Minimally Invasive Surgery Using Intra-operative Real-time Capsule Endoscopy for Small Bowel Lesions

The small bowel has been considered as the “black box” in gastroenterology and a small bowel bleeding point is difficult to detect. It is stressful for surgeons to perform an operation for a bleeding lesion, the exact site of which is unknown. We report the successful management of small bowel bleeding lesion by intra-operative real-time capsule endoscopy (CE) and minimally invasive surgery. Methods: This management was approved by the Ethical Review Board of Kawasaki Medical School Hospital. Beforehand, we developed a tool (KY-tube) that is similar to the Miller-Abbott double lumen tube, but thinner and longer compared to it. The KY-tube, a catheter of 10 Fr. in diameter and 450cm in length with an apical balloon, is very simple. The KY-tube is inserted nasally three or four days before the operation. Its balloon tip should reach the anus by the operative day. At the operation, a CE is connected to the balloon tip of the KY-tube as it protrudes from the anus. Next, an assistant pulls on the nasal end of KY-tube and, then, the balloon tip and CE are pulled into the bowel through the anus. A video system shows real-time images that the CE makes. Surgeons can find flashing CE through the bowel wall via a small skin incision or laparoscope. Result: We employed this procedure for two patients with repeated melena. Though both patients took various examinations, gastro-endoscopy and total colonoscopy, there was no bleeding lesion except for the small bowel. In these two cases, each bleeding lesion was thought to be located in the small bowel, but the exact site was unknown. Minimally invasive surgeries were performed for these patients, one by laparoscope and another by open mini laparotomy. In the laparoscopic case, though it was a little difficult to control the small bowel, a small tumor was detected by the real-time images the CE made and resection of the lesion was performed successfully. In the mini laparotomy case, it was easy to control the small bowel and CE – a bleeding lesion was detected clearly by real-time images the CE made. The operation was performed successfully. Conclusion: Contemporary CE by itself gives results that can only be read. Intra-operative CE combined with the KY-tube gives surgeons real-time images and shows the exact site of lesions. The KY-tube helps surgeons to control the CE position, aids suction of intra-luminal liquid or inflates intra-lumen to allow clear views. The procedure with the KY-tube and the CE seems to facilitate good management for small bowel lesions.