Deep intubation of the small bowel during double-balloon enteroscopy
(DBE), as described by Yamamoto et al. [1]
[2]
[3], relies on the principles of
minimal small-bowel stretching and loop reduction. This is achieved by
simultaneous traction provided by the enteroscope and overtube balloons,
combined with a “pull-back” maneuver that allows loop resolution
and straightening of the free and untethered small bowel [1]. In our experience and that of others [4], this insertion method may be unsuccessful, for example
when small-bowel tethering due to intra-abdominal adhesions occurs in patients,
because deep loops are formed that are difficult to reduce when the enteroscope
is advanced. The result is a decreased insertion depth and a higher rate of
failure for the procedure. We describe an adaptation of the conventional
insertion method that may be useful when deep looping occurs during DBE.
Step 1: Progress is hindered (e. g.
because of a fixed mesentery or small-bowel tethering) resulting in the
formation of a deep loop on enteroscope advancement ([Fig. 1 i]). The loop is stabilised by the
inflated enteroscope balloon as the overtube is advanced with its balloon
deflated ([Fig. 1 ii]).
Fig. 1 (i) Failure to progress
with the enteroscope (a) as fixed mesentery forms a deep
loop (b). (ii) The enteroscope
balloon is inflated (a), the overtube balloon is
deflated (b), and the overtube is advanced (c).
Step 2: The overtube balloon is inflated
and the overtube is pulled back as the enteroscope is advanced through the loop
with its balloon deflated ([Fig. 2]).
Fig. 2 The overtube balloon is
inflated (a), the enteroscope balloon is deflated (b), and the enteroscope is advanced as the overtube is
pulled back (c).
Step 3: The enteroscope is pulled back with
its balloon inflated as the overtube is advanced with its balloon deflated.
This step is key to the success of this variation in insertion method and
relies on the use of the enteroscope balloon alone (which is not available in
other deep enteroscopy techniques such as single-balloon or spiral enteroscopy)
([Fig. 3]).
Fig. 3 The enteroscope balloon
is inflated (a), the overtube balloon is deflated (b), and the overtube is advanced as the enteroscope is
pulled back (c).
Step 4: The overtube balloon is inflated
and the enteroscope with its balloon deflated is advanced through the partially
reduced deep loop as the overtube is pulled back ([Fig. 4]).
Fig. 4 The overtube balloon is
inflated (a), the enteroscope balloon is deflated (b), and the enteroscope is advanced as the overtube is
pulled back (c).
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