Measurement of insertion depth in vivo was validated in the porcine model during progression and withdrawal. Estimation during progression was more accurate and allowed exploration dynamics and efficiency to be plotted, which might be used as approximate reference values for humans.
This article reports on the face, content, and construct validity of a new realistic composite simulator (Simuldog) used to provide training in canine gastrointestinal flexible endoscopy. The basic endoscopic procedures performed on the simulator were esophagogastroduodenoscopy (EGD), gastric biopsy (GB), and gastric foreign body removal (FBR). Construct validity was assessed by comparing the performance of novices (final-year veterinary students and recent graduates without endoscopic experience, n=30) versus experienced subjects (doctors in veterinary medicine who had performed more than 50 clinical upper gastrointestinal endoscopic procedures as a surgeon, n=15). Tasks were scored based on completion time, and specific rating scales were developed to assess performance. Internal consistency and inter-rater agreement were assessed. Face and content validity were determined using a 5-point Likert-type scale questionnaire. The novices needed considerably more time than the experts to perform EGD, GB, and FBR, and their performance scores were significantly lower (p<.010). Inter-rater agreement and the internal validity of the rating scales were good. Face validity was excellent, and both groups agreed that the endoscopy scenarios were very realistic. The experts highly valued the usefulness of Simuldog for veterinary training and as a tool for assessing endoscopic skills. Simuldog is the first validated model specifically developed to be used as a training tool for endoscopy techniques in small animals.
The use of CO(2) for insufflation during DBE was safe and no complications associated with CO(2) were observed. In addition, the use of CO(2) offers benefits over the use of room air for insufflation during DBE.
Double balloon enteroscopy (DBE) is an endoscopic technique broadly used to diagnose and treat small bowel diseases. Among the associated complications of the oral DBE, post-procedure pancreatitis has taken the most attention due to its gravity and the thought that it might be associated to the technique itself and anatomical features of the pancreas. However, as the etiology has not been clarified yet, this paper aims to review the published literature and adds new results from a porcine animal model. Biochemical markers, histological sections and the vascular perfusion of the pancreas were monitored in the pig during DBE practice. A reduced perfusion of the pancreas and bowel, the presence of defined hypoxic areas and disseminated necrotic zones were found in the pancreatic tissue of pigs. All these evidences contribute to support a vascular distress as the most likely etiology of the post-DBE pancreatitis.
Four pigs were subjected to enteroscopic exploration and divided into two groups: Double Balloon Enteroscopy (DBE group) and Spiral Enteroscopy (SE group). The explored length from the pylorus, the feed rate and the time of withdrawal were measured. 1 Simultaneous laparoscopic view allowed evaluation of the enteroscopy maneuvers.During laparoscopy control it was easy to see air trapped in the intestine bent over the overtube, mainly in the DBE group, whereas vascular stress of the bowel wall was higher in the SE group, which was probably related with the spiral torsion observed in the jejunal vessels and the root of the mesentery (Fig. 1). This was not observed in the DBE group. Nevertheless, subperitoneal ecchymosis was observed in both groups, but with higher significance in the SE group. Furthermore, a small tear in the visceral peritoneum appeared in one pig (Fig. 2).The small bowel examined was 219.6 Ϯ 12.7 and 180.0 Ϯ 14.1 cm long, the feed rate was 4.05 and 5.62 cm/min and the time of withdrawal was 67 and 138 s, for the DBE and SE groups, respectively.The vascular supply to the bowel was apparently more altered in the SE group, which is likely determined by a compressive effect of the DSB overtube on the intestinal wall and intense rotation of the root of the mesentery. Akerman et al. 2 indicate that small-bowel pleating is accomplished without apparent twisting of the small bowel because the mesentery attachment to the small bowel resists its rotation; however the laparoscopic visualization in the porcine model suggested that this process could be more iatrogenic than expected.The clockwise rotation of the DSB overtube mimics the motion of a corkscrew and pleats the small bowel onto the overtube, hence twisting the bowel and the mesenteric vessels in a more compressive way. The longer time of withdrawal in the SE could represent a clinical problem. 3
REFERENCES1. May A, Nachbar L, Scheneider M, Neumann M, Ell C. Pushand-pull enteroscopy using the double-balloon technique: Method of assessing depth of insertion and training of the enteroscopy technique using the Erlangen Endo-trainer. Endoscopy 2005; 37: 66-70. 2. Akerman PA, Agrawal D, Chen W, Cantero D, Avila J, Pangtay J. Spiral enteroscopy: A novel method of enteroscopy by using the Endo-Ease Discovery SB overtube and a pediatric colonoscope. Gastrointest. Endosc. 2009; 69: 327-32. 3. Schembre DB, Ross AS. Spiral enteroscopy: a new twist on overtube-assisted endoscopy. Gastrointest. Endosc. 2009; 69: 333-6.Fig. 1. Spiral Enteroscopy group. Clockwise torsion of the mesentery root. Fig. 2. Spiral Enteroscopy group. Ecchymosis (black arrow) and peritoneal tear (white arrows).
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