Device-assisted enteroscopy: Are we ready to dismiss the spiral?

Abstract

Motorized spiral enteroscopy (MSE) is the latest advance in device-assisted enteroscopy. Adverse events related to MSE were discussed in a recent large systematic review and meta-analysis and were directly compared with those of balloon enteroscopy in a case-matched study and a randomized controlled trial. Following the real-life application of MSE, an unexpected safety issue emerged regarding esophageal injury and the technique has been withdrawn from the global market, despite encouraging results in terms of diagnostic and therapeutic yield. We conducted an Italian multicenter real-life prospective study, which was prematurely terminated after the withdrawal of MSE from the market. The primary goals were the evaluation of MSE performance (both diagnostic and therapeutic) and its safety in routine endoscopic practice, particularly in the early phase of introduction in the endoscopic unit. A subanalysis, which involved patients who underwent MSE after unsuccessful balloon enteroscopy, demonstrated, for the first time, the promising performance of MSE as a rescue procedure. Given its remarkable performance in clinical practice and its potential role as a backup technique following a previously failed enteroscopy, it may be more appropriate to refine and enhance MSE in the future rather than completely abandoning it.

Keywords: AGREE classification; Adverse events; Diagnostic yield; Motorized spiral enteroscopy; Rescue enteroscopy.

Figure 1

The two cases of motorized spiral enteroscopy esophageal entrapment during withdrawal. A: A 49-year-old female patient (body mass index 18) with familiar adenomatous polyposis and a small tubular adenoma of the jejunum resected by en bloc polypectomy. Final inspection documented linear laceration of the cervical esophagus; B: A 29-year-old female patient (body mass index 20) with Peutz–Jeghers syndrome and a major jejunal polyp (25 mm), which was resected by piecemeal mucosal resection and retrieved with a net snare; circumferential and deep laceration of the cervical esophagus was seen during withdrawal.

Figure 2

A 21-year-old female patient with juvenile polyposis associated with Osler–Weber–Rendu disease (hereditary hemorrhagic telangiectasia) and a 10-mm hamartomatous polyp of the jejunum. A: Single balloon enteroscopy was used to reach the medium jejunum; B: A tattoo with submucosal ink was placed at the maximum insertion depth; C: A few months later, the same endoscopist performed motorized spiral enteroscopy, reaching the distal jejunum: D: The polyp could be detected and easily removed with standard polypectomy. Note the different looping of the scope in the fluoroscopic view.