How to approach the small bowel with flexible enteroscopy

Nowadays, 5 nonsurgical flexible endoscopic techniques are available for small bowel endoscopy: push enteroscopy (PE), balloon-assisted enteroscopy using 2 balloons (double-balloon enteroscopy [DBE]) or 1 balloon (single-balloon enteroscopy [SBE]), balloon-guided enteroscopy (BGE), and spiral enteroscopy (SE). PE is a cost-saving, easy, and fast procedure for the examination of the proximal jejunum, but for a deep small bowel endoscopy, the other flexible enteroscopic techniques are required. BGE does not play a considerable role in deep small bowel endoscopy. DBE is the oldest flexible enteroscopic technique. Actually, the balloon-assisted enteroscopy (BAE) techniques with one balloon (SBE) or two balloons (DBE) are the mainly used techniques. DBE has become established throughout the world for diagnostic and therapeutic examinations of the small bowel and is now used universally in clinical routine work. DBE is still regarded as the gold standard nonsurgical procedure for deep small bowel endoscopy, because it provides the highest rates of complete enteroscopy, which becomes increasingly useful. The recently introduced SE technique represents a promising method but still needs technical improvement. Larger prospective studies on SE and prospective studies comparing the 3 systems (DBE, SBE, SE) are awaited before conclusive assessments can be made.     

Single balloon enteroscopy: Technical aspects and clinical applications

The small bowel has long been considered a black box for endoscopists because of its long length and the presence of multiple complex loop. Most of the small bowel is inaccessible by traditional endoscopic means. In addition, radiographic studies have significant limitations with regard to diagnostic yield, and surgery is an invasive alternative. This limitation was overcome through the development of balloon enteroscopy that becomes established throughout the world for diagnostic and therapeutic examinations of the small bowel. The single-balloon enteroscope (SBE) system (Olympus, Tokyo, Japan) was introduced into the commercial market in 2007. Several study demonstrated its efficacy and safety. Early reports on the use of singleballoon enteroscopy have suggested a high diagnostic yield and similar therapeutic potential to that of the double-balloon endoscope. SBE is viable technique for in the management of small bowel disease. Technically, it is easy to perform, may be efficient, and in the literature data available, seems to provide high diagnostic and therapeutic yield.     

Enteroscopy in the pediatric population

Balloon-assisted enteroscopy (BAE) is a significant advance in gastrointestinal endoscopy. Two systems are currently available including double-balloon enteroscopy and single-balloon enteroscopy. In adult patients, BAE is a validated indication for the investigation of obscure gastrointestinal bleeding, but is also routinely used for other disorders specific to the small bowel. Although there is limited experience on the use of BAE in children, the current available literature suggests that BAE is safe and effective for diagnosing and treating various disorders of the small bowel in children.     

Current status of single-balloon enteroscopy: Insertability and clinical applications

The single-balloon enteroscopy (SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy (DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. However, many methods have been proposed to improve the depth of insertion with the SBE system, involving several techniques and endoscopic accessories. SBE is used for investigating not only small bowel diseases, but also diseases of the pancreatobiliary and colonic structures. SBE is a necessary advancement for many endoscopic procedures and applications in modern clinical practice. In our review, we summarized the current literature concerning the insertability of SBE and described the technical aspects of improving the rate of deep insertion in SBE procedures. In addition, the recent applications of SBE to diseases besides those of the small bowel are described.     

Hyperamylasemia and pancreatitis following spiral enteroscopy

BACKGROUND

Acute pancreatitis is a significant potential complication with double-balloon enteroscopy. Hyperamylasemia is frequently observed after both double-balloon enteroscopy and single-balloon enteroscopy but often without associated pancreatitis. Whether the same phenomenon occurs with spiral enteroscopy is currently unknown.

AIMS:

To determine the incidence of pancreatitis and hyperamylasemia following spiral enteroscopy.

METHODS:

A prospective cohort study of consecutive patients undergoing proximal spiral enteroscopy was conducted. Serum amylase levels were measured immediately before and following the procedure, combined with observation for clinical signs of pancreatitis.

RESULTS:

A total of 32 patients underwent proximal spiral enteroscopy, with a mean total procedure time of 51 min (range 30 min to 100 min) and mean depth of insertion of 240 cm (range 50 cm to 350 cm). The diagnostic yield was 50%, with 31% of all procedures being therapeutic. While no patients exhibited signs that raised suspicion of pancreatitis, hyperamylasemia was common (20%). Hyperamylasemia was not significantly associated with procedure duration or depth of insertion but was linked to patients with Peutz-Jeghers syndrome and with the use of propofol sedation, suggesting that it may be more common in difficult cases.

CONCLUSIONS:

Postprocedural hyperamylasemia occurred frequently with proximal spiral enteroscopy, while no associated pancreatitis was observed. This finding suggests that hyperamylasemia may not necessarily reflect pancreatic injury nor portend a risk for pancreatitis.     

Diagnostic yield of deep enteroscopy techniques for small-bowel bleeding and tumors

Endoscopic evaluation and management with deep enteroscopy techniques have largely replaced the role of intraoperative enteroscopy in the management of small-bowel (SB) disorders. While capsule endoscopy (CE) enables visualization of the entire SB, therapeutic deep enteroscopy techniques (balloon-assisted enteroscopy and spiral enteroscopy) facilitate diagnostic and therapeutic management deep within the SB. CE is currently recommended as the third test of choice in the evaluation of obscure gastrointestinal bleeding after a negative bidirectional endoscopy. The test also has a role in the diagnosis of SB tumors and surveillance of familial polyposis syndromes. Therapeutic deep enteroscopy techniques are mainly used for evaluation and management of CE findings, but they may also have a role in patients with a negative CE but high clinical suspicion for an SB disorder. Because preliminary data suggest a comparable diagnostic and therapeutic yield with double-balloon, single-balloon, and spiral enteroscopy, selection of the enteroscope should be based on availability and the endoscopist's experience with the technique.     

Diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in a series of 100 patients with suspected small bowel diseases

BACKGROUND: Double-balloon enteroscopy is a newly developed endoscopic method allowing non-surgical full-length exploration of the small bowel, biopsies sample and endoscopic treatment of previously inaccessible lesions. AIM: To prospectively assess the diagnostic and therapeutical impact of double-balloon enteroscopy in patients with suspected or documented small bowel disease. PATIENTS AND METHODS: One hundred consecutive patients referring to our centre for suspected small bowel disease underwent double-balloon enteroscopy. Starting insertion route (anal or oral) of double-balloon enteroscopy was chosen according to the estimated location of the suspected lesions basing on the clinical presentation and on the findings, when available, of previous endoscopic or radiological investigations. Major indications for the procedures were acute recurrent or chronic mid-gastrointestinal bleeding (n=71), suspected gastrointestinal tumours (n=10), suspected Crohn's disease (n=6), chronic abdominal pain and/or chronic diarrhoea (n=8), refractory celiac disease (n=5). RESULTS: One hundred and eighteen double-balloon enteroscopy procedures were carried out. Oral and anal route double-balloon enteroscopies were performed in 54 and 28 patients, respectively, while 18 patients underwent a combination of both approaches. Overall diagnostic yield of double-balloon enteroscopy resulted 69%. Most common pathological findings included angiodysplasias (n=39), ulcerations and erosions of various aetiologies (n=21), tumours (n=7) and ileal stenosis in patients with Crohn's disease suspicion (n=2). In the 65% of the patients examined, double-balloon enteroscopy findings influenced the subsequent clinical management (endoscopic, medical or surgical treatment). No major complications related to the procedure occurred. CONCLUSIONS: Our prospective analysis shows that double-balloon enteroscopy is a useful, safe and well-tolerated new method with a high diagnostic and therapeutic impact for the management of suspected or documented small bowel diseases.     

Double-balloon endoscopy for the diagnosis and treatment of small intestinal disease

Evaluation of the small bowel has long been hampered because of its long and multiple complex loop configurations. Yamamoto et al have developed a new method of inserting an endoscope, known as the double-balloon method of enteroscopy, the Fujinon double-balloon endoscopy system being specialised for this application. Two types of endoscope are currently available for this technique. The EN-450 P5 is a thin endoscope for regular use, whereas the EN-450 T5 is a therapeutic double-balloon endoscope with a larger accessory channel of 2.8mm in diameter. Double-balloon endoscopy enables visualisation of the entire small bowel and also allows for interventional therapy in the small intestine. This method can be used either from an oral or an anal insertion. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, haemostasis, balloon dilatation, stent placement, polypectomy and endoscopic mucosal resection, to be performed. In our large study series, it was demonstrated that double-balloon endoscopy permitted exploration of the small intestine with the high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.     

Small bowel enteroscopy

For the examination of the small bowel in patients with suspected small bowel bleeding, endoscopic tools to perform deep enteroscopy have become essential. Double balloon enteroscopy has gained worldwide acceptance as an endoscopic technique that can be used safely and effectively to provide complete examination of the small bowel, offer therapeutic intervention, and favorably affect clinical outcomes. Single balloon enteroscopy seems to have utility similar to that of the double balloon system. Preliminary experience with a novel overtube device using either the single or double balloon enteroscope has suggested that this may be a very viable approach to deep enteroscopy. Collectively, these are remarkable innovations that allow access to portions of the small bowel that were previously only available by intraoperative enteroscopy or laparotomy. On the basis of the available data, each of these procedures seems to have unique merits, is generally safe and well tolerated, and is highly likely to be clinically beneficial.     

双气囊小肠镜对小肠出血的诊断价值

目的探讨双气囊小肠镜对小肠出血的诊断价值及安全性。方法对2007年1月-2008年12月我院经常规检查怀疑为小肠出血的56例患者行双气囊小肠镜检查,分别接受经口或经肛双气囊小肠镜检查。主要分析检查时间、内镜插入深度、确诊情况和并发症发生率。结果所有患者无严重并发症,操作时间为35-150 min,平均（76±22）min;平均插入小肠长度经口和经肛分别为（254±126）cm和（182±103）cm。小肠病变中阳性发现46例（82.1%）,主要包括血管畸形、小肠溃疡、克罗恩病、慢性非特异性炎症、肿瘤、息肉及憩室等。结论双气囊小肠镜检查安全有效,为小肠出血疾病的诊断提供了新的手段。     

Advances in modern enteroscopy therapeutics

Advances in modern enteroscopy have been largely due to endoscope development but also through the improved availability of endoscopic accessories along with improved understanding in their application. Device assisted enteroscopy began with the double balloon system in 2001 and was quickly followed by single balloon enteroscopy and spiral enteroscopy. These tools revolutionised deep small bowel endoscopy and allowed for the delivery of virtually all known therapeutic endoscopy intervention to almost all segments of the small bowel. This review covers the types of interventions in regards to indications, methods and their safety profiles as well as reviewing the various device assisted endoscopes available and their attributes.     

Jejunal diverticular bleeding diagnosed by double-balloon enteroscopy: a case report and review of literatures]

Jejunal diverticula is a rare disease and an unusual cause of obscure gastrointestinal hemorrhage. Obscure gasterointestinal bleeding is difficult to treat because the bleeding site cannot be identified by routine endoscopy and contrast studies. A wireless capsule endoscopy is not invasive and can visualize the entire small bowel. However, this method has limitations of incapability of taking biopsies and performing endoscopic interventions such as polypectomy or stent insertion. The double-balloon enteroscopy is being used frequently for the diagnosis and management of various small bowel diseases. We report a case of proximal jejunal diverticular bleeding diagnosed by double-balloon enteroscopy and treated with angiographic embolization.     

Complications of small bowel endoscopy

With the advent of techniques to fully image and intervene on the small intestine, including capsule endoscopy, single- and double-balloon enteroscopy, and spiral enteroscopy, our diagnostic and therapeutic capabilities have increased significantly. These new technologies are not without risk, and these techniques have led to a large body of literature addressing the complications that can arise from these procedures. This chapter will review the complications associated with capsule endoscopy, single- and double-balloon enteroscopy, and spiral enteroscopy.     

Ileal gallstone obstruction: Single-balloon enteroscopic removal

Gallstone-induced ileus is a rare complication of cholelithiasis. Since localization of gallstones impacted in the small bowel, especially in the ileum, prevents access by conventional endoscopy in most cases, the mainstay of treatment remains surgical. Recent invention of double- and single-balloon enteroscopy has added much to the ability of imaging the small bowel and enables endoscopically directed therapy. Herein, for the first time, we report a successful endoscopic calculus removal via peroral single-balloon enteroscopy in an 81-year-old woman suffering from gallstone ileus of the ileum.     

Treatment of small-bowel diaphragm disease by using double-balloon enteroscopy

BACKGROUND: Double-balloon enteroscopy is a new technique that allows endoscopic therapy throughout the entire length of the small bowel. Diaphragm disease, characterized by thin septa that narrow the small-bowel lumen, is traditionally treated surgically by segmental resection. OBJECTIVE: To report successful endoscopic treatment of diaphragm disease by double-balloon enteroscopy. PATIENTS: Three patients. DESIGN: Case report. INTERVENTIONS: Double-balloon enteroscopy and stricture balloon dilation. RESULTS: We report, for the first time, 3 cases in which diaphragm strictures were successfully treated during double-balloon enteroscopy. In 2 cases, a retained capsule endoscope was removed by the retrograde approach after stricture dilation. LIMITATIONS: Small number of patients and brief length of patient follow up. CONCLUSION: Double-balloon enteroscopy may be used to treat patients with diaphragm disease, thus avoiding potentially complicated surgery.     

Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications

Enteroscopy, defined as direct visualization of the smallbowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past severalyears. The need for endoscopic access to improvediagnosis and treatment of small bowel disease hasled to the development of novel technologies one ofwhich is noninvasive, the video capsule, and a type of invasive technique, the deviceassisted enteroscopy.In particular, the device-assisted enteroscopy consiststhen of three different types of instruments all able toallow, in skilled hands, to display partially or throug-hout its extension (if necessary) the small intestine.Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowelenteroscopy, focusing on indications, modifications toimprove imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endo-scopic skills and determining their role in the diagnosisand treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved.Studies are underway to determine the best strategy toapply new enteroscopy technologies for the diagnosisand management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocar cinomaor gas trointestinal stromal tumors. Complete entero-scopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and the rapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective ran-domized studies are needed to guide diagnostic testing and the rapy with these new endoscopic techniques.     

双气囊电子小肠镜临床应用初探

目的探讨小肠疾病检查新方法——双气囊电子小肠镜的操作、诊断效果、适应证等问题。方法应用双气囊电子小肠镜对13例疑诊小肠疾病的患者进行双气囊小肠镜检查。分别从口侧或肛侧进镜，利用外套管、内镜前端的双气囊交替充气、放气和交替滑进，推进小肠镜进入小肠检查。记录检查范围、时间、耐受性及病变等。结果13例患者共行小肠镜检查19例次(11例次接受了口侧进镜，8例次接受了肛侧进镜)，每侧进镜术程平均80min。从口侧进镜均达第3～6组小肠，从肛侧进镜达4～6组小肠。发现空肠良性问质瘤1例、空肠淋巴瘤1例、回肠溃疡狭窄及憩室2例、空肠息肉2例、空肠糜烂2例。口侧进镜患者，术中多数出现恶心、消化液自口及外滑管口溢出，偶尔出现一过性轻微腹痛；肛侧进镜患者无明显不适及反应；未出现出血、穿孔等并发症。结论双气囊小肠镜是一种新型小肠疾病检查手段，平均2～3h可检查完所有小肠，进镜迅速。于操作直视下观察病变，通过活检对病变进行定性检查。病变检出率明显优于小肠钡剂造影，具有安全、可控性、直视、图像清晰等优点，适用于无肠粘连及严重脏器功能不全的小肠疾病患者。     

胶囊内镜和双气囊内镜对小肠克罗恩病诊断价值的比较

克罗恩病（CD）是一种原因未明的慢性炎性肉芽肿性病变,可侵及全消化道各部位,约70％的病变累及小肠,诊断需联合其临床表现、内镜检查、组织病理学、影像学、实验室检生化查等。新型检查技术如胶囊内镜和双气囊内镜对评估小肠疾病具有重要作用。本文就胶囊内镜和双气囊内镜在小肠CD中的诊断率作一综述,以进一步明确两者的诊断价值。     

Spiral enteroscopy: Prime time or for the happy few?

Spiral enteroscopy is the newest of the deep enteroscopy techniques. The current technique employs an overtube with a raised spiral at the distal end to pleat the small intestine and achieve deep small bowel intubation. Although spiral enteroscopy is a novel technique, the learning curve is comparable to the balloon enteroscopy techniques. There is some evidence of improved speed of spiral enteroscopy procedures with superior control compared to the balloon endoscopy technologies. Altered surgical anatomy deep enteroscopy has been shown to have similar safety and efficacy to competitive technologies, particularly in cases of Roux-en-Y ERCP cases. Spiral enterosopy is safe and effective for deep small bowel enteroscopy and diagnostic yield and therapeutic yields are similar to alternate technologies. There are bright future applications of the technology with enteroscopes and an integrated spiral. Spiral enteroscopy is an advanced technique that can be performed by any skilled endoscopist.