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• W1998710394 abstract "DBE is recommended to follow up any CE demonstrating lesions that require sampling or endoscopic therapy. DBE is recommended to follow up any CE demonstrating lesions that require sampling or endoscopic therapy. Within the past decade, there have been dramatic advances in our ability to image the small intestine. We can now more thoroughly evaluate the small-intestinal mucosa by using capsule endoscopy (CE) and small-intestinal wall abnormalities with CT or magnetic resonance imaging (MRI) enterography than we could with older methods. The new modalities are less invasive than intraoperative enteroscopy and enable more complete imaging than push enteroscopy. Yet the new technologies also have their limitations. For example, although MRI and CT enterography may play a role in evaluating Crohn's disease or small-bowel neoplasms, their utility in diagnosing flat lesions such as angiodysplasia, or neoplasms less than 15 mm in diameter is limited.1Mackalski B.A. Bernstein C.N. New diagnostic imaging tools for inflammatory bowel disease.Gut. 2006; 55: 733-741Crossref PubMed Scopus (86) Google Scholar, 2Mishkin D.S. Chuttani R. Croffie J. et al.ASGE Technology Status Evaluation Report: wireless capsule endoscopy.Gastrointest Endosc. 2006; 63: 539-545Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar, 3Paulsen S.R. Huprich J.E. Fletcher J.G. et al.CT enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience with over 700 cases.Radiographics. 2006; 26 (discussion 657–62): 641-657Crossref PubMed Scopus (359) Google Scholar In addition, all of these newer imaging techniques are unable to provide a tissue diagnosis or render any therapy. Only with the description of double-balloon enteroscopy (DBE) by Yamamoto et al4Yamamoto H. Sekine Y. Sato Y. et al.Total enteroscopy with a nonsurgical steerable double-balloon method.Gastrointest Endosc. 2001; 53: 216-220Abstract Full Text Full Text PDF PubMed Scopus (1196) Google Scholar in 2001 did the ability to simultaneously visualize the entire small bowel and sample lesions finally become a reality. DBE can be performed on an outpatient basis by using only conscious sedation. Antegrade DBE can examine 3 times the length of small bowel as push enteroscopy, with a corresponding increase in diagnostic yield.5May A. Nachbar L. Schneider M. et al.Prospective comparison of push enteroscopy and push-and-pull enteroscopy in patients with suspected small-bowel bleeding.Am J Gastroenterol. 2006; 101: 2016-2024Crossref PubMed Scopus (125) Google Scholar In addition, retrograde DBE allows more consistent evaluation of the ileum and, when combined with antegrade DBE, the possibility of complete small-bowel examination. The literature on DBE has mushroomed in recent years as the new scopes have been applied for various conditions, including some outside the small bowel.6Haber G.B. Double balloon endoscopy for pancreatic and biliary access in altered anatomy (with videos).Gastrointest Endosc. 2007; 66: S47-S50Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 7Kita H. Yamamoto H. New indications of double balloon endoscopy.Gastrointest Endosc. 2007; 66: S57-S59Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar DBE has had the small-bowel endoscopy market to itself since becoming commercially available in the United States in 2004. However, last year a single-balloon enteroscope was introduced in the United States (Olympus America, Center Valley, Pa). Kawamura et al8Kawamura T. Yasuda K. Tanaka K. et al.Clinical evaluation of a newly developed single-balloon enteroscope.Gastrointest Endosc. 2008; 68: 1112-1116Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar describe their early experience with single-balloon enteroscopy (SBE) in this issue of Gastrointestinal Endoscopy. The 2 systems share many features, including scope length, diameter, accessory channel size, and overtube design. Both require 2 people to manipulate and advance the scope/overtube as well as control the balloons. The most important design difference between the systems is that the SBE does not have a distal balloon on the scope; the only balloon is on the tip of the overtube. As a result, the sequence of steps to advance the scope through the small bowel is slightly shorter in SBE. After the DBE scope is advanced but before the overtube is advanced, the DBE scope balloon is inflated to stabilize the tip. In the SBE system, the scope is turned in toward the bowel wall to help fix the tip as the overtube is advanced over the scope. This position is maintained as the scope and the advanced overtube, now with its balloon inflated, are pulled back to pleat the intestine onto the scope. After the pullback of the scope and overtube in the DBE system, the scope's balloon is deflated before advancing the scope. This step is avoided in SBE because the tip is simply turned toward the forward-viewing position for renewed advance. Minor differences between systems include the following: (1) the DBE balloons are latex, whereas the SBE balloon is silicone; (2) the DBE scope balloon must be attached before the case, analogous to the placement of the balloon for endoscopic US; and (3) the DBE balloon pump has auditory signals during inflation, whereas the SBE system does not. Use of either scope requires a technician to assist with handling of the overtube as well as balloon inflation/deflation. In addition, fluoroscopy to monitor scope position and sedation appropriate for prolonged procedures are requirements shared by both systems. In experienced hands, DBE evaluation of the entire small bowel is possible in 45% to 84% of patients in whom it is attempted.9May A. Nachbar L. Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease.Gastrointest Endosc. 2005; 62: 62-70Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar, 10Yamamoto H. Kita H. Sunada K. et al.Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.Clin Gastroenterol Hepatol. 2004; 2: 1010-1016Abstract Full Text Full Text PDF PubMed Scopus (653) Google Scholar, 11Zhong J. Ma T. Zhang C. et al.A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases.Endoscopy. 2007; 39: 208-215Crossref PubMed Scopus (144) Google Scholar Complete small-bowel examination usually requires a combination of antegrade and retrograde DBE; it can rarely be achieved with antegrade DBE alone.9May A. Nachbar L. Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease.Gastrointest Endosc. 2005; 62: 62-70Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar, 10Yamamoto H. Kita H. Sunada K. et al.Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.Clin Gastroenterol Hepatol. 2004; 2: 1010-1016Abstract Full Text Full Text PDF PubMed Scopus (653) Google Scholar Reported mean examination times are 73 minutes for antegrade DBE and 78 minutes for retrograde examinations.12DiSario J.A. Petersen B.T. Tierney W.M. et al.Technology status evaluation report: enteroscopes.Gastrointest Endosc. 2007; 65: 872-880Abstract Full Text Full Text PDF Scopus (38) Google Scholar Findings significant enough to change management are reported in most patients (65%-76%).9May A. Nachbar L. Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease.Gastrointest Endosc. 2005; 62: 62-70Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar, 11Zhong J. Ma T. Zhang C. et al.A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases.Endoscopy. 2007; 39: 208-215Crossref PubMed Scopus (144) Google Scholar, 13Gross S.A. Stark M.E. Initial experience with double-balloon enteroscopy at a U.S. center.Gastrointest Endosc. 2008; 67: 890-897Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar In fact, as the likelihood of complete small-bowel traversal increases with experience, so does the probability that the test will be clinically helpful.13Gross S.A. Stark M.E. Initial experience with double-balloon enteroscopy at a U.S. center.Gastrointest Endosc. 2008; 67: 890-897Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar Therapeutic maneuvers are reported in a large proportion of patients (41%-61%).9May A. Nachbar L. Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease.Gastrointest Endosc. 2005; 62: 62-70Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar, 13Gross S.A. Stark M.E. Initial experience with double-balloon enteroscopy at a U.S. center.Gastrointest Endosc. 2008; 67: 890-897Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar The diagnostic yield of DBE is highly dependent on the indication for the study.11Zhong J. Ma T. Zhang C. et al.A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases.Endoscopy. 2007; 39: 208-215Crossref PubMed Scopus (144) Google Scholar In the evaluation of obscure GI bleeding—the most common indication for enteroscopy—DBE identifies the bleeding source 53% to 80% of the time, with complete visualization of the small bowel in 56% to 61% of attempted cases.11Zhong J. Ma T. Zhang C. et al.A retrospective study of the application on double-balloon enteroscopy in 378 patients with suspected small-bowel diseases.Endoscopy. 2007; 39: 208-215Crossref PubMed Scopus (144) Google Scholar, 14Lo S.K. Mehdizadeh S. Therapeutic uses of double-balloon enteroscopy.Gastrointest Endosc Clin N Am. 2006; 16: 363-376Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 15Ohmiya N. Yano T. Yamamoto H. et al.Diagnosis and treatment of obscure GI bleeding at double balloon endoscopy.Gastrointest Endosc. 2007; 66: S72-S77Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar These DBE results are comparable to those with CE in a recent series of patients with obscure GI bleeding in which CE identified the bleeding source in 53% of patients and complete small-bowel visualization was achieved in 74%.16Carey E.J. Leighton J.A. Heigh R.I. et al.A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding.Am J Gastroenterol. 2007; 102: 89-95Crossref PubMed Scopus (281) Google Scholar How does DBE compare with capsule endoscopy? Only 3 small prospective studies directly comparing CE to DBE have been published in peer-reviewed journals.17Matsumoto T. Esaki M. Moriyama T. et al.Comparison of capsule endoscopy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis.Endoscopy. 2005; 37: 827-832Crossref PubMed Scopus (185) Google Scholar, 18Hadithi M. Heine G.D. Jacobs M.A. et al.A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding.Am J Gastroenterol. 2006; 101: 52-57Crossref PubMed Scopus (273) Google Scholar, 19Nakamura M. Niwa Y. Ohmiya N. et al.Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding.Endoscopy. 2006; 38: 59-66Crossref PubMed Scopus (245) Google Scholar All included patients with obscure GI bleeding. Nakamura et al19Nakamura M. Niwa Y. Ohmiya N. et al.Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding.Endoscopy. 2006; 38: 59-66Crossref PubMed Scopus (245) Google Scholar reported on 28 patients who underwent CE and then DBE, with the endoscopist blinded to the results of the CE. The authors divided the findings into 2 groups: A1 lesions that required immediate hemostatic measures, and A2 lesions that could be closely observed rather than immediately treated. CE detected lesions in 17 patients (11 with A1 lesions and 6 with A2 lesions). DBE was positive in 12 patients (all but one had A1 lesions). Both CE and DBE found 3 A1 lesions that the other modality missed. Thus, both modalities found 11 of 14 A1 lesions. In addition, CE found 5 A2 lesions not found by DBE. Complete small-bowel traversal by DBE was attempted in 16 cases and was successful in 10. In the study of CE versus DBE by Hadithi et al,18Hadithi M. Heine G.D. Jacobs M.A. et al.A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding.Am J Gastroenterol. 2006; 101: 52-57Crossref PubMed Scopus (273) Google Scholar the endoscopist knew of the preceding CE results when performing DBE in all 35 patients. Findings were not classified as in the study by Nakamura et al19Nakamura M. Niwa Y. Ohmiya N. et al.Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding.Endoscopy. 2006; 38: 59-66Crossref PubMed Scopus (245) Google Scholar; rather, they were all considered to have equal clinical significance. Complete small-bowel imaging was achieved in 86% of CE examinations and in 57% of DBE attempts. CE findings were abnormal in 80% of the cases. However, one of these abnormal cases was not confirmed by DBE or surgery, so the positive rate was 77% (27/35). DBE found abnormalities in 60% of cases, and all were treated with coagulation devices or were endoscopically removed. DBE found only 1 lesion not seen on CE. Matsumoto et al17Matsumoto T. Esaki M. Moriyama T. et al.Comparison of capsule endoscopy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis.Endoscopy. 2005; 37: 827-832Crossref PubMed Scopus (185) Google Scholar reported on 13 patients with obscure GI bleeding evaluated initially by a diagnostic DBE and then CE. The reader of the CE was blinded to the results of the DBE. The CE and DBE agreed on 6 patients with positive findings and on 3 with negative examinations. Two CE findings were not confirmed by DBE. On one patient a confirmatory DBE was not performed, and in another, DBE found an ulcer missed by CE. The authors concluded that the 2 studies were equivalent in diagnosing obscure GI bleeding. Combining the results of the 3 studies, CE and DBE agreed in 68% of all cases and in 63% of positive cases.17Matsumoto T. Esaki M. Moriyama T. et al.Comparison of capsule endoscopy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis.Endoscopy. 2005; 37: 827-832Crossref PubMed Scopus (185) Google Scholar, 18Hadithi M. Heine G.D. Jacobs M.A. et al.A prospective study comparing video capsule endoscopy with double-balloon enteroscopy in patients with obscure gastrointestinal bleeding.Am J Gastroenterol. 2006; 101: 52-57Crossref PubMed Scopus (273) Google Scholar, 19Nakamura M. Niwa Y. Ohmiya N. et al.Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding.Endoscopy. 2006; 38: 59-66Crossref PubMed Scopus (245) Google Scholar DBE found lesions missed on CE 7% of the time, and CE found lesions not found by DBE in 26% of cases. However, some of these CE findings—such as the five A2 lesions, and one not confirmed at surgery—are of dubious significance. A recent meta-analysis that included these 3 prospective studies as well as results published only in abstract form compared the diagnostic ability of CE and DBE for small-bowel conditions, including obscure GI bleeding. The authors found no difference in diagnostic yield between CE and DBE.20Pasha S.F. Leighton J.A. Das A. et al.Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis.Clin Gastroenterol Hepatol. 2008 Mar 19; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (333) Google Scholar A meta-analysis by Chen et al21Chen X. Ran Z.H. Tong J.L. A meta-analysis of the yield of capsule endoscopy compared to double-balloon enteroscopy in patients with small bowel diseases.World J Gastroenterol. 2007; 13: 4372-4378Crossref PubMed Scopus (120) Google Scholar reached the same conclusion, with the caveat that the yields were comparable if DBE evaluated the entire small bowel. However, none of the comparative studies included a diagnostic criterion standard such as surgery or intraoperative enteroscopy. Thus, the true clinical impact of DBE compared with CE remains to be elucidated.20Pasha S.F. Leighton J.A. Das A. et al.Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis.Clin Gastroenterol Hepatol. 2008 Mar 19; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (333) Google Scholar In contrast with the literature on DBE, the previously published data on SBE are sparse, with most reports in abstract form.22Forman Js K.B. Uradomo L.T. Darwin P.E. et al.Single balloon enteroscopy of the small bowel: diagnostic and therapeutic yield in patients with obscure gastrointestinal bleeding.Gastrointest Endosc. 2007; 65 ([abstract]): AB172Abstract Full Text Full Text PDF Google Scholar, 23Lapalus Mg P.T. Chemali M. Fabien P. et al.Single-balloon enteroscopy: a preliminary experience.Gastrointest Endosc. 2007; 65 ([abstract]): AB184Abstract Full Text Full Text PDF Google Scholar, 24Nista E.C. Spada C. Urgesi R. et al.A new method of enteroscopy: the single-balloon enteroscope.Gastrointest Endosc. 2007; 65 ([abstract]): AB174Abstract Full Text Full Text PDF Google Scholar, 25Tsujikawa T. Saitoh Y. Andoh A. et al.Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences.Endoscopy. 2008; 40: 11-15Crossref PubMed Scopus (294) Google Scholar, 26Vargo Jj U.B. Dumot J.A. Zuccaro G. et al.Clinical utility of the Olympus single balloon enteroscope: the initial U.S. experience.Gastrointest Endosc. 2007; 65 ([abstract]): AB90Abstract Full Text Full Text PDF PubMed Google Scholar Only 107 patients undergoing 147 SBE examinations have been previously reported. The rate of complete examination of the small bowel, given in only 2 reports, has been 25%.24Nista E.C. Spada C. Urgesi R. et al.A new method of enteroscopy: the single-balloon enteroscope.Gastrointest Endosc. 2007; 65 ([abstract]): AB174Abstract Full Text Full Text PDF Google Scholar, 25Tsujikawa T. Saitoh Y. Andoh A. et al.Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences.Endoscopy. 2008; 40: 11-15Crossref PubMed Scopus (294) Google Scholar, 26Vargo Jj U.B. Dumot J.A. Zuccaro G. et al.Clinical utility of the Olympus single balloon enteroscope: the initial U.S. experience.Gastrointest Endosc. 2007; 65 ([abstract]): AB90Abstract Full Text Full Text PDF PubMed Google Scholar Mean procedure times have been 45 minutes to 63 minutes for antegrade SBE.25Tsujikawa T. Saitoh Y. Andoh A. et al.Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences.Endoscopy. 2008; 40: 11-15Crossref PubMed Scopus (294) Google Scholar, 26Vargo Jj U.B. Dumot J.A. Zuccaro G. et al.Clinical utility of the Olympus single balloon enteroscope: the initial U.S. experience.Gastrointest Endosc. 2007; 65 ([abstract]): AB90Abstract Full Text Full Text PDF PubMed Google Scholar Diagnoses have been reached in 69% of cases,22Forman Js K.B. Uradomo L.T. Darwin P.E. et al.Single balloon enteroscopy of the small bowel: diagnostic and therapeutic yield in patients with obscure gastrointestinal bleeding.Gastrointest Endosc. 2007; 65 ([abstract]): AB172Abstract Full Text Full Text PDF Google Scholar and only one serious complication has been previously reported. To this small data set, Kawamura et al8Kawamura T. Yasuda K. Tanaka K. et al.Clinical evaluation of a newly developed single-balloon enteroscope.Gastrointest Endosc. 2008; 68: 1112-1116Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar add their experience with 37 SBE examinations in 27 patients. These examinations were performed by 3 endoscopists with no prior experience with balloon enteroscopy. The mean procedure time was 83 minutes for antegrade SBE and 90 minutes for retrograde SBE. The diagnostic yield was only 41%. Complete small-bowel examination was attempted in 8 cases but was successful in only one. There was one bowel perforation. Although the SBE experience of Kawamura et al8Kawamura T. Yasuda K. Tanaka K. et al.Clinical evaluation of a newly developed single-balloon enteroscope.Gastrointest Endosc. 2008; 68: 1112-1116Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar does not approach the levels of technical success with DBE reported from institutions that have substantial experience, these SBE results do compare favorably to reports of initial experiences with DBE.27Kaffes A.J. Koo J.H. Meredith C. Double-balloon enteroscopy in the diagnosis and the management of small-bowel diseases: an initial experience in 40 patients.Gastrointest Endosc. 2006; 63: 81-86Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 28Mehdizadeh S. Ross A. Gerson L. et al.What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.Gastrointest Endosc. 2006; 64: 740-750Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar For example, in their first 40 patients undergoing 62 DBE examinations, Kaffes et al27Kaffes A.J. Koo J.H. Meredith C. Double-balloon enteroscopy in the diagnosis and the management of small-bowel diseases: an initial experience in 40 patients.Gastrointest Endosc. 2006; 63: 81-86Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar had no complete traversals of the small intestine in 10 attempts, and 1 bowel perforation occurred. In a report of the initial DBE experience at 6 U.S. tertiary-care centers—188 patients undergoing 237 DBEs by 8 different endoscopists—the overall mean procedure time was 93 minutes, with institutional mean times ranging from 81 to 118 minutes.28Mehdizadeh S. Ross A. Gerson L. et al.What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.Gastrointest Endosc. 2006; 64: 740-750Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar A statistically significant decline was seen in the mean time for antegrade DBE after the first 10 procedures were performed at a given institution, but no such decrease was seen in retrograde DBE times. However, there was no improvement in the length of small bowel examined with greater experience. Complete small-bowel traversal was achieved in only 5% of attempts, and the rate of failure to maintain intubation of the terminal ileum on retrograde DBE was 29%. The diagnostic yield in these early reports was only 43% to 47.5%, and therapeutic maneuvers were carried out in 27% to 33% of patients.27Kaffes A.J. Koo J.H. Meredith C. Double-balloon enteroscopy in the diagnosis and the management of small-bowel diseases: an initial experience in 40 patients.Gastrointest Endosc. 2006; 63: 81-86Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 28Mehdizadeh S. Ross A. Gerson L. et al.What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.Gastrointest Endosc. 2006; 64: 740-750Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar Is SBE comparable to DBE for evaluation and treatment of small-bowel diseases? The simpler SBE system design may not translate into a shorter learning curve. The emerging data on the learning curve with DBE argue that the early optimism that 10 cases would be sufficient experience to achieve proficiency was misplaced.13Gross S.A. Stark M.E. Initial experience with double-balloon enteroscopy at a U.S. center.Gastrointest Endosc. 2008; 67: 890-897Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 28Mehdizadeh S. Ross A. Gerson L. et al.What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.Gastrointest Endosc. 2006; 64: 740-750Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar, 29Lo S.K. Technical matters in double balloon enteroscopy.Gastrointest Endosc. 2007; 66: S15-S18Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar The shape of the learning curve for SBE remains to be defined. The 37 SBE cases described by Kawamura et al8Kawamura T. Yasuda K. Tanaka K. et al.Clinical evaluation of a newly developed single-balloon enteroscope.Gastrointest Endosc. 2008; 68: 1112-1116Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar were performed by 3 endoscopists, all new to balloon enteroscopy, over 16 months—a rate of less than one case per physician per month. In contrast, Gross and Stark13Gross S.A. Stark M.E. Initial experience with double-balloon enteroscopy at a U.S. center.Gastrointest Endosc. 2008; 67: 890-897Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar reported 11.8 DBE procedures per month by one physician over 17 months, yet with continued improvement in performance even after 150 total cases. The simpler SBE design impact on procedure time is unclear, because reported examination times are not universally shorter than early DBE experience. In addition, shorter examination times could result from less bowel being examined rather than more efficient scope progression. The complication profile of DBE has recently been coming into focus, with rates of serious complications as high as 1% in diagnostic studies and 3.4% to 4.3% in therapeutic procedures.28Mehdizadeh S. Ross A. Gerson L. et al.What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.Gastrointest Endosc. 2006; 64: 740-750Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar, 30May A. Nachbar L. Pohl J. et al.Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations.Am J Gastroenterol. 2007; 102: 527-535Crossref PubMed Scopus (227) Google Scholar, 31Mensink P.B. Haringsma J. Kucharzik T. et al.Complications of double balloon enteroscopy: a multicenter survey.Endoscopy. 2007; 39: 613-615Crossref PubMed Scopus (335) Google Scholar The reported complication rate of SBE rivals that of diagnostic DBE, but again, the data are preliminary. Finally, these early reports on SBE have not demonstrated a clinical impact comparable to that of DBE at centers with extensive experience. Further studies are needed to define SBE's effect on clinical management. What features of DBE or SBE could be modified to facilitate learning, improve the diagnostic yield, and reduce complications? The introduction of the larger therapeutic DBE scope led to increased ileal intubation rates on retrograde examinations.28Mehdizadeh S. Ross A. Gerson L. et al.What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.Gastrointest Endosc. 2006; 64: 740-750Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar Would a variable-stiffness feature be beneficial as in push enteroscopy?32Harewood G.C. Gostout C.J. Farrell M.A. et al.Prospective controlled assessment of variable stiffness enteroscopy.Gastrointest Endosc. 2003; 58: 267-271Abstract Full Text PDF PubMed Scopus (28) Google Scholar The 2.8-mm accessory channels on both enteroscopes would seem adequate for insertion of most endoscopic accessories, yet with a long scope in various tortured configurations, passage of devices can be problematic.33Lo S.K. Small bowel endoscopy: have we conquered the final frontier?.Am J Gastroenterol. 2007; 102: 536-538Crossref PubMed Scopus (11) Google Scholar In addition, some devices, such as clip devices, fail to function properly after a high-resistance passage to a target lesion, so a larger channel size should be considered. A problem with retrograde examinations is maintaining ileal position during pullback, even with balloons fully inflated.28Mehdizadeh S. Ross A. Gerson L. et al.What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers.Gastrointest Endosc. 2006; 64: 740-750Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar Putting the issue of number of balloons aside, is balloon size and inflation pressure ideal? Perhaps balloon size and/or pressure should differ for retrograde versus antegrade examinations.29Lo S.K. Technical matters in double balloon enteroscopy.Gastrointest Endosc. 2007; 66: S15-S18Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Overtubes need to be reconfigured to reduce the amount of body fluid that tracks back around the scope and out the proximal end, spilling onto the examination table, patient, and endoscopy personnel. Are overtube length and stiffness ideal? A shorter tube may allow advance in larger increments, reducing the number of cycles required to traverse the small bowel. The balloon inflation/deflation process needs to be quicker, with greater endoscopist control via a foot pedal, and auditory signals are useful to indicate full inflation and deflation. Would using carbon dioxide for insufflation, rather than air, facilitate the examination for both the endoscopist and patient, as suggested by the work of Domagk et al?34Domagk D. Bretthauer M. Lenz P. et al.Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial.Endoscopy. 2007; 39: 1064-1067Crossref PubMed Scopus (108) Google Scholar Finally, the complication rate for therapeutic procedures is troublesome, but perhaps can be reduced with changes in technique.35Matsushita M. Shimatani M. Uchida K. et al.Safer endoscopic therapy of small-bowel diseases during double-balloon enteroscopy.Endoscopy. 2007; 39 (author reply 1108): 1107Crossref PubMed Scopus (5) Google Scholar If an endoscopist is considering acquiring a new small-bowel endoscope, deciding between the DBE and SBE systems comes down to comparing the increasingly well known to the vaguely known. More fundamentally, the gastroenterologist must recognize that these procedures place significant demands on endoscopy lab resources. In addition, the costs associated with these resource-intensive procedures are not yet recognized by the Current Procedural Terminology (CPT) coding system.13Gross S.A. Stark M.E. Initial experience with double-balloon enteroscopy at a U.S. center.Gastrointest Endosc. 2008; 67: 890-897Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 36Coding for deep enteroscopy procedures in an era of emerging technology.Gastrointest Endosc. 2008; 67: 391-393Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar If the needed resources are available and both systems are under consideration, then factors such as compatibility with existing endoscope platforms, acquisition cost, maintenance expense, accessory costs, and technical support, in addition to clinical performance, come into play.12DiSario J.A. Petersen B.T. Tierney W.M. et al.Technology status evaluation report: enteroscopes.Gastrointest Endosc. 2007; 65: 872-880Abstract Full Text Full Text PDF Scopus (38) Google Scholar What is the role of balloon enteroscopy in the evaluation and management of small-bowel diseases? Recent guidelines from the British Society for Gastroenterology recommend CE as the initial study in most cases of suspected small bowel disease except those believed to have strictures.37Sidhu R. Sanders D.S. Morris A.J. et al.Guidelines on small bowel enteroscopy and capsule endoscopy in adults.Gut. 2008; 57: 125-136Crossref PubMed Scopus (208) Google Scholar DBE is recommended to follow-up any CE demonstrating lesions that require sampling or endoscopic therapy.37Sidhu R. Sanders D.S. Morris A.J. et al.Guidelines on small bowel enteroscopy and capsule endoscopy in adults.Gut. 2008; 57: 125-136Crossref PubMed Scopus (208) Google Scholar In addition, DBE is recommended in cases of continued obscure GI bleeding after negative CE. However, the yield of DBE after negative CE has yet to be defined. Although CE is easy to perform and has a low risk profile, incomplete visualization of the small bowel still occurs in 15% to 26% of examinations, and it is not possible to pause at or wash any area of interest during CE.16Carey E.J. Leighton J.A. Heigh R.I. et al.A single-center experience of 260 consecutive patients undergoing capsule endoscopy for obscure gastrointestinal bleeding.Am J Gastroenterol. 2007; 102: 89-95Crossref PubMed Scopus (281) Google Scholar, 38Rondonotti E. Herrerias J.M. Pennazio M. et al.Complications, limitations, and failures of capsule endoscopy: a review of 733 cases.Gastrointest Endosc. 2005; 62 (quiz 752, 754): 712-716Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar, 39Rondonotti E. Villa F. Mulder C.J. et al.Small bowel capsule endoscopy in 2007: indications, risks and limitations.World J Gastroenterol. 2007; 13: 6140-6149Crossref PubMed Scopus (100) Google Scholar A pooled analysis comparing CE to dated modalities such as push enteroscopy, small-bowel series, and colonoscopy by ileoscopy found that CE missed 11% of lesions and 19% of neoplastic processes.40Lewis B.S. Eisen G.M. Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials.Endoscopy. 2005; 37: 960-965Crossref PubMed Scopus (251) Google Scholar This miss rate is likely to be significantly higher with more studies comparing CE to the more robust DBE or SBE technology. Predictably, reports of lesions missed by CE but detected by DBE have already begun appearing.13Gross S.A. Stark M.E. Initial experience with double-balloon enteroscopy at a U.S. center.Gastrointest Endosc. 2008; 67: 890-897Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 41Chong A.R.K. Chin B.W.K. Meredith C.G. Clinically significant small-bowel pathology identified by double-balloon enteroscopy but missed by capsule endoscopy.Gastrointest Endosc. 2006; 64: 445-449Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar, 42Ross A. Mehdizadeh S. Tokar J. et al.Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy.Dis Dig Sci. 2008 Feb 13; ([Epub ahead of print])Crossref PubMed Scopus (177) Google Scholar For now, CE and DBE can be viewed as complementary, with DBE providing sampling and therapeutic capabilities as well as improved localization ability compared to CE. How SBE will fit into the gastroenterologist's armamentarium remains to be determined. However, the small bowel once viewed as beyond the endoscopist's reach is not only accessible; there are multiple approaches to the last frontier. I thank Dr Mark E. Stark for sharing his insight and experience with balloon enteroscopy. The author reports the following conflicts: W. A. Ross is a speaker for Olympus America Corp." @default.
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