Jejunal endoscopic full-thickness biopsy for chronic idiopathic intestinal pseudo-obstruction

A 40-year-old man presented with a 2-year history of recurrent bowel obstruction without mechanical causes. Abdominal radiography and computed tomography demonstrated marked small bowel dilatation, suggesting chronic idiopathic intestinal pseudo-obstruction ( Fig. 1 ). Although surgical full-thickness biopsy is regarded as the gold standard for definitive diagnosis, concerns remain regarding its invasiveness and risk of postoperative adhesions ¹ . Endoscopic mucosal resection with an over-the-scope clip (EMRO), initially developed for submucosal lesions ² , was adapted for jejunal endoscopic full-thickness biopsy (EFTB) ( Video 1 ).

Fig. 1.

Pre-admission abdominal radiography and computed tomography images. a Abdominal radiograph demonstrating marked dilatation of the small intestine. b Computed tomography revealing significant small intestinal dilatation associated with gas-fluid levels.

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Jejunal endoscopic full-thickness biopsy with the endoscopic mucosal resection using an over-the-scope clip technique.

Video 1

Jejunal EFTB with EMRO was performed under sedation with midazolam, using an EI-580BT enteroscope (Fujifilm, Tokyo, Japan). A 10-mm over-the-scope clip (Type T; Ovesco Endoscopy, Tübingen, Germany) was mounted 10 mm beyond the enteroscope tip. Resection was performed using a 10-mm snare (SnareMaster Plus; Olympus, Tokyo, Japan) and an electrosurgical generator (VIO 200D; Erbe, Tübingen, Germany) set to ENDO CUT Q mode (effect: 3, cut duration: 2, and cut interval: 2). Total procedure time was 16 min, with no additional closure required. Histopathological examination confirmed full-thickness sampling, including the subserosal layer, without abnormalities in the submucosal or myenteric plexus, confirming the diagnosis of chronic idiopathic intestinal pseudo-obstruction ( Fig. 2 ).

Fig. 2.

Histopathological evaluation of the resected specimen. a Hematoxylin and eosin staining showing full-thickness resection extending to the muscularis propria (indicated by white arrowheads). b HuC/D immunostaining demonstrating normally distributed and morphologically intact ganglion cells (indicated by black arrowheads), consistent with a diagnosis of chronic idiopathic intestinal pseudo-obstruction.

In patients with suspected chronic idiopathic intestinal pseudo-obstruction and unexplained obstructive symptoms, a jejunal full-thickness biopsy followed by detailed histological assessment is recommended ^{1 3} . Surgical full-thickness biopsy often requires adhesiolysis, with a median operative time of 50 min. Approximately 2% of patients require conversion to open surgery, and 10% are readmitted ¹ . At our institution, all four patients who underwent this procedure were readmitted because of postoperative ileus. Although devices such as the full-thickness resection device (FTRD) or the “close and resect” technique have been used for EFTB ^{4 5} , neither has been reported for jejunal applications, and the FTRD is not approved for use in Japan. This is the first study on jejunal EFTB with EMRO, offering a promising diagnostic alternative for severe gastrointestinal motility disorders.

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