SBE procedure
Before SBE procedures, patients were advised to abdominal ultrasound and CT enterography (CTE) for primary evaluation of small bowel. All the SBE procedures were performed by experienced endoscopists using the SIF-Q260 (Olympus, Japan) with a 200 cm working length and 2.8 mm working channel. In general, both anal and oral SBE procedures were performed. Unless it was clear that no polyps were present in the ileum, the anal approach was performed first because large polyps removed via the oral route may pile up on remaining distal polyps and cause obstruction or intussusception. Patients were advised to fluid diet the day before SBE operation, and poly ethylene glycol-electrolyte powder was used for intestinal cleaning. Because the SBE procedure time was long, all examinations were carried out with patients under general anesthesia with endotracheal intubation.
Polyps were resected during withdrawing endoscope to avoid bleeding and perforation at the wound after polypectomy. A diathermy loop was used to resect a polyp as one block or multi-block according to the size and pattern of base. The polyp size was estimated according to the width of the biopsy forceps or the diameter of the polypectomy snare. The retrieved polyps were measured with a ruler to determine the greatest dimension (Figure 1). Polyp resection was performed for polyps larger than 10 mm. However, if many polyps were found, polyps of over 20 mm in diameter were given priority for resection to prevent intussusception[14] (Figure 2). Complete treatment was defined by the absence of polyps≥20mm after SBE resections. The absence of residual polyps was considered when all polyps detected at CTE examination were removed. If all of the large polyps could not be removed in one hospitalization, next SBE treatment was repeated within 6 months. Usually, endoclips (ROCC-D-26-230-C, Micro-Tech (Nanjing) Co. Ltd) were used to close the wound to prevent delayed bleeding and perforation. Only large and/or irregularly shaped polyps were retrieved for pathological examination. During the first intubation of SBE, endoclips were used at the deepest position for mark (Figure 3). Insertion depth was measured by accumulation of net advancement of each push-and-pull maneuver as described by Rondonotti et al [21]. Complications related to enteroscopy such as bleeding, perforation and acute pancreatitis were noted. Complications were classified as intraprocedural, early (within 24 hours), or delayed (2-30 days)[15]. All complications were obtained from hospitalization records or outpatient assessment.