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Intraoperative Endoscopy; A Safe and Valuable Tool for the Diagnosis and Treatment of Midgut Pathology

Amanda Fazzalari, MD1, Shruthi Srinivas, BS1, Natalie Pozzi, MD2, Christopher Schlieve, MD1, Jonathan Green, MD1, Demetrius Litwin, MD, MBA, FACS1, David Cave, MD, PhD1, Mitchell Cahan, MD, MBA, FACS1. 1University of Massachusetts, 2Saint Mary’s Hospital

Objective: Intraoperative endoscopy (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 diagnosis and treatment of small intestinal bleeding (SIB) and non-adhesive obstructive small bowel disease (OSBD; Green et al., 2018). Existing literature lacks clear guidelines vis-a-vis 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 initial endoscopies are non-diagnostic and there is a suspicion for a resectable lesion (i.e tumor or diverticulum). 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 retrograde 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 is advanced as tolerated.

Conclusions: 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. 


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 93702

Program Number: P439

Presentation Session: Poster Session (Non CME)

Presentation Type: Poster

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