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ORIGINAL ARTICLE
Year : 2015  |  Volume : 11  |  Issue : 8  |  Page : 248-252

Two different endoscopic long intestinal tube placements for small bowel obstruction: Transnasal ultrathin endoscopy versus conventional endoscopy


1 Digestive Endoscopy Center, People's Hospital of Liaoning Province, Shenyang 110016, Liaoning, China
2 Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, P. R, China

Date of Web Publication26-Nov-2015

Correspondence Address:
Mei-Dong Xu
Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180, Fenglin Road, Shanghai 200032
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.170531

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 > Abstract 

Aim: To investigate and compare the effect on small bowel obstruction (SBO) of a long intestinal tube inserted by two different endoscopic placements which are transnasal ultrathin endoscopy and conventional endoscopy.
Patients and Methods: Twenty-nine patients who had been diagnosed as suffering from SBO underwent long tube insertion placed by transnasal ultrathin endoscopy were included as subjects. Thirty-two patients who had undergone insertion of a long tube placed by conventional endoscopy were included as controls. The success rate of intubation of the small bowel, the time required for the procedure, and complications were compared between the subjects and controls.
Results: The success rate of intubation was 100% (29/29) in subjects and 93.8% (30/32) in controls, without a significant difference (P = 0.493). There are 2 failed cases that the procedure was attempted near 60 min in 2 patients who had performed Billroth II anastomosis before, and the intestinal tube could not be inserted into efferent loops of jejunum in controls. The mean time required for the procedure was 15.3 min in subjects and 22.9 min in controls, respectively, and with a significant difference (P < 0.001). Epistaxis occurred in both groups, and 2 cases encountered bleeding of the gastrointestinal tract in controls.
Conclusion: Long tube insertion facilitated by transnasal ultrathin endoscopy takes shorter time and has a higher success rate compared with the procedure conducted with the help of conventional endoscopy. It is safe and useful to insert a long intestinal tube assisted by transnasal ultrathin endoscopy for the decompression of small bowel.

Keywords: Conventional endoscopy, long intestinal tube, small bowel obstruction, transnasal ultrathin endoscopy


How to cite this article:
Li S, Yuan C, Xu MD. Two different endoscopic long intestinal tube placements for small bowel obstruction: Transnasal ultrathin endoscopy versus conventional endoscopy. J Can Res Ther 2015;11, Suppl S4:248-52

How to cite this URL:
Li S, Yuan C, Xu MD. Two different endoscopic long intestinal tube placements for small bowel obstruction: Transnasal ultrathin endoscopy versus conventional endoscopy. J Can Res Ther [serial online] 2015 [cited 2020 Jan 24];11:248-52. Available from: http://www.cancerjournal.net/text.asp?2015/11/8/248/170531


 > Introduction Top


Small bowel obstruction (SBO) is a common problem in general surgery and is associated with considerable morbidity and mortality. It is commonly caused by postoperative adhesions, and sometimes by the recurrence and metastasis of the abdominal tumor. The conventional method is to intubate a common nasogastric tube, which can only suction the fluid in the stomach, and has limited effects.[1] In recent years, the long intestinal tube has been applied for intestinal decompression and proved to be efficient and necessary for the treatment of patients who suffer the SBO, especially those with partial obstruction. The early studies reported that most long intestinal tubes are inserted only under fluoroscopy which had some disadvantages such as the long operation time and the exposure to more radiation.[2],[3],[4]

As the endoscopic technique develops, more investigators have tried endoscope-guider intubation to facilitate the procedure.[5],[6],[7] A novel endoscopy with a transnasal ultrathin endoscopy was shown to be more convenient and better tolerated by patients.[8] However, although there are some researchers reporting the advantages of placing the long intestinal tube with the help of transnasal ultrathin endoscope over placing the tube under fluoroscopy, few investigators have compared the effects of transnasal ultrathin endoscopy and conventional endoscopy for placement of a long intestinal tube in patients with SBO.[9],[10] So we conducted a prospective, randomized, controlled trial to evaluate the effects of these two different endoscopic methods for long tube insertion for SBO. The results are reported here.


 > Patients and Methods Top


Patients

From 2009 to 2014, 61 consecutive patients who were diagnosed with SBO by the radiologic examination and/or computed tomography (CT) were enrolled in this study (30 women and 31 men; mean [standard deviation] age 57.5 ± 14.8 years, range 23–86 years). All the patients who had operation history of tumors (digestive tumor, urologic tumor, or female genital tumor) took the positron emission tomography-CT examination to figure out if the SBO was caused by the recurrence or metastasis of the tumor.

The patients were randomly assigned to two groups: Group A (n = 29), in which the transnasal ultrathin endoscopy was used, as subjects, and Group B (n = 32), in which the conventional endoscopy was used, as controls.

Instruments

We perform transnasal ultrathin endoscopy with an endoscope (GIF-XP260, Olympus, Japan), which has a 5.9 mm outer diameter, an accessory channel of 2.0 mm, and a working length of 110 cm. Conventional endoscopy was accomplished with an endoscope (GIF-H260, Olympus, Japan), which has a 9.8 mm outer diameter, an accessory channel of 2.8 mm, and a working length of 110 cm. The long intestinal tube used in the present study has an outer diameter of 16 Fr, a working length of 3000 mm, a positioning balloon and a leading balloon at its tip, a guidewire channel, and an injection channel with an antireflux valve. The Cliny guidewire we used has a working length of 4200 mm and an outer diameter of 0.052 inch (Create Medic Co., Japan).

Procedure

Transnasal ultrathin endoscopy

After a topical anesthesia, the transnasal ultrathin endoscope, of which the front end was coated with lidocaine hydrochloride mucilage, was inserted nasally into at least the second portion of the duodenum or beyond, the Cliny guidewire was then introduced through the working channel into the upper jejunum. After that, the endoscope was carefully removed from the gastrointestinal (GI) tract, with the guidewire left in place. The long intestinal tube was advanced over the guidewire into the jejunum, and the balloon was inflated with 15–20 mL distilled water, and the Cliny guidewire was carefully removed.

Conventional endoscopy

The long intestinal tube, of which the front end was tied with multistrand black silk suture and coated with lidocaine hydrochloride mucilage, was inserted into the stomach via nasal cavity. Then, the endoscope was advanced through the mouth and esophagus into the stomach, and the suture at the tip of the tube was grasped by the grasping or foreign body forceps. The endoscope and tube were advanced through the pylorus and duodenum and as far into the jejunum as possible. The balloon was inflated with air until it engaged the wall of the bowel, usually 60 ml; the forceps released the suture, and the endoscope was removed leaving the tube in the jejunum. The air was aspirated from the balloon, and 15–20 ml water was injected into the balloon.

After the intubation, the contrast agent was injected via intestinal tube under fluoroscopy to confirm that the balloon was beyond the descending part of duodenum or jejunum; otherwise, the tube should be inserted again.

In both procedures, the afferent loop and efferent loop were identified under fluoroscopy before the intubation of intestinal tube for patients who had performed Billroth II anastomosis, and then the tube was introduced into the efferent loop under fluoroscopy.

Both procedures were performed by a team including 1 endoscopist and 1 nurse. The endoscopists who performed insertion by transnasal ultrathin endoscopy have 4–5 years of experience and who performed insertion by conventional endoscopy have 5–10 years of experience. All the operators had undergone at least 10 cases of long tube insertion with either method before participating in this study.

Outcome measurements

There are three main outcome measurements in this study: (1) Procedure time: We defined it as the total time from the insertion of the ultrathin endoscope (Group A) or intestinal tube (Group B) via nasal cavity until the guideline (Group A), or the endoscope (Group B) was removed and then insure that the tube intubation succeeded under fluoroscopy. (2) Success rate: Successful intubation was defined as the balloon in the front end of the long tube was beyond the descending part of the duodenum or further jejunum which was observed by injecting contrast agent via intestinal tube under fluoroscopy. If the long tube could not be inserted into the jejunum or the procedure could not be finished in <60 min, the procedure should be stopped in order to avoid increasing the discomforts of patients, and the procedure was regarded as a failure. (3) Complications: Complications included bleeding or perforation caused by damage and laceration of GI tract mucosa and epistaxis related to the operation.

Statistical analysis

Statistical differences were assessed by the Mann–Whitney U-test between 2 independent groups and by the χ2 test or the Fisher exact test between 2 proportions. A statistical significance was defined as a value of P < 0.05.


 > Results Top


The patient demographic data are shown in [Table 1]. There was no significant difference of the mean age or the sex between Group A and B. There were 4 patients in Group A and 5 patients in Group B, who had performed Billroth II anastomosis respectively. Similarly, there was no significant difference of ratio of cause of SBO and patients with history of Billroth II anastomosis between two groups.
Table 1: Clinical characteristics of the patients

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The outcomes of long tube insertion by two methods are shown in [Table 2]. There was significant difference of procedure time between two groups, which it took shorter time in patients of Group A than those of Group B. Moreover, the total success rates and success rates of patients who had a history of Billroth II anastomosis were higher in Group A but without a significant difference. Epistaxis occurred in 8 patients of Group A and 7 patients of Group B, which was stopped by local compression. In two patients of Group B, bleeding of GI tract took place when the endoscope and intestinal tube twined around each other, and patients felt nausea, leading to the cardiac orifice mucosal laceration. Bleeding was staunched by endoscopic therapy. However, the rate of complications did not have a significant difference between two groups.
Table 2: Outcomes of long tube insertion by the transnasal ultrathin endoscopy method (Group A) and the conventional endoscopy method (Group B)

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 > Discussion Top


SBO is usually caused by postoperative adhesion and occasionally caused by recurrence and metastasis of abdominal tumor. Most obstructions are partial, without necrosis or strangulation.[1] For patients with adhesive SBO, nonoperative treatment is equally safe and efficient compared with operative treatment, with lower risk of morbidity and mortality.[2],[3],[11] Moreover, for patients who have SBO due to the recurrence and metastasis of an abdominal tumor, decompression of the small bowel by intubation of the long intestinal tube considers to be preferred therapy. The method has changed a lot in recent years. The conventional method is to place the tube under fluoroscopy. Operators first insert the tube via the nasal cavity into the stomach then require the patient to change the position for manipulation of the tube through the pylorus and into the duodenum or jejunum. It costs much time and increases the risk of the radiation exposure to both patients and operators with a comparatively lower success rate.

In 1973, Keller first introduced a new technique of intestinal intubation with endoscope in which a line was tied to the metal tip of the long tube and pulled from the biopsy forceps via biopsy channel, and then the tube can be easily inserted into the duodenum with the help of biopsy forceps.[12] This method has been widely used by endoscopists, and the technique has been improved afterward.[13],[14] However, the endoscopic procedure increases the discomfort and compliance of patients, and the intestinal tube could be pulled out during the withdrawing of the endoscope due to the fiction and close relationship between them. The procedure can be hard, especially in patients after Billroth II anastomosis, for the afferent loop and efferent loop sometimes are difficult to distinguish under endoscopy. Moreover, as the anastomotic stoma has a certain angle, it is really tough to get through it into efferent loop with the endoscope and tube together.

In 1984, Kawamura et al. reported on a unique method, in which the endoscope was inserted through the nostril rather than through the mouth before the long tube placement. However, the endoscope used in the study had an outer diameter of approximately 8–9 mm, which was designed for oral insertion. In this case, patient felt much pain during the procedure, and the insertion cannot be accomplished in the patient with narrow nasal cavity or nasal inflammation, so the procedure did not get widely used in early years.[6] More recently, new ultrathin endoscope with an outer diameter of approximately 5–6 mm has been widespread and with an advantage of unsedation and better tolerance of patients.[15] There are some reports comparing the effects of the intestinal intubation under transnasal ultrathin endoscopy to fluoroscopy only; the results reveal that under transnasal ultrathin endoscopy is superior to only under fluoroscopy.[9],[10]

Our experience is that both procedures should be conducted in the room equipped with X-ray machine. The radiography is mainly for confirming whether the procedure is success or not after the intubation. In the patients after Billroth II anastomosis, the radiography should be conducted before the intubation to distinguish afferent loop from efferent loop, and endoscopist inserts the tube into efferent loop under fluoroscopy. Otherwise, the radiography is not necessary during the intubation.

We found in our study that in the group of transnasal ultrathin endoscopy, the procedure time was significantly shorter, and patients had better tolerance. One reason is that, in the conventional endoscopy group, longer time is needed, because tube and endoscope entered the esophagus at the same time, the procedure slowed down due to the friction. In particular, the insertion could increase discomfort of patients when getting through the pylorus and anastomotic stoma, leading to longer procedure time. The other reason is that the long tube was easily pulled out because the endoscope and tube rubbed and even twined around each other, so the endoscope should be withdrawn slowly. Relatively, ultrathin endoscope could easily move through the pylorus and anastomotic stoma for its smaller diameter, and the tube could not be pulled out when withdrawing the guidewire.

Although the total success rate and the success rate in patients with history of Billroth II anastomosis of ultrathin transnasal endoscopy was higher than those of conventional endoscopy, the difference was not significant. We think that the sample size was not enough to get a significant result, but the intubation could more probably succeed by ultrathin transnasal endoscopy, especially in patients who had done Billroth II anastomosis. In these patients, the changed anatomy of GI tract, the smaller dimension of anastomotic stoma and anastomosis made the intubation more difficult. There are 2 failed cases in the controls that the procedure was attempted near 60 min in patients who had performed Billroth II anastomoses before, and the intestinal tube could not be inserted into efferent loops of jejunum by conventional endoscopy, mainly because of the small anastomotic stoma and the complexed anatomy. With the help of ultrathin transnasal endoscope, the procedure could be done more easily, as the insertion of the tube and endoscope is not simultaneous, avoiding the conflicts between them. And like other reports revealed, patients who have experienced ultrathin endoscopy are more likely to tolerate the procedure.[15],[16] However, if the patients had narrow nasal route, they would felt more uncomfortable, and endoscopists found transnasal introduction more difficult in these patients. Hence, conventional endoscopy may be more suitable for them.[17]

Epistaxis is the most common complication of the procedure in both groups. There are 8 cases in subjects and 7 cases in controls occurring epistaxis, respectively. The incidence is a little higher in subjects than that in controls, without a significant difference. We found that in the early period of clinical practice of using transnasal ultrathin endoscope, when the endoscopists were unfamiliar with the anatomy of nasal route, the occurrence of epistaxis is higher. As the expertise improved, the occurrence decreased. However, epistaxis existed inevitably in both groups, for the intestinal tube was introduced via nasal cavity without direct observation. Epistaxis is a common complication, but not severe, and could be stopped by local compression. There are two more serious complications during the procedure which are bleeding and perforation of GI tract. In our study, no patients encountered perforation, but 2 patients who had performed Billroth II anastomosis occurred bleeding in controls. It took place when the endoscope and intestinal tube twined around each other, and patients felt nausea, leading to the cardiac orifice mucosal laceration. Bleeding was staunched by endoscopic therapy, and the procedure time increased as a consequence. In subjects, the ultrathin transnasal endoscope could move through the anastomotic stoma easily, and patients felt less discomfortable, decreasing the risk of nausea and bleeding. Although there was no significant difference between two groups, probably due to limited sample size, we think intubation used by ultrathin transnasal endoscope is safer and faster than that assisted by conventional endoscope, especially in patient with Billroth II anastomosis.

There were some limitations in our study, however. First, both groups did not have data of the effects of the procedure postoperatively, for example, the volume of drainage and anus exhaust time. Second, because the procedures were conducted by different endoscopists with different experience and proficiency, the expert bias cannot be ignored. Third, we did not use visual analog scale score or other assessments to investigate the discomforts of people by two different procedures.


 > Conclusion Top


We strongly recommend that the placement of the long intestinal tube should be done by the transnasal ultrathin endoscope, especially for patients who performed Billroth II anastomosis. The method is superior to the conventional endoscope method with shorter procedure time, less complications, and higher success rates. Further research should be conducted by more institutions with more cases, and we believe that this technique can be widely used in the future for patients with SBO.

Financial support and sponsorship

This study was supported by the grants from the Major Project of Shanghai Municipal Science and Technology Committee (14441901500 and 15JC1490300), National Natural Science Foundation of China (81302098, 81370588 and 81201902). No other financial relationships relevant to this publication were disclosed.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

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Wilson MS, Ellis H, Menzies D, Moran BJ, Parker MC, Thompson JN. A review of the management of small bowel obstruction. Members of the surgical and clinical adhesions research study (SCAR). Ann R Coll Surg Engl 1999;81:320-8.  Back to cited text no. 1
    
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Fevang BT, Jensen D, Svanes K, Viste A. Early operation or conservative management of patients with small bowel obstruction? Eur J Surg 2002;168:475-81.  Back to cited text no. 2
    
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Williams SB, Greenspon J, Young HA, Orkin BA. Small bowel obstruction: Conservative vs. surgical management. Dis Colon Rectum 2005;48:1140-6.  Back to cited text no. 3
    
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Cox MR, Gunn IF, Eastman MC, Hunt RF, Heinz AW. The safety and duration of non-operative treatment for adhesive small bowel obstruction. Aust N Z J Surg 1993;63:367-71.  Back to cited text no. 4
    
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Gowen GF. Long tube decompression is successful in 90% of patients with adhesive small bowel obstruction. Am J Surg 2003;185:512-5.  Back to cited text no. 5
    
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Kawamura R, Okabe M, Misumi A. Rapid long tube intubation of the jejunum – An improved technique. Jpn J Surg 1984;14:299-304.  Back to cited text no. 6
    
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Byrne KR, Fang JC. Endoscopic placement of enteral feeding catheters. Curr Opin Gastroenterol 2006;22:546-50.  Back to cited text no. 7
    
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Dumortier J, Josso C, Roman S, Fumex F, Lepilliez V, Prost B, et al. Prospective evaluation of a new ultrathin one-plane bending videoendoscope for transnasal EGD: A comparative study on performance and tolerance. Gastrointest Endosc 2007;66:13-9.  Back to cited text no. 8
    
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Sato R, Watari J, Tanabe H, Fujiya M, Ueno N, Konno Y, et al. Transnasal ultrathin endoscopy for placement of a long intestinal tube in patients with intestinal obstruction. Gastrointest Endosc 2008;67:953-7.  Back to cited text no. 9
    
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Kanno Y, Hirasawa D, Fujita N, Noda Y, Kobayashi G, Ishida K, et al. Long intestinal tube insertion with the ropeway method facilitated by a guidewire placed by transnasal ultrathin endoscopy for bowel obstruction. Dig Endosc 2009;21:196-200.  Back to cited text no. 10
    
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Wolfson PJ, Bauer JJ, Gelernt IM, Kreel I, Aufses AH Jr. Use of the long tube in the management of patients with small-intestinal obstruction due to adhesions. Arch Surg 1985;120:1001-6.  Back to cited text no. 11
    
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Keller RT. A technique of intestinal intubation with the fiberoptic endoscope. Gut 1973;14:143-4.  Back to cited text no. 12
    
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Chung RS, Denbesten L. New procedures. Improved technique for placement of intestinal feeding tube with the fibreoptic endoscope. Gut 1976;17:264-6.  Back to cited text no. 13
    
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Chang WK, McClave SA, Chao YC. Simplify the technique of nasoenteric feeding tube placement with a modified suture tie. J Clin Gastroenterol 2005;39:47-9.  Back to cited text no. 14
    
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Dean R, Dua K, Massey B, Berger W, Hogan WJ, Shaker R. A comparative study of unsedated transnasal esophagogastroduodenoscopy and conventional EGD. Gastrointest Endosc 1996;44:422-4.  Back to cited text no. 15
    
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Garcia RT, Cello JP, Nguyen MH, Rogers SJ, Rodas A, Trinh HN, et al. Unsedated ultrathin EGD is well accepted when compared with conventional sedated EGD: A multicenter randomized trial. Gastroenterology 2003;125:1606-12.  Back to cited text no. 16
    
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Craig A, Hanlon J, Dent J, Schoeman M. A comparison of transnasal and transoral endoscopy with small-diameter endoscopes in unsedated patients. Gastrointest Endosc 1999;49(3 Pt 1):292-6.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2]



 

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