Safer endoscopic therapy of small-bowel diseases during double-balloon enteroscopy

We read with interest the article by Mensink et al. [1] on a multicenter survey of complications of double-balloon enteroscopy (DBE). The authors encountered 40 complications in 2362 DBEs (1.7 %), of which 13 occurred after 1728 diagnostic DBEs (0.8 %), and 27 occurred after 634 therapeutic DBEs (4.3 %). The complications consisted of pancreatitis (n = 7), bleeding (n = 19), perforations (n = 6), and others (n = 8). The authors concluded that the complication rate in therapeutic DBE is considerably higher than that associated with therapeutic colonoscopy. We believe that simple techniques can reduce the complication rate.

Before the recent advance of DBE, our routine approach for small-bowel diseases was transenterotomy panenteroscopy, assisted by laparoscopy with mini-laparotomy, which can investigate the entire small-bowel with a standard endoscope [2]. DBE is a novel technique for visualizing the entire small-bowel via either the peroral and/or peranal approach, and provides high diagnostic yields and therapeutic capabilities [3]. Although DBE is considered to be a safe procedure without major complications, perforation, bleeding, and pancreatitis have been reported after DBE [3] [4], as in the series of Mensink et al. [1].

Because we [3] and Honda et al. [4] have experienced hyperamylasemia and acute pancreatitis after peroral DBE, but not after peranal procedure, we suspect that the six pancreatitis of Mensink et al. [1] that occurred after diagnostic DBE would occur after peroral DBE: one of the seven pancreatitis cases occurred after therapeutic DBE (papillotomy). During peroral DBE, the duodenum is markedly shortened, and is straight from the pyloric ring to the ligament of Treitz [4]. In these conditions, the pancreas body and/or tail may be subjected to severe strain, with traumatic injury and/or ischemia. In the reported cases of acute pancreatitis after DBE, including our case [3] [4] and the cases of Mensink et al. [1], the pancreatitis was mostly localized to the pancreas body and/or tail. We suspect therefore that the pancreatitis probably occurs as a result of prolonged mechanical strain on the pancreas body and/or tail [3]. Although DBE requires repeated stretching of the endoscope to telescope the small-bowel onto the overtube, gentle procedure might prevent the pancreatitis.

The major complications of endoscopic polypectomy are bleeding and perforation, especially in the removal of large pedunculated polyps [5]. Although Mensink et al. [1] encounted no perforation after polypectomy, there were 12 cases of postpolypectomy bleeding. For safer polyp removal, a detachable snare is designed for endoscopic ligation, and is composed of an attached nylon loop and an operating part [5], 2300 mm in working length, which makes the snare available for DBE [6]. Endoscopic polypectomy of large pedunculated polyps with a detachable snare is reported to be safer than conventional polypectomy without the snare [5]. We believe that endoscopic polypectomy during DBE can be safely performed with a detachable snare.

Although argon plasma coagulation (APC) is considered to be a relatively inexpensive, simple, and safe technique for first-line therapy of angiodysplasia, the commonly used power settings for APC lead to transmural damage, which results in a higher risk of perforation [7]. In the series of Mensink et al. [1], three perforations occurred after APC of angiodysplasia (despite diminished power settings to account for the thin wall of the small-bowel), which subsequently required laparotomy. Because submucosal saline injection reduces deep injury caused by APC, Suzuki et al. [7] applied the injection before APC in 10 colonic angiodysplasias without complications. We recommend prior submucosal injection as a safe technique for APC, especially in the thin gastrointestinal tract.

Competing interests: None

References

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