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219]

Original Article

Two different endoscopic long intestinal

tube placements for small bowel
obstruction: Transnasal ultrathin
endoscopy versus conventional endoscopy
ABSTRACT
Aim: To investigate and compare the effect on small bowel obstruction(SBO) of a long intestinal tube inserted by two different
endoscopic placements which are transnasal ultrathin endoscopy and conventional endoscopy.
Patients and Methods: Twentynine patients who had been diagnosed as suffering from SBO underwent long tube insertion placed
by transnasal ultrathin endoscopy were included as subjects. Thirtytwo patients who had undergone insertion of a long tube placed
by conventional endoscopy were included as controls. The success rate of intubation of the small bowel, the time required for the
procedure, and complications were compared between the subjects and controls.
Results: The success rate of intubation was 100%(29/29) in subjects and 93.8%(30/32) in controls, without a significant
difference(P=0.493). There are 2 failed cases that the procedure was attempted near 60min in 2patients who had
performed Billroth II anastomosis before, and the intestinal tube could not be inserted into efferent loops of jejunum in controls.
The mean time required for the procedure was 15.3min in subjects and 22.9min in controls, respectively, and with a significant
difference(P 0.001). Epistaxis occurred in both groups, and 2cases encountered bleeding of the gastrointestinal tract in controls.
Conclusion: Long tube insertion facilitated by transnasal ultrathin endoscopy takes shorter time and has a higher success rate
compared with the procedure conducted with the help of conventional endoscopy. It is safe and useful to insert a long intestinal
tube assisted by transnasal ultrathin endoscopy for the decompression of small bowel.
KEY WORDS: Conventional endoscopy, long intestinal tube, small bowel obstruction, transnasal ultrathin endoscopy

INTRODUCTION
Small bowel obstruction(SBO) is a common
problem in general surgery and is associated
with considerable morbidity and mortality. It is
commonly caused by postoperative adhesions,
and sometimes by the recurrence and metastasis
of the abdominal tumor. The conventional method
is to intubate a common nasogastric tube, which
can only suction the fluid in the stomach, and has
limited effects.[1] In recent years, the long intestinal
tube has been applied for intestinal decompression
and proved to be efficient and necessary for the
treatment of patients who suffer the SBO, especially
those with partial obstruction. The early studies
reported that most long intestinal tubes are
inserted only under fluoroscopy which had some
disadvantages such as the long operation time and
the exposure to more radiation.[24]

As the endoscopic technique develops, more

investigators have tried endoscopeguider
intubation to facilitate the procedure.[57] A novel
endoscopy with a transnasal ultrathin endoscopy
was shown to be more convenient and better
tolerated by patients.[8] However, although there
are some researchers reporting the advantages
of placing the long intestinal tube with the help
of transnasal ultrathin endoscope over placing
the tube under fluoroscopy, few investigators
have compared the effects of transnasal ultrathin
endoscopy and conventional endoscopy for
placement of a long intestinal tube in patients
with SBO.[9,10] So we conducted a prospective,
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Shengxi Li,
Chu Yuan1,
MeiDong Xu1
Digestive Endoscopy
Center, Peoples
Hospital of Liaoning
Province, Shenyang
110016, Liaoning,
1
Endoscopy Center and
Endoscopy Research
Institute, Zhongshan
Hospital, Fudan
University, Shanghai
200032, P. R. China
For correspondence:
Prof. MeiDong Xu,
Endoscopy Center
and Endoscopy
Research Institute,
Zhongshan Hospital,
Fudan University,
180, Fenglin Road,
Shanghai 200032,
P. R. China.
Email:xu.meidong@
aliyun.com

Shengxi Li and Chu

Yu a n c o n t r i b u t e d
equally to this work.
Access this article online
Website: www.cancerjournal.net
DOI: 10.4103/0973-1482.170531
PMID: ***
Quick Response Code:

For reprints contact: reprints@medknow.com

Cite this article as: Li S, Yuan C, Xu MD. Two different endoscopic long intestinal tube placements for small bowel obstruction:
Transnasal ultrathin endoscopy versus conventional endoscopy. J Can Res Ther 2015;11:C248-52.

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2015 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer -Medknow

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Li, etal.: Long intestinal tube placements:transnasal ultrathin versus conventional endoscopy

randomized, controlled trial to evaluate the effects of these

two different endoscopic methods for long tube insertion for
SBO. The results are reported here.
PATIENTS AND METHODS
Patients
From 2009 to 2014, 61 consecutive patients who were
diagnosed with SBO by the radiologic examination and/
or computed tomography(CT) were enrolled in this
study(30 women and 31 men; mean[standard deviation] age
57.514.8years, range 2386years). All the patients who
had operation history of tumors(digestive tumor, urologic
tumor, or female genital tumor) took the positron emission
tomographyCT examination to figure out if the SBO was
caused by the recurrence or metastasis of the tumor.
The patients were randomly assigned to two groups:
GroupA(n=29), in which the transnasal ultrathin
endoscopy was used, as subjects, and GroupB(n=32),
in which the conventional endoscopy was used, as controls.
Instruments
We perform transnasal ultrathin endoscopy with an
endoscope(GIFXP260, Olympus, Japan), which has a 5.9mm
outer diameter, an accessory channel of 2.0mm, and a working
length of 110cm. Conventional endoscopy was accomplished
with an endoscope(GIFH260, Olympus, Japan), which has a
9.8mm outer diameter, an accessory channel of 2.8mm, and a
working length of 110cm. The long intestinal tube used in the
present study has an outer diameter of 16 Fr, a working length
of 3000mm, a positioning balloon and a leading balloon at
its tip, a guidewire channel, and an injection channel with an
antireflux valve. The Cliny guidewire we used has a working
length of 4200mm and an outer diameter of 0.052 inch(Create
Medic Co., Japan).

mouth and esophagus into the stomach, and the suture at the
tip of the tube was grasped by the grasping or foreign body
forceps. The endoscope and tube were advanced through
the pylorus and duodenum and as far into the jejunum as
possible. The balloon was inflated with air until it engaged
the wall of the bowel, usually 60ml; the forceps released the
suture, and the endoscope was removed leaving the tube in
the jejunum. The air was aspirated from the balloon, and
1520ml water was injected into the balloon.
After the intubation, the contrast agent was injected via
intestinal tube under fluoroscopy to confirm that the balloon
was beyond the descending part of duodenum or jejunum;
otherwise, the tube should be inserted again.
In both procedures, the afferent loop and efferent loop were
identified under fluoroscopy before the intubation of intestinal
tube for patients who had performed Billroth II anastomosis,
and then the tube was introduced into the efferent loop under
fluoroscopy.
Both procedures were performed by a team including 1
endoscopist and 1 nurse. The endoscopists who performed
insertion by transnasal ultrathin endoscopy have 45years
of experience and who performed insertion by conventional
endoscopy have 510years of experience. All the operators
had undergone at least 10cases of long tube insertion with
either method before participating in this study.

Procedure
Transnasal ultrathin endoscopy
After a topical anesthesia, the transnasal ultrathin endoscope,
of which the front end was coated with lidocaine hydrochloride
mucilage, was inserted nasally into at least the second portion
of the duodenum or beyond, the Cliny guidewire was then
introduced through the working channel into the upper
jejunum. After that, the endoscope was carefully removed from
the gastrointestinal(GI) tract, with the guidewire left in place.
The long intestinal tube was advanced over the guidewire into
the jejunum, and the balloon was inflated with 1520mL
distilled water, and the Cliny guidewire was carefully removed.

Outcome measurements
There are three main outcome measurements in this study:(1)
Procedure time: We defined it as the total time from the
insertion of the ultrathin endoscope(GroupA) or intestinal
tube(GroupB) via nasal cavity until the guideline(GroupA),
or the endoscope(GroupB) was removed and then insure that
the tube intubation succeeded under fluoroscopy.(2) Success
rate: Successful intubation was defined as the balloon in the
front end of the long tube was beyond the descending part
of the duodenum or further jejunum which was observed by
injecting contrast agent via intestinal tube under fluoroscopy.
If the long tube could not be inserted into the jejunum
or the procedure could not be finished in<60min, the
procedure should be stopped in order to avoid increasing the
discomforts of patients, and the procedure was regarded as
a failure.(3) Complications: Complications included bleeding
or perforation caused by damage and laceration of GI tract
mucosa and epistaxis related to the operation.

Conventional endoscopy
The long intestinal tube, of which the front end was tied
with multistrand black silk suture and coated with lidocaine
hydrochloride mucilage, was inserted into the stomach via
nasal cavity. Then, the endoscope was advanced through the

Statistical analysis
Statistical differences were assessed by the MannWhitney
Utest between 2 independent groups and by the test or
the Fisher exact test between 2 proportions. Astatistical
significance was defined as a value of P 0.05.

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Li, etal.: Long intestinal tube placements:transnasal ultrathin versus conventional endoscopy

RESULTS
The patient demographic data are shown in Table1. There
was no significant difference of the mean age or the sex
between GroupA and B. There were 4patients in GroupA
and 5patients in GroupB, who had performed Billroth II
anastomosis respectively. Similarly, there was no significant
difference of ratio of cause of SBO and patients with history
of Billroth II anastomosis between two groups.
The outcomes of long tube insertion by two methods are
shown in Table2. There was significant difference of procedure
time between two groups, which it took shorter time in
patients of GroupA than those of GroupB. Moreover, the total
success rates and success rates of patients who had a history
of Billroth II anastomosis were higher in GroupA but without
a significant difference. Epistaxis occurred in 8patients of
GroupA and 7patients of GroupB, which was stopped by
local compression. In two patients of GroupB, bleeding of
GI tract took place when the endoscope and intestinal tube
twined around each other, and patients felt nausea, leading to
the cardiac orifice mucosal laceration. Bleeding was staunched
by endoscopic therapy. However, the rate of complications did
not have a significant difference between two groups.
DISCUSSION
SBO is usually caused by postoperative adhesion and
occasionally caused by recurrence and metastasis of abdominal
tumor. Most obstructions are partial, without necrosis or
strangulation.[1] For patients with adhesive SBO, nonoperative
treatment is equally safe and efficient compared with operative
Table1: Clinical characteristics of the patients

Mean age(year)
Male/female
Cause(number)
Adhesive obstruction
Recurrence or metastasis of tumor
History of Billroth II anastomosis

Group A
(n=29)
59.114.2
13/16

Group B
(n=32)
55.615.5
18/14

25
4
4

29
3
5

P
0.88
0.45
0.70
1.00

Table2: Outcomes of long tube insertion by the transnasal

ultrathin endoscopy method(Group A) and the conventional
endoscopy method(Group B)
Group A
(n=29)
15.32.5

Group B
(n=32)
22.92.4

Procedure time(meanSD, min)

<0.001*
Success rate(%)
Total
100(29/29) 93.8(30/32) 0.493
No history of Billroth II
100(25/25) 100(27/27)

anastomosis
History of Billroth II anastomosis 100(4/4)
60(3/5)
0.444
Complications
Bleeding of GI tract
0
2
0.493
Perforation
0
0

Epistaxis
8
7
0.767
*Significant difference. SD=Standard deviation, GI=Gastrointestinal

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treatment, with lower risk of morbidity and mortality.[2,3,11]

Moreover, for patients who have SBO due to the recurrence
and metastasis of an abdominal tumor, decompression of the
small bowel by intubation of the long intestinal tube considers
to be preferred therapy. The method has changed a lot in
recent years. The conventional method is to place the tube
under fluoroscopy. Operators first insert the tube via the nasal
cavity into the stomach then require the patient to change
the position for manipulation of the tube through the pylorus
and into the duodenum or jejunum. It costs much time and
increases the risk of the radiation exposure to both patients
and operators with a comparatively lower success rate.
In 1973, Keller first introduced a new technique of intestinal
intubation with endoscope in which a line was tied to the
metal tip of the long tube and pulled from the biopsy forceps
via biopsy channel, and then the tube can be easily inserted
into the duodenum with the help of biopsy forceps.[12] This
method has been widely used by endoscopists, and the
technique has been improved afterward.[13,14] However, the
endoscopic procedure increases the discomfort and compliance
of patients, and the intestinal tube could be pulled out
during the withdrawing of the endoscope due to the fiction
and close relationship between them. The procedure can be
hard, especially in patients after Billroth II anastomosis, for
the afferent loop and efferent loop sometimes are difficult to
distinguish under endoscopy. Moreover, as the anastomotic
stoma has a certain angle, it is really tough to get through
it into efferent loop with the endoscope and tube together.
In 1984, Kawamura etal. reported on a unique method, in
which the endoscope was inserted through the nostril rather
than through the mouth before the long tube placement.
However, the endoscope used in the study had an outer
diameter of approximately 89mm, which was designed for
oral insertion. In this case, patient felt much pain during the
procedure, and the insertion cannot be accomplished in the
patient with narrow nasal cavity or nasal inflammation, so
the procedure did not get widely used in early years.[6] More
recently, new ultrathin endoscope with an outer diameter
of approximately 56mm has been widespread and
with an advantage of unsedation and better tolerance of
patients.[15] There are some reports comparing the effects of
the intestinal intubation under transnasal ultrathin endoscopy
to fluoroscopy only; the results reveal that under transnasal
ultrathin endoscopy is superior to only under fluoroscopy.[9,10]
Our experience is that both procedures should be conducted
in the room equipped with Xray machine. The radiography
is mainly for confirming whether the procedure is success
or not after the intubation. In the patients after Billroth II
anastomosis, the radiography should be conducted before
the intubation to distinguish afferent loop from efferent loop,
and endoscopist inserts the tube into efferent loop under
fluoroscopy. Otherwise, the radiography is not necessary
during the intubation.
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Li, etal.: Long intestinal tube placements:transnasal ultrathin versus conventional endoscopy

We found in our study that in the group of transnasal ultrathin

endoscopy, the procedure time was significantly shorter,
and patients had better tolerance. One reason is that, in the
conventional endoscopy group, longer time is needed, because
tube and endoscope entered the esophagus at the same time,
the procedure slowed down due to the friction. In particular,
the insertion could increase discomfort of patients when
getting through the pylorus and anastomotic stoma, leading
to longer procedure time. The other reason is that the long
tube was easily pulled out because the endoscope and tube
rubbed and even twined around each other, so the endoscope
should be withdrawn slowly. Relatively, ultrathin endoscope
could easily move through the pylorus and anastomotic stoma
for its smaller diameter, and the tube could not be pulled out
when withdrawing the guidewire.

perforation of GI tract. In our study, no patients encountered

perforation, but 2patients who had performed Billroth II
anastomosis occurred bleeding in controls. It took place when
the endoscope and intestinal tube twined around each other,
and patients felt nausea, leading to the cardiac orifice mucosal
laceration. Bleeding was staunched by endoscopic therapy, and
the procedure time increased as a consequence. In subjects,
the ultrathin transnasal endoscope could move through the
anastomotic stoma easily, and patients felt less discomfortable,
decreasing the risk of nausea and bleeding. Although there was
no significant difference between two groups, probably due
to limited sample size, we think intubation used by ultrathin
transnasal endoscope is safer and faster than that assisted by
conventional endoscope, especially in patient with Billroth II
anastomosis.

Although the total success rate and the success rate in

patients with history of Billroth II anastomosis of ultrathin
transnasal endoscopy was higher than those of conventional
endoscopy, the difference was not significant. We think that
the sample size was not enough to get a significant result,
but the intubation could more probably succeed by ultrathin
transnasal endoscopy, especially in patients who had done
Billroth II anastomosis. In these patients, the changed
anatomy of GI tract, the smaller dimension of anastomotic
stoma and anastomosis made the intubation more difficult.
There are 2 failed cases in the controls that the procedure
was attempted near 60min in patients who had performed
Billroth II anastomoses before, and the intestinal tube could
not be inserted into efferent loops of jejunum by conventional
endoscopy, mainly because of the small anastomotic stoma and
the complexed anatomy. With the help of ultrathin transnasal
endoscope, the procedure could be done more easily, as the
insertion of the tube and endoscope is not simultaneous,
avoiding the conflicts between them. And like other reports
revealed, patients who have experienced ultrathin endoscopy
are more likely to tolerate the procedure.[15,16] However,
if the patients had narrow nasal route, they would felt
more uncomfortable, and endoscopists found transnasal
introduction more difficult in these patients. Hence,
conventional endoscopy may be more suitable for them.[17]

There were some limitations in our study, however. First,

both groups did not have data of the effects of the procedure
postoperatively, for example, the volume of drainage and
anus exhaust time. Second, because the procedures were
conducted by different endoscopists with different experience
and proficiency, the expert bias cannot be ignored. Third, we
did not use visual analog scale score or other assessments
to investigate the discomforts of people by two different
procedures.

Epistaxis is the most common complication of the procedure

in both groups. There are 8cases in subjects and 7cases
in controls occurring epistaxis, respectively. The incidence
is a little higher in subjects than that in controls, without a
significant difference. We found that in the early period of
clinical practice of using transnasal ultrathin endoscope, when
the endoscopists were unfamiliar with the anatomy of nasal
route, the occurrence of epistaxis is higher. As the expertise
improved, the occurrence decreased. However, epistaxis
existed inevitably in both groups, for the intestinal tube
was introduced via nasal cavity without direct observation.
Epistaxis is a common complication, but not severe, and could
be stopped by local compression. There are two more serious
complications during the procedure which are bleeding and
Journal of Cancer Research and Therapeutics - Volume 11 - Special Issue 3- 2015

CONCLUSION
We strongly recommend that the placement of the long
intestinal tube should be done by the transnasal ultrathin
endoscope, especially for patients who performed Billroth
II anastomosis. The method is superior to the conventional
endoscope method with shorter procedure time, less
complications, and higher success rates. Further research
should be conducted by more institutions with more cases,
and we believe that this technique can be widely used in the
future for patients with SBO.
Financial support and sponsorship
This study was supported by the grants from the Major Project
of Shanghai Municipal Science and Technology Committee
(14441901500 and 15JC1490300), National Natural Science
Foundation of China (81302098, 81370588 and 81201902).
No other financial relationships relevant to this publication
were disclosed.
Conflicts of interest
There are no conflicts of interest.
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