Preliminary results of alternative “simultaneous” technique for single-balloon enteroscopy

We read with great interest the article by Tsujikawa and coworkers [1] on a novel single-balloon enteroscopy (SBE) system for the examination of the small bowel.

The authors performed 78 SBE procedures (38 by the oral approach and 40 by the anal approach) in 41 patients. They describe a conventional technique for advancing the endoscope: in order to shorten the intestine and to advance into the small bowel, the endoscope and the overtube, with inflated balloon, are withdrawn together. Then, with the balloon still inflated in order to maintain position, the endoscope is pushed maximally into the small bowel. The repetition of these maneuvers allows progression of the endoscope and exploration of the small bowel.

We also read a technical note about enteroscopy by Hartmann and colleagues [2], particularly regarding insertion options, which describes the technique used by Tsujikawa and also an alternative technique that consists of withdrawing only the inflated overtube in order to shorten the intestine, and simultaneously pushing the endoscope as deep as possible into the small bowel. Of course, the two options can be alternately used in the same exam.

Here we describe our experience: we wanted to analyze, prospectively, the differences between the two techniques in respect of the duration of the procedure and the length of small bowel visualized. We thought of the “simultaneous” technique subsequently described by Hartmann and started to use it. Between May and September 2007, we performed eight procedures in eight patients (6 by the oral approach and 2 by the anal approach) with a prototype of this single-balloon enteroscope made by Olympus (Olympus Co., Ltd., Tokyo, Japan). The indications were: obscure gastrointestinal bleeding (6 patients; all of these were successfully treated with argon plasma coagulation for intestinal multiple angiodysplasia), Crohn’s disease (2 patients). We performed the first four examinations using only the technique described by Tsujikawa (3 by the oral approach and 1 by the anal approach) and the other four using only the alternative technique, later described by Hartmann et al. (3 by the oral approach and 1 by the anal approach).

This second method allowed a lower mean duration of the procedure (58.3 vs. 65.9 minutes for the oral approach, and 66.4 vs. 74.1 minutes for the anal approach, using the simultaneous technique and the conventional technique respectively). Moreover, the mean length of small bowel visualized (from the pylorus for the oral approach), measured according to the method of May and coworkers [3], did not seem to be significantly different between the two techniques (240 vs. 250 cm for the oral approach, and 180 vs. 160 cm for the anal approach, using the simultaneous technique and the conventional technique, respectively). No adverse events were registered. These results do not correlate with the skill of the operators, who were the same two operators already experienced in double-balloon enteroscopy.

In conclusion, we agree with Tsujikawa, Hartmann and their colleagues, confirming the complexity but also the safety and the efficacy of this new enteroscopy system, which requires dedicated operators. Both the techniques described above permit good performance of the procedure, although the “simultaneous” technique (withdrawal of the overtube and simultaneous pushing of the endoscope) seems to be time-saving and the length of small bowel visualized to be equal. Our limited experience (8 cases) must be increased in order to confirm these results.

References

• 1 Tsujikawa T, Saitoh Y, Andoh A. et al . Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences.  Endoscopy. 2008;  40 11-15
• 2 Hartmann D, Eickhoff A, Tamm R. et al . Balloon-assisted enteroscopy using a single-balloon technique.  Endoscopy. 2007;  DOI: 10.1055/s-2007-966616
• 3 May A, Nachbar L, Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease.  Gastrointest Endosc. 2005;  62 62-70