Safe, effective and here to stay!: The benefits and safety of double-balloon enteroscopy

By Edward John Despott (Associate Professor, UCL; Consultant Interventional Endoscopist, The Royal Free Hospital & The Wellington Hospital, London, UK)?

The small-bowel is the longest part of the gastrointestinal tract and can reach up to 8 metres in its length. Its anatomy, as a long and ‘floppy’ tube, while allowing it to perform its function as the primary site for digestion and absorption of the food that we eat, creates a great challenge to effective endoscopic investigation and minimally-invasive endoscopic therapy.?

Although the year 2001 may have been a ‘Space Odyssey’ for the late Mr Stanley Kubrick, for us endoscopist, 2001 was a ‘Small-bowel Odyssey’, since it saw the birth of small-bowel capsule endoscopy (SBCE) and double-balloon enteroscopy (DBE). Together, these two complementary technologies, have revolutionised the minimally invasive endoscopic investigation and management of small-bowel disease.?

Although SBCE complements DBE and is very frequently used as a ‘scout’ to evaluate the small-bowel to guide a DBE procedure. SBCE is however limited by the fact that it is only designed to take representative pictures of the inner lining of the small-bowel, whereas DBE allows for tissue-sampling and endoscopic therapy.?

Developed by Professor Hironori Yamamoto and Fujifilm, DBE is performed using a long, slim instrument (enteroscope) with an inflatable balloon at its tip. A slightly wider and shorter tube (overtube) also equipped with a balloon at its tip, runs on the enteroscope. Together, the enteroscope and the overtube (through sequential inflation and deflation of their balloons) allow gentle gripping and manipulation of the small-bowel, to enable effective and safe passage of the enteroscope with prevention of looping and stretching of the small-bowel.?

This allows the specially-trained endoscopist to take biopsies, treat bleeding lesions, to remove polyps and to stretch (dilate) narrowed parts of the small-bowel (strictures) without the need for a major surgical operation. If the encountered disease would still require surgery for curative management (e.g., a tumour), DBE allows the marking of its exact location, to guide minimally-invasive laparoscopic (key-hole) surgery.?

Although several competing technologies have come and gone (due to safety concerns), over the last 22-years since its introduction to clinical practice, DBE has stood the test of time as a safe and effective minimally-invasive endoscopic option for the investigation of small-bowel diseases. Professor Yamamoto designed DBE with safety being the primary goal, and as reflected in the vast published evidence and in our own current practice (which is among the busiest in the world), the procedure has a very low over all major complication rate of less than 1% and a very high success rate (of >85%). There is therefore no doubt that DBE is very safe and effective, and that is why it is here to stay!