Staged Retrograde Intraoperative Enteroscopy: Description of the 5-Step Surgical Technique for the Diagnosis and Treatment of Small Bowel Bleeding.

ABSTRACT

Background: Small bowel bleeding (SB) comprises 5%-10% of gastrointestinal (GI) bleeding cases. This article describes the staged retrograde intraoperative enteroscopy (SRIE) surgical technique for the etiological diagnosis and treatment of small bowel bleeding. Methods: SRIE was performed on patients with persistent SB at a quaternary university hospital in Brazil from 2020 to 2023. The technique is described in 5 steps, alongside visual aids, including images and a depicting a portion of the procedure. Patients presenting with confirmed coagulopathies, pregnancy, or unwillingness for surgery were excluded. Surgical procedures were performed after informed consent. Case Series Four participants were submitted to SRIE, including 2 females (64 and 83 years old), and 2 males (46 and 57 years old). Three out of four (75%) of the patients received a confirmed diagnosis of GI bleeding, attributed to angioectasia, acquired von Willebrand disease, and vitamin K deficiency. SRIE was conducted via enterotomy, involving a subsequent insufflation-inspection-deflation of 10 to 10 cm segments of the small bowel (Steps 1 to 5). The procedure was successfully executed in all four patients without complications, allowing confirmation of the etiological diagnosis of SB or exclusion of anatomical causes of hemorrhage. Conclusions: SRIE is a valuable but invasive tool for assessing SB hemorrhage when conventional imaging falls short. When performed systematically and standardized, it allows accurate visualization of SB using a standard endoscope.