Intraoperative Enteroscopy for the Identification of Obscure Bleeding Source Caused by Gastrointestinal Angiodysplasias: Through a Balloon-tip Trocar is Better

Aim: Intraoperative Enteroscopy (IE) is a valid diagnostic tool which can be adopted in order to identify the precise location of bleeding gastrointestinal angiodysplasias (GIADs) of the small bowel. We describe a novel IE technique that may increase the diagnostic yield by maintaining a steady distension of the bowel and that prevents microtrauma to the intestinal mucosa and spillage of enteric content into the operative field. Methods: After laparotomy, a centimetric transverse enterotomy is performed approximatively at the middle of the small bowel. A 12mm trocar with balloon is than introduced and insufflated. The small bowel is gently distended by carbon-dioxide insufflation. Through the trocar, a paediatric colonscope is then inserted and the enteroscopy is performed either retrogradely to the duodenum or anterogradely to the cecum. Once located, surgery is tailored to the precise site of bleeding, with a consequent sparing of intestinal resection. Results: IE with 12mm trocar with balloon was adopted in four elderly patients undergoing surgery for bleeding GIADs. The length of small bowel resection ranged from 10 to 200 cm, depending on the number of GIADs. Operating time ranged from 210 to 275 minutes. Intraoperative blood loss was nihil. No patient developed organ-space or wound infections. There was no recurrence of bleeding from the midgut. Conclusion: Performing IE through a balloon trocar may increase the diagnostic accuracy of the procedure with the benefit of reducing the risk of traumatic injury to the bowel and the risk of surgical site infection.