A n d y P e tro ia n u
P e ro p e ra tiv e e n te ro sc o p y
Gastroenterology,
Nlltrition and Digestive Sllrgery Unit, University Hospital o/the
Universidade
Federal de
Minas Gerais - Belo Horizonte, Brazil
C u rre n t d ia g n o s tic a lte rn a tiv e s fo r le s io n s o f th e s m a ll in te s tin e a re s o m e tim e s in s u ffic ie n t. P e ro p e ra tiv e e n te ro s c o p y is p re s e n te d a s a u s e fu l m e th o d to id e n tify a n d tre a t in te s tin a l p o ly p o s is a n d a n g io d y s p la s ia s th a t c a n n o t b e fo u n d b y o th e r m e th o d s . T h is te c h n iq u e w a s u s e d o n tw o p a tie n ts . In b o th c a s e s , th is p ro c e d u re w a s h e lp fu l a n d th e a p p ro p ria te tre a tm e n t s u c c e s s fu lly c o m p le te d .
U N IT E R M S : E n d o s c o p y - p e ro p e ra tiv e , in te s tin a l b le e d in g , in te s tin a l tu m o r, p o ly p o s is , a n g io d y s p la s ia .
IN T R O D U C T IO N
U
c o lo n o s c o p yp p e r g a s tr o in te s tin a la r e w e ll- e s ta b lis h e d( G I ) e n d o s c o p yd ia g n o s tic a n da n d th e r a p e u tic m e th o d s f o r d is e a s e s o f th ee s o p h a g u s , s to m a c h , u p p e r d u o d e n u m a n d c o lo n o
H o w e v e r , p a th o lo g ic c o n d itio n s o f th e s m a ll in te s tin e m a y
b e d if f ic u lt to d ia g n o s is .
G Is e r ie s c la s s ic a lly id e n tif y I a r g e r in te s tin a l tu m o r s ,
s tr ic tu r e s o r d ila ta tio n s . A r te r io g r a p h ie s a n d s c in tig r a p h ie s
a r e a b le to s h o w a c tiv e b le e d in g s . C T s c a n s a n d u ltr a s o u n d
a r e v e r y u s e f u l to v e r if y th e p r e s e n c e o f la r g e r n e o p la s m s .
B u t e v e n w ith a ll th e s e m e th o d s , s o m e d is e a s e s , s u c h a s
a n g io d y s p la s ia s w ith o u t a c tiv e b I e e d in g s o r s m a ll tu m o r s ,
c a n n o t b e d ia g n o s e d . T h e e n te r o s c o p e is h e I p f u l to
c o m p le te th e in v e s tig a tio n o f th e s m a ll b o w e l, b u t it is
v e r y e x p e n s iv e , a n d o n ly f e w m e d ic a I c e n te r s m a y m a in ta in
th is k in d o f p a n e n d o s c o p e .
T h e p r e s e n t c o m m u n ic a tio n d e s c r ib e s a n e f f ic ie n t
m e th o d to p r e c is e ly id e n tif y s m a ll b o w e l d is e a s e s :
p e r o p e r a tiv e e n te r o s c o p y . T h is p r o c e d u r e w a s h e lp f u l in
tw o p a tie n ts .
A d d re s s fo r c o rre s p o n d e n c e :
A n d y P e tro ia n u
A v e n id a A fo n s o P e n a , 1 6 2 6A p to . 1 9 0 1 B e lo H o riz o n te /M G - B ra s il- C E P 3 0 1 3 0 -0 0 5
C A S E R E P O R T S
T h r o u g h a s m a ll m e d ia n s u p r a - u m b ilic a l I a p a r o to lllY ,
th e m id d I e p a r t o f je ju n u m is id e n tif ie d . A 2 - c e n tim e te r
je ju n o to m y is p e r f o r m e d a n d a p a n e n d o s c o p e is in tr o d u c e e l
a n d a d v a n c e d in to th e p r o x im a l je ju n u m ( F ig . I ) . T h e
e n d o s c o p e m u s t b e p r e v io u s ly c I e a n e d w ith io d in a te
s o I u tio n .
T h e s m a ll b o w e l is r u c k e d u p o v e r th e e n d o s c o p e
th a t r e a c h e s th e u p p e r d u o d e n u m . T h e n , b y in je c tin g a ir ,
it is p o s s ib le to o b s e r v e th e in te r n a I p a r t o f th e in te s tin e .
T h e tr a n s illu m in a tio n o b ta in e d w ith th e e n d o s c o p e lig h t
p e r m its a d ir e c t e x te r n a I v ie w o f th e e n te r ic w a l I . A f te r
a s p ir a tin g th e a ir , th e e n d o s c o p e is s lo w ly w ith d r a w n , a n e l
n e w in te s tin a l s e g m e n ts a r e s e e n . F o llo w in g a c o m p le te
s tu d y o f th e d u o d e n u m a n d u p p e r je ju n u lll, th e e n d o s c o p e
is a d v a n c e d in to th e d is ta I je ju n u m a n d ile u m , w h ic h a r e
r u c k e d u p o v e r it. T h e p r o c e s s d e s c r ib e d a b o v e i s u s e d to
a s s e s s th e r e s t o f th e s m a ll b o w e I . A t th e e n d o f th e
p r o c e d u r e , th e je ju n o to m y s ite s h o u ld b e c le a n e d w ith to p ic
io d in a te s o I u tio n .
T h is te c h n iq u e w a s s u c c e s s f u lly e m p lo y e d in tw o
p a tie n ts . A n 1 8 - y e a r - o I d m a n w a s d ia g n o s e d a s h a v in g
P e u tz - J e g h e r s s y n d r o m e w ith s e v e r e a n e m ia a n d p a r tia l
je ju n a l o b s tr u c tio n d u e to in te s tin a l p o I y p s . T h e je ju n U lT I
w a s o p e n a t th e s ite o f th e o b s tr u c tio n , 2 0 c e n tim e te r s a f te r
1374
Figure 1 -
T h e e n d o s c o p e (a rro w ) b e in g in tro d u c e d in to th e je ju n u m .Figure 2 -
P e u tz -J e g h e rs p o ly p s o f je ju n u m a n d ile u m re m o v e d e n d o s c o p ic a lly . O b s e rv e th e la rg e p o ly p (a rro w ) th a t w a s re m o v e d a lo n g w ith a s e g m e n t o f je ju n u m .the ligament ofTreitz. A large polyp was withdrawn, along
with part of the surrounding jejunum. The endoscope was
advanced
through the proximal jejunum
and duodenum.
Six polyps were found. and endoscopically
removed. The
endoscope
was withdrawn
and then advanced
into the
distaI
jejunum
and ileUlTI. Three
other
polyps
were
identified
and excised
(Fig.
2).The
patient
had an
uneventful postoperative
recovery, and his hemoglobin was
normal in two weeks.
S ã o P a u lo M e d ic a i J o u rn a l/R P M 1 1 5 (1 ): 1 3 7 3 -1 3 7 5 , 1 9 9 7
The second patient was an 18-year-old
WOlTIanwith
angiodysplasias
and severe anemia.
She was previollsly
submitted,
during
an eight-year
period,
to GI series,
enemas,
upper endoscopy,
colonoscopy,
angiography,
scintigraphy,
ultrasound
and CT scan of the abdolTIen
without identification
of the bleeding
source. Following
the procedure
described
above, the site of the bleeding
was found in the middle jejunum, and she was sllccessflllly
treated
(Fig. 3).
1375
Figure 3 -Identification of angiodysplasias (arro\tv)through the transillumination obtained form the light of the endoscope introduced into the jejunum.
DISCUSSION
W e used peroperative endoscopy to identify polyps
in a patient w ith Peutz-Jeghers syndrom e, and bIeeeling
intestinal angiodyspIasias in. another patient. T heir
treatm ents w ere precisely perform ed. T his m ethod is
sim ple and can be easily carried out in m ost hospitaIs
w ithout special traihing. T he endoscope is the sam e as
that routinely em ployed in upper G I eneloscopies, but
colonoscope m ay be also useel for this procedure.
W e beIieve that it is w orthw hile to consieler this
m ethoel to eliagnose anel eventually treat intestinal lesions
that cannot be identified by other techniques.
ACKNOW LEDGMENTS
T he author thanks Prof. D ulm ar G arcia C arvalho anel
D r. Silas C astro C arvalho for their assistance w ith the
endoscopies.
