**2. Indications**

In the current era, despite the widespread use of DAE, IOE plays an important in the management of various GI disorders. In a 10-year study by Kopacova et al., the authors performed IOE in 41 patients with the commonest indication being obscure gastrointestinal bleeding followed by Peutz-Jeghers syndrome (PJS) [6]. The indications of IOE in the present scenario are as follows:


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*Role of Intraoperative Endoscopy in the Management of Small Bowel Diseases*

*Computed tomography - a 53-year-old lady presented with anemia, weight loss and recurrent abdominal pain for one year. On computed tomography, she was found to have thickening in the mid segment of the ileum (arrow) with proximal dilated bowel loops containing feculent material (A: Axial section, B – Coronal* 

in many cases for complete exploration of small bowel and resection of large or malignant polyps (**Figure 4**). In a recent study of 27 patients with PJS, the success rate of enteroscopy was 76% [14]. IOE was required in 4 patients which improved the complete treatment rate to 92%. IOE has also been shown to facilitate polyp resection, reduce the number of laparotomies [6] and

*Intraoperative enteroscopy via enterotomy of the patient with ileal thickening on computed tomography showing normal mucosal folds (A, B, C), a suspected vascular lesion (arrow, D), a small mucosal lesion (arrow, E) which was biopsied (F). No ileal stricture or significant mucosal disease was identified.*

• Familial adenomatous polyposis (FAP) – It is an autosomal dominant disorder characterized by development of premalignant adenomatous polyps in the colon. Moreover, these patients are at the risk of development of duodenal polyposis, duodenal cancer, jejunal and ileal polyps [16]. Most of these can be visualized using conventional upper gastrointestinal endoscopy and colonoscopy. CE and DAE are useful for the visualization of jejunal and ileal polyps. However, in FAP patients with history of abdominal surgery such as pancreatoduodenectomy for duodenal cancer or total proctocolectomy for colorectal

*DOI: http://dx.doi.org/10.5772/intechopen.95851*

**Figure 1.**

*section).*

**Figure 2.**

extensive bowel resection [15].

*Role of Intraoperative Endoscopy in the Management of Small Bowel Diseases DOI: http://dx.doi.org/10.5772/intechopen.95851*

#### **Figure 1.**

*Endoscopy in Small Bowel Diseases*

sitting

vision

sitting

**Table 1.**

Complete bowel examination is possible in same

Allows peritoneal, mesentery and omental examination and biopsy, if required

in patients with multiple lesions like PJS

The procedure is safe as it is performed under direct

Allows definitive treatment of the disease in the same

Minimizes the number of procedures and enterotomies

*Advantages and disadvantages of intraoperative endoscopy.*

IOE have been summarized in **Table 1**.

**2. Indications**

facilities. The reported success rate of IOE to achieve complete enteroscopy ranges between 57–100% in different series [1–10]. The advantages and disadvantages of

Anesthesia and laparotomy related complications

Availability of the endoscopy equipments and

Inability to negotiate the endoscope in case of

Inability to visualize the mucosa in case of

Enterotomy related complications

endoscopist at the time of surgery

dense bowel adhesions

massive bleeding

**Advantages of IOE Disadvantages of IOE**

In the current era, despite the widespread use of DAE, IOE plays an important in the management of various GI disorders. In a 10-year study by Kopacova et al., the authors performed IOE in 41 patients with the commonest indication being obscure gastrointestinal bleeding followed by Peutz-Jeghers syndrome (PJS) [6].

• Obscure gastrointestinal bleeding – It is recurrent or persistent bleeding from the unknown source in the GI tract that could not be identified on conventional endoscopy, colonoscopy and barium studies or enteroclysis [11]. Small bowel lesions account for 45–75% cases of obscure gastrointestinal bleed [11, 12]. In such cases, extensive investigations including enterography using computed tomography (CT) or magnetic resonance imaging (MRI), CE, DBE and RBC scan can often help in identifying the lesion (**Figure 1**). However, sometimes it is not possible to identify the site and cause of GI bleed in such patients despite exhaustive work-up. IOE is very helpful in detecting the mucosal lesions within the small bowel of patients with GI bleed (**Figure 2**). In a recent series of 67 patients with GI bleed, CE, colonoscopy, upper gastrointestinal endoscopy and DBE was performed in 96%, 87%, 87% and 73% cases respectively [10]. Despite these preoperative investigations, IOE was performed in 40% patients

• PJS – It is characterized by presence of multiple hamartomatous polyps throughout the GI tract, mucocutaneous pigmentation and an increased risk of GI cancers. These polyps are predominantly located in the small and can lead to several problems including recurrent abdominal pain, GI bleed, intussusception, bowel obstruction and perforation. As per the recommended guidelines, polyps more than 1 cm should be excised to prevent future complications [13]. Previously, these patients required surgical excision with or without IOE. But with the availability of DAE, many of these polyps can be removed endoscopically (**Figure 3**). Nevertheless, surgery and IOE is required

The indications of IOE in the present scenario are as follows:

with the diagnostic yield of 76% [10].

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*Computed tomography - a 53-year-old lady presented with anemia, weight loss and recurrent abdominal pain for one year. On computed tomography, she was found to have thickening in the mid segment of the ileum (arrow) with proximal dilated bowel loops containing feculent material (A: Axial section, B – Coronal section).*

#### **Figure 2.**

*Intraoperative enteroscopy via enterotomy of the patient with ileal thickening on computed tomography showing normal mucosal folds (A, B, C), a suspected vascular lesion (arrow, D), a small mucosal lesion (arrow, E) which was biopsied (F). No ileal stricture or significant mucosal disease was identified.*

in many cases for complete exploration of small bowel and resection of large or malignant polyps (**Figure 4**). In a recent study of 27 patients with PJS, the success rate of enteroscopy was 76% [14]. IOE was required in 4 patients which improved the complete treatment rate to 92%. IOE has also been shown to facilitate polyp resection, reduce the number of laparotomies [6] and extensive bowel resection [15].

• Familial adenomatous polyposis (FAP) – It is an autosomal dominant disorder characterized by development of premalignant adenomatous polyps in the colon. Moreover, these patients are at the risk of development of duodenal polyposis, duodenal cancer, jejunal and ileal polyps [16]. Most of these can be visualized using conventional upper gastrointestinal endoscopy and colonoscopy. CE and DAE are useful for the visualization of jejunal and ileal polyps. However, in FAP patients with history of abdominal surgery such as pancreatoduodenectomy for duodenal cancer or total proctocolectomy for colorectal

#### **Figure 3.**

*Peutz-Jeghers syndrome – The follow-up gastroscopy of the patient with Peutz-Jeghers syndrome one year after intraoperative enteroscopy and polyp excision showing multiple small polyps throughout the stomach (A). Few pedunculated polyps were present in the large bowel (B, C) which were excised endoscopically (D).*

#### **Figure 4.**

*Peutz-Jeghers syndrome – A 29-year-man presented with recurrent abdominal pain. On evaluation, he was found to have multiple polyps throughout the small and large intestine causing intussusception. At surgery, intraoperative enteroscopy via oral and anal route was performed and small polyps amenable to endoscopic resection were excised. Two large polyps, one in the transverse colon (A) and another in the proximal jejunum (B) were marked by endoscopy and excised surgically.*

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*Role of Intraoperative Endoscopy in the Management of Small Bowel Diseases*

can be used to achieve complete clearance [16].

cancer, diagnostic and/or therapeutic DAE can be difficult. In such cases, IOE

• Crohn's disease (CD) – It is an inflammatory bowel disease predominantly affecting the small intestine. The transmural inflammation leads to the development of deep ulcers causing GI bleeding and small bowel strictures causing intestinal obstruction. In presence of strictures, CE is contraindicated due to the risk of impaction. DAE also has its limitation in passing across the tight strictures making complete small bowel examination difficult. IOE helps in examining the mucosal side of the involved bowel segments to determine the disease activity. Previous studies involving CD patients have reported that IOE can identify new lesions not seen on preop-

Patients not responding to medical therapy or those who develop persistent GI bleeding or intestinal obstruction require surgical intervention. At surgery, multiple segments of small bowel with skip areas are often involved. The extent and type of surgery in such cases is difficult to ascertain. IOE allows complete small bowel examination and helps in surgical planning. In such cases, surgical intervention is most often performed for tight strictures (<15 mm diameter), stricture with active

IOE is also useful in CD patients undergoing emergency surgery for intestinal obstruction or perforation without prior endoscopic examination. In such cases, complete small bowel evaluation along with ileocecal junction is important to

• Bowel obstruction or perforation – Sometimes, patients presenting with small bowel obstruction or perforation without prior endoscopic evaluation may require IOE for appropriate surgical treatment. One such situation is the presence of multiple strictures on preoperative CT. Similar to CD, patients with multiple strictures due to other causes such as tuberculosis requiring emergency surgery for intestinal obstruction or perforation can undergo IOE in the same sitting if feasible to allow complete small bowel examination and avoid multiple surgeries (**Figure 5**). Another clinical situation is difficulty in identification of the cause of bowel obstruction. In one of our previously reported cases, a patient of moderately severe acute gallstone pancreatitis developed colonic obstruction in the follow up [19]. On CT abdomen, there was a resolving peripancreatic collection surrounding the transverse colon with grossly dilated ascending colon and small bowel loops. In order to rule out mucosal disease, IOE via enterotomy route was performed (**Figure 6**). As there was no mucosal disease, side-to-side ileo-transverse colonic anastomosis was

• Foreign body (FB) removal – Most of the cases of non-impacted FB ingestion can be managed conservatively. Sharp FB ingestion require endoscopic removal if feasible. Few cases with impacted FB in the small bowel not accessible to endoscopic removal or those who develop complications such as intesti-

Some cases with multiple FB ingestion located at different locations may require IOE to remove all the foreign bodies with minimum enterotomies. IOE can also help

in such cases to confirm complete clearance during the operation [20].

prevent postoperative complications and avoid repeated surgeries.

performed without colonic resection [19].

nal perforation require surgery.

*DOI: http://dx.doi.org/10.5772/intechopen.95851*

erative examination [17].

ulcer and bleeding ulcer [18].

cancer, diagnostic and/or therapeutic DAE can be difficult. In such cases, IOE can be used to achieve complete clearance [16].

• Crohn's disease (CD) – It is an inflammatory bowel disease predominantly affecting the small intestine. The transmural inflammation leads to the development of deep ulcers causing GI bleeding and small bowel strictures causing intestinal obstruction. In presence of strictures, CE is contraindicated due to the risk of impaction. DAE also has its limitation in passing across the tight strictures making complete small bowel examination difficult. IOE helps in examining the mucosal side of the involved bowel segments to determine the disease activity. Previous studies involving CD patients have reported that IOE can identify new lesions not seen on preoperative examination [17].

Patients not responding to medical therapy or those who develop persistent GI bleeding or intestinal obstruction require surgical intervention. At surgery, multiple segments of small bowel with skip areas are often involved. The extent and type of surgery in such cases is difficult to ascertain. IOE allows complete small bowel examination and helps in surgical planning. In such cases, surgical intervention is most often performed for tight strictures (<15 mm diameter), stricture with active ulcer and bleeding ulcer [18].

IOE is also useful in CD patients undergoing emergency surgery for intestinal obstruction or perforation without prior endoscopic examination. In such cases, complete small bowel evaluation along with ileocecal junction is important to prevent postoperative complications and avoid repeated surgeries.


Some cases with multiple FB ingestion located at different locations may require IOE to remove all the foreign bodies with minimum enterotomies. IOE can also help in such cases to confirm complete clearance during the operation [20].

*Endoscopy in Small Bowel Diseases*

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**Figure 4.**

*(B) were marked by endoscopy and excised surgically.*

**Figure 3.**

*Peutz-Jeghers syndrome – The follow-up gastroscopy of the patient with Peutz-Jeghers syndrome one year after intraoperative enteroscopy and polyp excision showing multiple small polyps throughout the stomach (A). Few* 

*Peutz-Jeghers syndrome – A 29-year-man presented with recurrent abdominal pain. On evaluation, he was found to have multiple polyps throughout the small and large intestine causing intussusception. At surgery, intraoperative enteroscopy via oral and anal route was performed and small polyps amenable to endoscopic resection were excised. Two large polyps, one in the transverse colon (A) and another in the proximal jejunum* 

*pedunculated polyps were present in the large bowel (B, C) which were excised endoscopically (D).*

#### **Figure 5.**

*Intraoperative enteroscopy via enterotomy of a patient with multiple small bowel strictures on computed tomography showing a narrow stricture in the proximal ileum (A). Rest of the small bowel showed mild mucosal edema at few places with no obvious strictures (B, C, D).*

#### **Figure 6.**

*Intraoperative enteroscopy via enterotomy of a patient with resolving acute pancreatitis and colonic obstruction showing mucosal edema at the site of obstruction (A, B) with grossly dilated colon loaded with feculent material (C).*


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*Role of Intraoperative Endoscopy in the Management of Small Bowel Diseases*

the patient is planned for abdominal surgery, then IOE can be performed in the

• Identification of the site of disease during surgery – In the era of DAE, most of the small bowel lesions requiring surgical excision are marked with India ink. However, in some cases were the ink is not visible or cases were the mucosal lesions were detected on CE such as ectopic pancreatic tissue, arteriovenous fistula, and hemangioma, IOE is useful for intraoperative localization.

• Lack of DAE facility – DAE is available at most centers in developed countries. However, in low income countries or in limited resource setting, IOE is a safe and effective alternative to DAE. It allows diagnosis and treatment of the small

IOE is mainly performed via conventional laparotomy. However, it can be performed by mini-laparotomy [22, 23] or laparoscopy [24–27]. IOE can be performed by gastroscope, colonoscope, pediatric scope or balloon enteroscope depending upon the probable site of the lesions, the indication for IOE and the availability of the equipments. In rare circumstances, IOE can be performed using a laparoscope [28]. IOE can be conducted through oral route, anal route and through an enterotomy site (**Figure 7**). The choice of the preferred route for IOE depends upon the location of the lesion. The patients are admitted before the procedure. All routine investigations including cardiorespiratory work up are done to rule out any contraindication for surgery. The day before the procedure the standard bowel preparation (the same as for colonoscopy) with either polyethylene glycol or sodium phosphate is given [29].

All the endoscopes and the accessories are sterilized before the procedure. The endoscopist has to scrub like any other member of the operating team. The part of the endoscope to be inserted in the operating field is covered with a plastic sleeve routinely used for laparoscopic procedures. This will help in maintaining the sterility

• Transoral endoscopy can be performed with the patient in supine or left lateral position [30]. Prior to the insertion of the endoscope, a nasogastric tube is placed to decompress the stomach. Subsequently, the nasogastric tube is

• Like the routine endoscopy, the gastroscope is passed in to the duodenum (**Figure 7A**). If the intraoperative endoscopy is pre-planned, then the endoscope can be passed as far as possible into the duodenum before the abdominal

incision to take benefit of the tamponade effect of the abdominal wall.

• During the passage of the endoscope, a loop tends to form along the greater curvature of the stomach and the 'C' of the duodenum. Once, the endoscope has reached the jejunum, the assistant surgeon can place the right hand along the greater curvature of the stomach and the left hand over the second part of the duodenum to straighten the endoscope. This will help in going further deep

*DOI: http://dx.doi.org/10.5772/intechopen.95851*

same sitting instead of DAE.

bowel diseases in the same sitting.

The patients are asked to fast for 6 hours before the surgery.

**3.1 Intraoperative endoscopy via oral route**

removed and the gastroscope is inserted.

in to the small bowel via the oral route.

of the procedure. The procedure is performed under general anesthesia.

**3. Techniques**

the patient is planned for abdominal surgery, then IOE can be performed in the same sitting instead of DAE.

