Post written by Partha Pal, MD, DNB, MRCP (UK), from the Asian Institute of Gastroenterology, Hyderabad, India.

This case describes a very rare instance of small-bowel transection (<1:1400 in our experience) after antegrade motorized spiral enteroscopy (MSE). The unpredictable adverse event was encountered during withdrawal of the enteroscope with the spiral overtube because of impaction deep into the mid-distal ileum. No difficulty was encountered during insertion except for inability to achieve total enteroscopy from the antegrade route.

However, that led to impaction of the spiral device deep into the small bowel, and resistance was encountered on withdrawal despite absence of luminal narrowing. Forward and backward rotation of the spiral overtube was performed as per user guidelines in the case of possible impaction or intussusception, which has been reported mainly in the esophagus and stomach. Detachment/impaction of the spiral overtube also has been reported in the deep small bowel.

Although there was loss of resistance after performing such a maneuver, small-bowel transection was noted on withdrawal and promptly managed with surgery and primary anastomosis.

We found that MSE was effective in achieving total enteroscopy with higher technical success, shorter time to greater depth, and higher total enteroscopy rates than single-balloon enteroscopy in a prospective study and 2 randomized controlled trials at our center, but reporting this extremely rare adverse event was important for 2 reasons.

Prompt withdrawal of the device in the case of nonprogression should be performed followed by enteroscopy from the opposite route. An impaction-related adverse event of the spiral overtube because of the built-in mechanism of “automatic deactivation” of the spiral motor can complicate the procedure. Secondly, stricter user guidelines for scope withdrawal in the case of nonprogression are warranted.

Small-bowel transection during MSE has not been reported in the literature. Reported adverse events were perforation (immediate/delayed), bleeding, and spontaneous detachment of the overtube. Impaction of the spiral overtube in the deep small bowel led to small-bowel transection in this case.

Although extremely rare in our experience, this can happen in prolonged procedures requiring total enteroscopy. The mechanism is impaction possibly because of intussusception, which has been reported with earlier manual spiral enteroscopy, as MSE uses rotational force to propel forward. Stopping enteroscopy from the antegrade route in the case of difficult or nonprogression followed by retrograde enteroscopy can help avoid this unpredictable, rare adverse reaction.

Despite considerable expertise, it may not be completely avoidable because of automatic deactivation of the overtube rotation while encountering resistance from the inbuilt mechanism and lack of tactile feedback. Hence, proper case selection and specific user guidelines in the case of nonprogression or device impaction are warranted.

A, Clip put at the depth of maximal insertion. B, Peritoneal cavity entered on withdrawal of enteroscope (arrow – liver). C, Lacerated end of the bowel on further withdrawal of enteroscope. D, Transected bowel in mid ileum (arrow) at laparotomy. E, Partially dislodged covering of overtube at proximal part (below) compared to normal, unused overtube (above). F, Detachment of the covering of spiral overtube and displacement of fins from underlying scaffold.

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