Double-balloon enteroscopy

Abstract: Small-bowel capsule endoscopy (SBCE) 1 ESGE recommends that prior to SBCE patients ingest a purgative (2 L of polyethylene glycol [PEG]) for better visualization. Strong recommendation, high quality evidence. However, the optimal timing for taking purgatives is yet to be established. 2 ESGE recommends that SBCE should be performed as an outpatient procedure if possible, since completion rates are higher in outpatients than in inpatients. Strong recommendation, moderate quality evidence. 3 ESGE recommends that patients with pacemakers can safely undergo SBCE without special precautions. Strong recommendation, low quality evidence. 4 ESGE suggests that SBCE can also be safely performed in patients with implantable cardioverter defibrillators and left ventricular assist devices. Weak recommendation, low quality evidence. 5 ESGE recommends the acceptance of qualified nurses and trained technicians as prereaders of capsule endoscopy studies as their competency in identifying pathology is similar to that of medically qualified readers. The responsibility of establishing a diagnosis must however remain with the attending physician. Strong recommendation, moderate quality evidence. 6 ESGE recommends observation in cases of asymptomatic capsule retention. Strong recommendation, moderate quality evidence. In cases where capsule retrieval is indicated, ESGE recommends the use of device-assisted enteroscopy as the method of choice. Strong recommendation, moderate quality evidence. Device-assisted enteroscopy (DAE) 1 ESGE recommends performing diagnostic DAE as a day-case procedure in patients without significant underlying co-morbidities; in patients with co-morbidities and/or those undergoing a therapeutic procedure, an inpatient stay is recommended. Strong recommendation, low quality evidence The choice between different settings also depends on sedation protocols. Strong recommendation, low quality evidence. 2 ESGE suggests that conscious sedation, deep sedation, and general anesthesia are all acceptable alternatives: the choice between them should be governed by procedure complexity, clinical factors, and local organizational protocols. Weak recommendation, low quality evidence. 3 ESGE recommends that the findings of previous diagnostic investigations should guide the choice of insertion route. Strong recommendation, moderate quality evidence. If the location of the small-bowel lesion is unknown or uncertain, ESGE recommends that the antegrade route should be generally preferred. Strong recommendation, low quality evidence. In the setting of massive overt bleeding, ESGE recommends an initial antegrade approach. Strong recommendation, low quality evidence. 4 ESGE recommends that, for balloon-assisted enteroscopy (i. e., single-balloon enteroscopy [SBE] and double-balloon enteroscopy [DBE]), small-bowel insertion depth should be estimated by counting net advancement of the enteroscope during the insertion phase, with confirmation of this estimate during withdrawal. Strong recommendation, low quality evidence. ESGE recommends that, for spiral enteroscopy, insertion depth should be estimated during withdrawal. Strong recommendation, moderate quality evidence. Since the calculated insertion depth is only a rough estimate, ESGE recommends placing a tattoo to mark the identified lesion and/or the deepest point of insertion. Strong recommendation, low quality evidence. 5 ESGE recommends that all endoscopic therapeutic procedures can be undertaken at the time of DAE. Strong recommendation, moderate quality evidence. Moreover, when therapeutic interventions are performed, additional specific safety measures are needed to prevent complications. Strong recommendation, high quality evidence.

Abstract: Background and study aims: Until recently, only the proximal small bowel was accessible for diagnostic and therapeutic endoscopy. This paper describes experience in the first 275 patients examined and treated with the new method of double-balloon enteroscopy (DBE), which is expected to make full-length enteroscopy possible. Patients and methods: Between November 2003 and May 2005, double-balloon enteroscopy was conducted in 275 consecutive patients presenting at two tertiary referral hospitals. The characteristics of the patients, indications for the procedures, procedural parameters, and diagnostic yield are described here. All conventional treatment options were available. The tolerability of the procedure was assessed in a small subset of the patients. After the procedure, the patients were monitored in a recovery room for at least 2 h. They were discharged afterwards, provided there were no signs of complications or complaints. Results: The main indication for DBE was suspected small-bowel bleeding (n = 168), and the lesions responsible for the bleeding were found in 123 patients (73 %) and treated in 61 (55 %). In patients with refractory celiac disease (n = 25), DBE revealed a high proportion (six patients, 23 %) of enteropathy-associated T-cell lymphomas that had not been suspected on other tests. Further DBE indications were surveillance and treatment of hereditary polyposis syndromes (n = 20); and suspected Crohn's disease, which was diagnosed with DBE in four of 13 patients (30 %). No relevant pathology was found in 24% of the patients. Panenteroscopy was successfully performed in 26 of 62 patients (42%) in whom it was attempted, in either one or two sessions. The average duration of the procedures was 90 min (range 30 - 180 min, SD 42), and the average insertion length was 270 cm (range 60 - 600 cm, SD 104). Patients' tolerance of the procedure was excellent. Severe complications were recognized in three cases (1 %), all involving pancreatitis. Conclusions: This large pilot series shows that DBE is a well-tolerated and safe new endoscopic technique with a high diagnostic yield in selected patients.