Intestinal perforation as a complication of balloon-assisted enteroscopy

In the May issue of Endoscopy, Aktas et. al. [1] reported the complications of single-balloon enteroscopy (SBE). They found that diagnostic SBE is a safe procedure without any significant complication. They had one perforation that occurred after dilation of a benign stricture. I believe the same as the authors: that SBE is a safe procedure.

Balloon-assisted enteroscopy (BAE) and therapeutic interventions during the procedure have expanded our limits. Indications for BAE such as mid-gastrointestinal bleeding, polyposis syndromes, and strictures all carry a possibility of intervention. Endoscopic interventions appear to be more difficult to carry out in the small bowel than in the upper or lower gastrointestinal tract. Some complications have been attributed to the use of a stiff overtube, but large surveys have shown that the complication rate of diagnostic procedures is low (0.4 – 0.8 %). Therapeutic interventions raise the overall complication rate to 3 – 4 %. Severe treatment-associated complications were seen after resection of large polyps [2] [3] [4].

In our clinic, we do SBE exclusively with the power suction maneuver instead of hooking of the tip, to prevent intestinal laceration. We have not encountered any incident so far. We had two patients with benign strictures (anastomotic in one case, Crohn’s strictures in the other) which were dilated enteroscopically without any complication. I am against the opinion that the tip of the enteroscope is more harmful than the overtube. I believe that the stiff overtube is more harmful for strictures or adhesions. Before the BAE era, surgery was the only modality for symptomatic benign strictures, in the form of either stricturoplasty or segmental resection and re-anastomosis. In addition, these procedures can also have the potential for development of adhesions or restructuring at the anastomosis or stricturoplasty sites.

The introduction of dilation by BAE provided an alternative to surgery. However, insertion of the enteroscope through the small bowel is challenging, especially in patients with adhesions, because of the multiple loops [5]. Pushing the enteroscope and the stiff overtube though the fixed small bowel exerts more pressure on the thin intestinal wall, increasing the risk of perforation. You can pass the endoscope with direct vision; if this is unsuccessful, you cannot simply try pushing hard. The overtube, on the other hand, is pushed without any visual guidance but just by feeling the resistance. The tight tip of the overtube has the potential to cause intestinal lacerations, which may augment partial-thickness tears into perforation if you push hard at the stricture site.

The bottom line is: dilation of small-bowel strictures is a safe procedure in selected patient groups. Although the aforementioned complication figures were derived from double-balloon enteroscopy series, I don’t think the figures for SBE will differ. More care should be given to large polyp polypectomies, which could cause more perforations than stricture dilations.

Competing interests: None

References

• 1 Aktas H, de Ridder L, Haringsma J. et al . Complications of single-balloon enteroscopy: a prospective evaluation of 166 procedures.  Endoscopy. 2010;  42 365-368
• 2 Pohl J, Delvaux M, Ell C. et al . European Society of Gastrointestinal Endoscopy (ESGE) Guidelines: flexible enteroscopy for diagnosis and treatment of small bowel diseases.  Endoscopy. 2008;  40 609-618
• 3 May A, Nachbar L, Pohl J. et al . Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations.  Am J Gastroenterol. 2007;  102 527-535
• 4 Möschler O, May A D, Müller M K. et al . Complications in double-balloon-enteroscopy: results of the German DBE register.  Z Gastroenterol. 2008;  46 266-270
• 5 Despott E J, Gupta A, Burling D. al. Effective dilation of small-bowel strictures by double-balloon enteroscopy in patients with symptomatic Crohn’s disease.  Gastrointest Endosc. 2009;  70 1030-1036