Consensus report of the 2nd International Conference on Double Balloon Endoscopy

Introduction

In the past 6 years new techniques have expanded the endoscopic evaluation of the small bowel up to total enteroscopy. In 2001, video capsule endoscopy (VCE) was approved by the FDA for the evaluation of small-bowel diseases. VCE can provide an endoscopic view of most of the small intestinal mucosa, but the diagnosis depends on the analysis of recorded images, and neither biopsy nor endoscopic treatment can be performed. The latter has become possible with double balloon endoscopy (DBE), which was first described by Yamamoto and colleagues in 2001 [1] and enables complete enteroscopy to be carried out. Additional applications of potential clinical use include difficult colonoscopies and access to the pancreatic and biliary tract in patients with altered postoperative anatomy. Within a short time period several feasibility studies, including data on diagnostic and therapeutic yield of DBE, have been published. Here we report the consensus on the current status of DBE that was developed during the 2nd International Conference on DBE in Berlin, 14 - 15 June 2007, which was sponsored by Fujinon. The paper does not fulfill the formal criteria for a consensus, but may be regarded as a guide to the clinical application of DBE techniques based on published evidence, as well as on the personal opinions and experiences of the participants. Moreover, it also shows that many clinically relevant questions need to be addressed by further studies. The new development of single balloon enteroscopy has not been included in the conference, as only preliminary data existed in abstract form (DDW 2007), reporting about feasibility and comparative data between both techniques are missing.

References

• 1 Yamamoto H, Sekine Y, Sato Y. et al . Total enteroscopy with a non surgical steerable double-balloon method.  Gastrointest Endosc. 2001;  53 216-220
• 2 Saurin J C, Delvaux M, Vahedi K. et al . Clinical impact of capsule endoscpopy compared to push enteroscopy: 1-year follow-up study.  Endoscopy. 2005;  37 318-323
• 3 Ell C, May A, Nachbar L. et al . Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study.  Endoscopy. 2005;  37 613-616
• 4 Sun B, Rajan E, Cheng S. et al . Diagnostic yield and therapeutic impact of double-balloon enteroscopy in a large cohort of patients with obscure gastrointestinal bleeding.  Am J Gastroenterol. 2006;  101 2011-2115
• 5 May A, Nachbar L, Ell C. Double-balloon enteroscopy (push-and-pullenteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease.  Gastrointest Endosc. 2005;  62 62-70
• 6 Mehdizadeh 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;  64 740-750
• 7 Heine G, Hadithi M, Groenen M. et al . Double Balloon Enteroscopy: Indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel-diseases.  Endoscopy. 2006;  38 42-48
• 8 Zhong 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;  39 208-215
• 9 Yamamoto 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 1010-1016
• 10 Sunada K, Yamamoto H, Kita H. et al . Clinical outcomes of enteroscopy using the double-balloon method for strictures of the small intestine.  World J Gastroenterol. 2005;  11 1087-1089
• 11 Pohl J, May A, Nachbar L. et al . Diagnostic and therapeutic yield of push-and pull enteroscopy for symptomatic small bowel Crohn’s strictures.  Eur J Gastroenterol Hepatol. 2007;  19 529-534
• 12 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
• 13 Lee B I, Choi H, Choi K Y. et al . Retrieval of a retained capsule endoscope by double-balloon enteroscopy.  Gastrointest Endosc. 2005;  62 463-465
• 14 Sun B, Shen R, Cheng S. et al . The role of double-balloon enteroscopy in diagnosis and management of incomplete small-bowel obstruction.  Endoscopy. 2007;  39 511-515
• 15 Pérez-Cuadrado E, Latorre R, Carballo F. et al . Training and new indications for double balloon endoscopy.  Gastrointest Endosc. 2007;  66 39-46
• 16 Haruta H, Yamamoto H, Mizuta K. et al . A case of successfull enteroscopic balloon dilation for late anastomotic stricture of choledochojejunostomy after living donor liver transplantation.  Liver Transpl. 2005;  11 1608-1610
• 17 Kuno A, Yamamoto H, Kita H. et al . Double-balloon enteroscopy through a Roux-en-Y anastomosis for EMR of an early carcinoma in the afferent duodenal limb.  Gastrointest Endosc. 2004;  60 1032-1034
• 18 Sakai P, Kuga R, Safatle-Ribeiro A V. et al . Is it feasible to reach the by-passed stomach after Roux-en-Y-gastric by pass for morbid obesity? The use of the double-balloon enteroscope.  Endoscopy. 2005;  37 566-569
• 19 May A, Nachbar L, Ell C. Push-and-Pull Enteroscopy using a single-balloon technique for difficult colonoscopy.  Endoscopy. 2006;  38 395-398
• 20 Monkemueller K, Knippig C, Rickes S. et al . Usefulness of the DBE in colonoscopies performed in patients with previously failed colonoscopy.  Scand J Gastroenterol. 2007;  30 277-278
• 21 Kaltenbach T, Soetikno R, Friedland S. Use of a double balloon enteroscope facilitates caecal intubation after incomplete colonoscopy with a standard colonoscope.  Dig Liver Dis. 2006;  38 921-925
• 22 Pasha S F, Harrison M E, Das A. et al . Utility of double-balloon colonoscopy for completion of colon examination after incomplete colonoscopy with conventional colonoscope.  Gastrointest Endosc. 2007;  65 848-853
• 23 Hadithi M, Al-Toma A, Oudejans J. et al . The value of double-balloon enteroscopy in patients with refractory celiac disease.  Am J Gastroenterol. 2007;  102 987-996
• 24 Ell C, May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and pull enteroscopy give rise to a new medical term.  Endoscopy. 2006;  38 73-75
• 25 Pennazio M, Santucci R, Rondonotti E. et al . Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases.  Gastroenterology. 2004;  126 643-653
• 26 Triester S L, Leighton J A, Leontiadis G I. et al . A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding.  Am J Gastroenterol. 2005;  100 2407-2418
• 27 Gay G, Delvaux M, Fassler I. Outcome of capsule endoscopy in determining indication and route for push-and-pull-enteroscopy.  Endoscopy. 2006;  38 49-58
• 28 Voderholzer W A. The role of PillCam endoscopy in Crohn’s disease: the European experience.  Gastrointest Endosc Clin N Am. 2006;  16 287-297
• 29 Triester S L, Leighton J A, Leontiadis G I. et al . A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn’s disease.  Am J Gastroenterol. 2006;  101 954-964
• 30 May A, Nachbar L, Schneider M. et al . Push-and-pull enteroscopy using the double-balloon technique: method of assessing depth of insertion and training of the enteroscopy technique using the Erlangen Endo-Trainer.  Endoscopy. 2005;  37 66-70
• 31 Mensink P, Haringsma J, Kucharzik T F. et al . Complications of double balloon enteroscopy: a multicenter survey.  Endoscopy. 2007;  39 613-615
• 32 Moeschler O, May A, Mueller M K. et al . Complications in double-balloonenteroscopy (DBE): results of the German DBE register.  DDW. 2007;  AB S1374
• 33 Groenen M JM, Moreels T GG, Orlent H. et al . Acute pancreatitis after double balloon enteroscopy: an old pathogenetic theory revisited as a result of using a new endoscopic tool.  Endoscopy. 2006;  38 82-85
• 34 Gay G, Delvaux M. Double-balloon colonoscopy after failed conventional colonoscopy: A pilot series with a new instrument.  Endoscopy. 2007;  39 788-792
• 35 Fukumoto A, Manabe N, Tanaka S. et al . Usefulness of EUS with double balloon enteroscopy for diagnosis of small bowel diseases.  Gastrointest Endosc. 2007;  65 412-420
• 36 Xu C D, Deng C H, Zhong J, Zhang C L. Application of double-balloon push enteroscopy in diagnosis of small bowl disease in children.  Zhonghua Er Ke Za Zhi. 2006;  44 90-92