiral Enteroscope versus Balloon-Assisted Enteroscope: Important Technical
Differences in Procedure
Balloon-assisted enteroscope (BAE) and PSE are entirely different with respect to
technology and scope specifications. This brings us to the point of noting important
differences in the technical and procedural steps which are detailed in [Table 2].
Table 2
Differences in the principles and procedure steps between PSE and BAE
|
PSE
|
BAE
|
|
Principle
|
Rotational movements
|
Push-pull technique
|
|
Operator
|
Single
|
≥2
|
|
Periodic delooping of scope
|
May be needed during negotiation at high-pressure segments
|
Needed during each cycle of inflation and deflation
|
|
Accessories used
|
Standard length
|
Long dedicated accessories
|
|
Scope stability
|
Stable
|
Unstable
|
|
Safety in post-surgical anatomy
|
Limited literature
|
Extensive literature
|
|
Routine preprocedure esophageal dilation
|
Strongly advised
|
Advised only if there are strictures
|
|
General anesthesia
|
Mandatory especially in antegrade procedures
|
Not mandatory
|
|
Control of movements
|
Foot pedal-controlled movements
|
Manual control with operators hands
|
|
High-pressure alarm signal
|
Visual, rotational movements cease
|
Visual and auditory
|
|
Withdrawal during emergency situations
|
Not possible
|
Possible
|
|
Luminal insufflation during insertion
|
Water
|
Air/CO2
|
|
Luminal insufflation during withdrawal
|
CO2
|
Air/CO2
|
|
Check for dental alignment and jaw opening
|
Mandatory to fit in wide mouth piece
|
Not mandatory
|
|
Procedure time
|
Appears to be quicker
|
Longer
|
|
Confirmation of overtube position in stomach while withdrawal
|
Advised to inspect the 80-cm mark at scope
|
Not needed
|
|
Gentle neck extension
|
Frequently needed to allow passage of spiral overtube
|
Not always required
|
|
Deflation of cuff of endotracheal tube
|
Frequently needed to allow passage of spiral overtube
|
Not always required
|
Abbreviation: BAE, balloon-assisted enteroscope; PSE, power spiral enteroscope.
Performance of Power Spiral Enteroscope: Current Evidence
Performance of Power Spiral Enteroscope: Current Evidence
To date, no comparative study is available between PSE and other enteroscopes in terms
of performance, safety, and efficacy, diagnostic and therapeutic yield, procedure
time, depth of maximum insertion (DMI), etc. The published literature on PSE suggests
that median DMI is between 450 and 521 cm (distal to the ligament of Treitz via antegrade
route) and 120 and 140 cm (proximal to ileocecal valve) which is achieved in 40 and
61 minutes (via antegrade route) and 35 and 90 minutes (via retrograde route). Total
enteroscopy rates ranges between 10.6 and 70%. Most common indications for PSE include
small bowel bleeding, unexplained pain abdomen, chronic diarrhea, etc. We commonly
come across ulcers, strictures ([Fig. 6]), angiodysplasias ([Fig. 7]), tumors ([Fig. 8]), etc., which warrant tissue sampling. The most common therapeutic interventions
performed are argon plasma coagulation ([Fig. 9]), endoclip application, endoscopic mucosal resection, polypectomy ([Fig. 10]), stricture dilatation, etc.[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22] Biliary interventions can be performed in surgically altered anatomy with careful
negotiation of PSE across the surgical anastomotic site ([Fig. 11]). It is usually a safe procedure. The most common adverse events reported are mucosal
abrasions and lacerations ([Fig. 12]). Rarely severe adverse events like bowel perforation are also reported.[9] A detailed summary of currently available literature is summarized in [Tables 3] and [4]. In addition to enteroscopy, PSE is also described for colonoscopic examination.[23] Mean procedure time was 20.8 minutes, and cecal intubation was achieved in 96.7%.
Cecum was reached in 7.1 minutes. In total, 3.3% required external manual compression
during the procedure. The adenoma detection rate was 46.7%. Interventions like endoscopic
mucosal resection, forceps polypectomy, etc., were performed in 20 out of 30 patients.
Table 3
Performance of PSE (cohort studies)
|
Author name
|
|
Prasad et al[11] (2020)
|
Ramchandani et al[10] (2020)
|
Beyna et al[12] (2020)
|
Beyna et al[9] (2021)
|
Giordano et al[13] (2020)
|
Our experience (Abstract submitted to ESGE Days 2022)
|
|
n
|
|
14
|
61
|
30
|
132
|
28
|
44
|
|
Mean age (years)
|
|
55.57
|
45.67
|
64
|
68
|
57
|
42.98
|
|
Male gender (n)
|
|
10M
|
43M
|
14M
|
74M
|
17M
|
33M
|
|
Study design
|
|
case series
|
Retrospective
|
Prospective
|
Prospective
|
Prospective
|
Retrospective
|
|
Procedure indications
|
|
|
|
|
|
|
|
|
Route of procedure (%)
|
Antegrade
|
35.71
|
55.7
|
100
|
97
|
67.9
|
29.54
|
|
Retrograde
|
28.57
|
8.1
|
80
|
|
32.1
|
40.9
|
|
Bidirectional
|
35.71
|
36
|
80
|
|
|
29.54
|
|
Tissue sampling (%)
|
|
57.14
|
50.8
|
46.7
|
|
|
79.55
|
|
Median depth of maximal insertion (centimeters)
|
Antegrade
|
|
465
|
490
|
450
|
521
|
211
|
|
Retrograde
|
|
140
|
120
|
No
|
|
119
|
|
Procedure time (minutes)
|
Antegrade
|
61.1
|
40
|
51
|
54
|
|
46.12
|
|
Retrograde
|
90
|
35
|
40
|
No
|
|
35.09
|
|
Total enteroscopy (%)
|
|
35.71
|
60.6
|
70
|
10.6
|
|
13.36
|
|
Adverse events (n)
|
|
Mild odynophagia (3)
Superficial mucosal abrasion (3)
Hypothermia (3)
Pancreatitis (1)
|
Superficial mucosal injury and throat discomfort (15)
|
Deep mucosal tears (3)
Hematoma of jejunal wall (1)
Mild swallowing discomfort (1)
|
Deep mucosal tears (3)
Mild bradycardia and arterial hypotension (3)
Mild abdominal pain (4)
Fever (3)
Mild swallowing discomfort (3)
Mild acute parotitis (1)
Perforation (1)
Mallory-Weiss tear (1)
|
|
Cricopharyngeal laceration (n = 2)
Ileal mucosal laceration (n = 1)
Hypothermia (n = 1)
|
Abbreviation: ESGE, European Society of Gastrointestinal Endoscopy.
Table 4
Performance of PSE (case reports)
|
Author name
|
Age
|
Indication
|
Intervention
|
Procedure time
|
Route
|
Adverse events
|
|
González-Suárez et al[14]
|
56
|
Polypoid lesion in mid jejunum identified by capsule endoscopy
|
resection of polyp
|
50 minutes
|
Antegrade
|
No
|
|
González-Suárez et al[15]
|
48
|
angioectasias in the jejunum and ileum
|
Treating vascular lesions, biopsy
|
less than 1 hour
|
Antegrade
|
No
|
|
Rodge et al[16]
|
59
|
Active bleeding of jejunum suggestive of Dieulafoy's lesion
|
Hemoclip application
|
|
Antegrade
|
No
|
|
Inavolu et al[17]
|
36
|
CE device in proximal ileal loop
|
CE retrieval and stricture dilatation
|
|
Antegrade
|
No
|
|
Steiner et al[18]
|
73
|
biliary stones, pain, and cholestasis
|
|
|
Antegrade
|
Disconnection of spiral overtube. Retrieved using through the scope balloon
|
|
Mans et al[19]
|
71
|
Iron deficiency anemia, Occult GI bleed
|
Angiodysplasia treated with APC
|
|
Antegrade
|
No
|
|
Beyna et al[20]
|
78
|
Obstructive jaundice post Roux-en-Y reconstructive surgery and high bilateral bilioenteric
anastomosis
|
Stricture in right and left hepatic duct managed with balloon dilation
|
51 minutes
|
Antegrade
|
no
|
|
Neuhaus et al[8]
|
48
|
Angiodysplasia in jejunum identified by small bowel capsule endoscopy
|
APC done
|
|
Antegrade
|
no
|
|
Viesca et al[21]
|
70
|
melena and hematochezia
|
Control of bleed and biopsy
|
|
Antegrade, Retrograde, Total enteroscopy done
|
pulmonary embolism
|
|
Tang et al[22]
|
87
|
Small bowel bleeding
|
Multiple ulcers in the small bowel
|
58 minutes
|
Antegrade, total enteroscopy done
|
|
Fig. 6 Ulcers with stricture in small bowel.
Fig. 7 Jejunal angiodysplasias with recent hemorrhage.
Fig. 8 Jejunal tumor (adenocarcinoma) on white light examination and narrow band imaging.
Fig. 9 Argon plasma coagulation of the jejunal angiodysplasias.
Fig. 10 Polypectomy in jejunum.
Fig. 11 PSE-guided ERCP in patient with hepaticojejunostomy. ERCP, endoscopic retrograde
cholangiopancreatography; PSE, power spiral enteroscope.
Fig. 12 Ileal mucosal laceration noted upon withdrawal during retrograde PSE. PSE, power
spiral enteroscope.
Power Spiral Enteroscope: Advantages and Improvements
Power Spiral Enteroscope: Advantages and Improvements
PSE has arrived with some advancements and advantages which were lacking with BAE.
Shorter scope length, the requirement of only a single operator, better ergonomics
due to controlled motorized propulsion of enteroscope even in the deep small bowel,
stable scope position, shorter procedure time, usage of endoscopic accessories of
standard length, etc., represent the advantages of PSE. Due to these advantages, PSE
becomes an attractive option to consider for small bowel enteroscopy.[9]
[10]
Power Spiral Enteroscope: Shortcomings and Scope for Improvement in Future
Power Spiral Enteroscope: Shortcomings and Scope for Improvement in Future
A shorter length of scope and motorized control of rotational movements of the spiral
overtube make PSE an attractive option for performing small bowel enteroscopy. But
there are certain important points to note that might cause procedure challenges in
certain patient populations.
(1) The spiral overtube is wider and more rigid compared with the balloon overtube.
This was designed to offer better coupling and engagement of scope and small bowel/colon.
A dedicated wider mouthpiece is needed to facilitate a smooth insertion of the enteroscope.
A rotational coupler is a segment to offer more resistance during scope navigation.
We noted during our initial experience that there might be some technical and procedure
challenges in patients with low body mass index, thick and short neck, and dental
malalignment. Also, there is no widespread evidence available about its safety and
challenges faced in postoperative anatomy and pediatric patients. Literature reported
more frequent mucosal lacerations/injury with PSE. A thinner and less rigid spiral
overtube might be needed in a certain population as described above to facilitate
a smooth and safe insertion and withdrawal of the scope.
(2) The small bowel is curled and pleated over the spiral overtube and the scope behind,
immediate withdrawal of the scope in emergency untoward situations like cardiorespiratory
arrest requiring cardiopulmonary resuscitation, block of the endotracheal tube, or
accidental dislodgment of the endotracheal tube in the middle of the procedure.
(3) CO2 insufflation is recommended for usage during the PSE procedure. This requires monitoring
of end-tidal CO2, and thus, the procedure is performed under general anesthesia. Candidates who are
at poor anesthesia risk might not tolerate the procedure.
Conclusion
PSE is the new kid on the block for the evaluation of small bowel mucosa. It comes
with a spiral overtube which works with a rotational principle completely controlled
by the operator using a foot pedal. It appears to be quick, safe, and offers a stable
working platform using standard endoscopic accessories and can be performed by a single
operator. Currently, the evidence is limited to areas like Europe and India and more
data about its performance, safety, and efficacy are needed from other parts of the
world. Randomized trials comparing PSE and BAE are needed to understand the role of
PSE visa-vis BAE in small bowel enteroscopy. More evidence is needed in patients with
postoperative anatomy and in children.
