Endoscopic overtube-guided deployment of a video capsule endoscope

A 58-year-old woman with polycystic kidney disease had recently undergone renal transplantation complicated by recurrent small-bowel obstruction with perforation and primary surgical anastomoses. Subsequently, she experienced melena, for which anterograde single-balloon enteroscopy (A-SBE) (Olympus SIF-Q180/ST SB-1 Overtube, Olympus, Center Valley, Pa, USA) and introduction of a video capsule endoscope (VCE) (Given Pillcam SB3, Given Imaging, Yokneam Israel) were performed. After the A-SBE was completed past the first anastomosis, the overtube was left in place at the point of maximal insertion with the balloon inflated, and the endoscope was withdrawn. The VCE was placed into the overtube and propelled forward with the endoscope, thus being deployed directly into the jejunum beyond the anastomosis (Fig. 1A; Video 1, available at www.giejournal.org). Both the capsule width and the inner diameter of the SB-1 overtube are 11 mm (Fig. 1B), although the double-balloon overtubes are smaller (Fujinon TS-12140 [10.0 mm]/13140 [10.8 mm] [Fujinon, Wayne, NJ, USA]). The first VCE image was in the jejunum, distal to the anastomosis. Traditional evaluation of obscure small-bowel bleeding in the setting of altered anatomy is limited by sequential approaches, antecedent endoscopic trauma confusing VCE interpretation, incomplete VCE transit resulting from poor motility, and an inability to intuit anastomoses on VCE interpretation alone. In conclusion, endoscopic overtube-guided deployment of a VCE overcomes several of these obstacles to enable efficient identification of the source of overt, occult bleeding.