Introduction: Overt obscure gastrointestinal bleeding (OGIB) is challenging and often needs intraoperative endoscopy (IOE) with a high risk of morbidity and mortality. The study was to compare the different approaches to perform IOE for overt OGIB. Patients and methods: We retrospectively reviewed the data of 98 patients who underwent trans-enterotomy IOE (IOE-E) or other approaches such as peroral IOE (IOE-oral), trans-anal IOE (IOE-anal), or combined route (IOE-combo). Patient characteristics, demographics, diagnostic tests, IOE findings, and follow-up outcomes were analyzed. Results: All 98 patients underwent IOE. There are 31 patients in the IOE-E group, 26 patients in the IOE-oral group, 23 patients in the IOE-anal group, and 18 patients in the IOE-combo group, respectively. Long-term follow-up information (>6 months) was successfully obtained in 72 patients. IOE-E has the lowest postoperative morbidity rate (16%, P < 0.05), the shortest time of operation (43.2 ± 17.4 min, P < 0.05) and shortest hospital length of stay (6.7 ± 5.1 days, P < 0.05), as compared to the other three approaches. Conclusions: Intraoperative endoscopy through enterotomy represents a safer and more ideal strategy in the management of overt OGIB. Graphical abstract Highlights

Introduction: Small bowel (SB) bleeding is one of the common gastrointestinal problems, particularly in elders. The study aimed to find the causes of refractory bleeding and overcome the challenges and difficulties of surgical treatment for SB refractory bleeding.Methods: All patients with SB refractory bleeding who underwent surgical treatment were included in this study. Patients' characteristics, surgical finding, and follow-up assessments were reviewed and analyzed through Hospital Information System records from October 1, 2014, to November 30, 2020. All analyses were performed using SPSS v23.0. Results:The causes of SB bleeding include vascular lesions (angioectasia, arteriovenous malformations, and dieulafoy lesions) 29.6%, tumors (Polyps, gastrointestinal stromal tumor, Adenocarcinoma, and other) 24.5%, diverticular 18.4%, ulcers/erosion 15.3%, inflammatory bowel disease 7.1%, and other 5.1%. Patients (age below 60 y) were highly developed SB bleeding caused by diverticular 26.4% compared with patients (age 60 y or older) 8.9%, whereas bleeding caused by vascular lesions was significantly higher in patients (age 60 y or older) 37.8%. Other causes, such as tumors and inflammatory bowel disease, showed no significant difference related in age. Exploratory laparotomy was the standard method of bowel extrinsic examination. The intraoperative enteroscopy enterotomy (IOE-E) and IOE-combined were performed in 52 patients (1:1). IOE-E shows lower postoperative morbidity and shorter time of operation P < 0.05 compared with the IOE-combined approach.Conclusions: Age and exhaustive patient history can assist in finding out the etiology. IOE-E is safe, and coordination between surgeon and endoscopist is necessary for IOE if an identifiable source cannot be found in endoscopy or exploratory laparotomy alone.

Introduction Small Bowel (SB) Bleeding is one of the common gastrointestinal problems, particularly in elders. The study aimed to find the causes of refractory bleeding and overcome the challenges and difficulties of surgical treatment for SB refractory bleeding. Methods All Patients with SB refractory bleeding who underwent surgical treatment were included in this study. Patients’ characteristics, surgical finding, and follow-up assessments were reviewed and analyzed through Hospital Information System (HIS) records from October 1st ,2014, to November 30th ,2020. All analyses were performed using SPSS v23.0. Results The causes of SB bleeding include Vascular lesions (Angioectasia, AVM, Dieulafoy lesions) 29.6%, Tumors (Polyps, GIST, Adenocarcinoma, and other) 24.5%, Diverticular 18.4%, Ulcers/erosion 15.3%, Inflammatory bowel disease 7.1% and other 5.1%. Patients (age < 60) were highly developed Small Bowel bleeding caused by diverticular 26.4% compared to patients (Age ≥ 60) 8.9%, while bleeding caused by vascular lesions was significantly higher in patients (Age ≥ 60) 37.8%. Other causes, such as tumors and IBD, showed no significant difference related in age. Exploratory laparotomy was the standard method of bowel extrinsic examination. The intraoperative enteroscopy enterotomy (IOE-E) and IOE-combined were performed in 52 patients (1:1). IOE-E shows lower postoperative morbidity and shorter time of operation P < 0.05 compared to the IOE-combined approach . Conclusions Age and exhaustive patient history can assist in finding out the etiology. IOE-E is safe, and coordination between surgeon and endoscopist is necessary for IOE if an identifiable source cannot be found in endoscopy or exploratory laparotomy alone.

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