Spiral enteroscopy is a new technique for diagnosis and treatment of
small-bowel disease. In July 2009, a 19-year-old woman with Peutz–Jeghers
syndrome was sent to our hospital for screening and treatment. The patient had
undergone segmental resection of the distal jejunum, 4 years previously, for
acute intestinal obstruction due to large Peutz–Jeghers polyps.
After informed consent had been obtained, we chose antegrade spiral
enteroscopy for small-bowel investigation. The procedure was performed under
monitored anesthesia. A standard Fujinon EN-450P5 enteroscope with an Endo-Ease
Discovery SB overtube was used. The insertion depth of the enteroscope was
about 220 cm beyond the ligament of Treitz. The duration of the
procedure was 44 min.
During the investigation, a normal Roux-en-Y anastomotic stoma was
found at about 200 cm beyond the ligament of Treitz ([Fig. 1]), and eight IIa-type hyperplastic polyps of
size 3 – 8 mm were found nearby. Argon plasma
coagulation (APC) was used for treatment of these polyps.
Fig. 1 Endoscopic view, showing
the anastomotic stoma in the distal jejunum.
The procedure of investigation and treatment was successful, and no
bleeding occurred. However, the patient experienced severe abdominal pain after
2 h. The abdominal computed tomography (CT) scan showed
pneumoperitoneum. During emergent surgery, a perforation of 15 mm was
seen at the anastomotic stoma, and intraperitoneal adhesion was severe. The
patient was clinically stable after repair of the perforation, and was
discharged 5 days later.
Diagnostic double-balloon enteroscopy (DBE) has an overall
complication rate of 1.7 % (perforation 0.3 %,
pancreatitis 0.3 %, bleeding 0.8 %). Therapeutic
DBE has a relatively high complication rate of 4.3 % (APC
perforation 1.2 %, dilation perforation 2.9 %)
[1]. In patients with small-bowel anastomoses,
perforations occur easily during diagnostic DBE procedures [2]. The rate of perforation after spiral enteroscopy is
reported to be 0.34 % [3]. Spiral
enteroscopy has been successfully performed in patients with surgically altered
anatomies [4], with no reports of perforation until now.
In this case, perforation was found to have occurred because of prior surgery
not therapeutic procedures. Avoiding excessive tension may help to limit
complications including perforation.
Endoscopy_UCTN_Code_CPL_1AI_2AD
