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Endoscopy 2008; 40(2): 156-160
DOI: 10.1055/s-2007-966994
Review

© Georg Thieme Verlag KG Stuttgart · New York

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

J.  Pohl1 , J.  M.  Blancas2 , D.  Cave3 , K.  Y.  Choi4 , M.  Delvaux5 , C.  Ell1 , G.  Gay5 , M.  A.  J.  M.  Jacobs6 , N.  Marcon7 , T.  Matsui8 , A.  May1 , C.  J.  J.  Mulder6 , M.  Pennazio9 , E.  Perez-Cuadrado10 , K.  Sugano11 , P.  Vilmann12 , H.  Yamamoto11 , T.  Yano11 , J.  J.  Zhong13
  • 1Department of Internal Medicine II, Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
  • 2Specialities Hospital CMN XXI, IMSS, Mexico City, Mexico
  • 3Department of Gastroenterology, University of Massachusetts, Worcester, USA
  • 4Catholic University of Korea, Department of Gastroenterology, Inchon, Korea
  • 5CHU de Nancy, Vandoeuvre les Nancy, France
  • 6Department of Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
  • 7Cardinal Carter South Wing, St Michael’s Hospital, Toronto, Ontario, Canada
  • 8Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
  • 9Division of Gastroenterology 2, San Giovanni AS Hospital, Turin, Italy
  • 10Small Bowel Unit, Hospital Morales Meseguer, Murcia, Spain
  • 11Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
  • 12Copenhagen County University Hospitals, Hellerup, Denmark
  • 13Shanghai Rui Jin Hospital, Shanghai, China
Further Information

J. Pohl, MD, PhD

Dr. Horst Schmidt Klinik
Internal Medicine II

Ludwig-Erhard-Str. 100
65199 Wiesbaden
Germany

Fax: +49-611-432418

Email: pohljuergen@web.de

Publication History

submitted 4 July 2007

accepted after revision 27 September 2007

Publication Date:
06 February 2008 (online)

Also available at
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Table of Contents #

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.

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Potential indications for DBE

In the literature on small-bowel imaging methods, conditions of scientific evaluation (namely assessment of sensitivity, specificity, predictive value etc. in relation to a gold standard) have been somewhat diluted by the introduction of the term “yield”, which is just a descriptive term. This dilemma is in large part due to a missing gold standard for endoscopy that explores areas hitherto not endoscoped, and may be overcome by DBE with possibility of biopsy. Outcome studies on capsule endoscopy have tried to correlate findings with outcome, and hence defined lesions according to their relevance [2]. These outcome studies are quite difficult to perform, as therapeutic interventions have been carried out in variable percentages of patients, mostly on the basis of individual decisions. Thus, indications for DBE listed below are not based on large-scale outcome studies, not even in mid-gastrointestinal bleeding.

1. Mid-gastrointestinal bleeding [3] [4] [5] [6] [7] [8] [9]

  • in patients with suspected mid-gastrointestinal bleeding (bleeding source not identified by conventional upper gastrointestinal endoscopy and colonoscopy), differential indication with VCE see below,

  • in patients with known mid-gastrointestinal-bleeding for endoscopic hemostasis.

2. DBE following VCE

  • in patients in whom a further diagnostic tests (e. g. biopsy sampling) or therapy is indicated.

3. Endoscopic diagnosis and treatment of stenoses

  • endoscopic or histologic diagnosis in patients with suspected stenoses [10] [11] [12],

  • balloon dilation for stenoses of the small intestine [10] [11] [12].

4. Tumors and mass lesions [1] [3] [4] [5] [6] [7] [8] [9]

  • endoscopic diagnosis and histologic confirmation of tumors or masses detected by other imaging modalities if considered necessary prior to surgery,

  • pre-operative marking (e. g. tattooing) in patients with discrete findings who are scheduled to undergo surgical endoscopic resection in the small intestine in suitable lesions [12].

5. Removal of foreign bodies from the small intestine [12] [13] (e. g. retained capsule endoscope).

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Indications under evaluation

A variety of indications has been reported in case series of various sample size. These include endoscopic and histologic diagnosis of Crohn’s disease involving the small intestine, and subsequent follow-up [3] [4] [5] [6] [7] [8] [9] endoscopic and histologic diagnosis of obstruction, including intussusception [14], and unexplained complications of small-bowel diseases [15]. Thus, no recommendations can be given at present.

Case series about endoscopic accesses in postoperative anatomy may lead to applications for endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II or Roux en-Y operation [16] [17], as an alternative to percutaneous biliary interventions, making the pancreatic duct also accessible. Another application reported recently is post bariatric surgery access to the biliary tree or gastric remnant [18].

In difficult colonoscopy cases, the use of DBE instruments was also reported [19] [20] [21] [22].

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Contraindications for DBE

Contraindications for DBE are essentially similar to conventional upper gastrointestinal endoscopy and colonoscopy.

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Proposals for differential application of DBE vs. VCE

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Mid-gastrointestinal bleeding

Small-bowel bleeding with an origin located between the papilla and the ileocecal valve is defined as mid-gastrointestinal bleeding [23]. In the absence of intestinal stenosis, reports show a high yield for VCE in patients with mid-gastrointestinal bleeding or chronic iron-deficiency anemia [24] [25]. Therefore in cases with lower probability of therapeutic intervention, the consensus was that VCE should be first. Depending on the clinical consequences, pathologic findings should be further defined (biopsy) or treated by DBE. In these cases, VCE might direct the route of insertion of the endoscope for the DBE, avoiding double procedures [26]. In the case of a negative VCE with ongoing mid-gastrointestinal bleeding, DBE should be considered.

Conference participants concluded that DBE should be applied first in patients with active ongoing bleeding with high probability of therapeutic interventions, as well as in patients with postoperative anatomy, especially those with an intestinal afferent loop, which cannot be assessed by VCE [18]. Individual decisions should be made if stenoses are suspected (clinically or by other imaging modalities).

The opinion was issued, that VCE and DBE have the potential to significantly decrease the role of intra-operative enteroscopy in patients with mid-gastrointestinal bleeding.

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Diagnosis and therapy of Crohn’s disease

No single modality can be regarded as the gold standard for diagnosing or excluding small-bowel Crohn’s disease. In suspected small-bowel Crohn’s disease with normal findings at ileocolonoscopy (including normal histopathologic findings) and other imaging modalities, VCE should be the first diagnostic step if no strictures are suspected. In case of known or suspected Crohn’s disease stricture, DBE is the method of choice to obtain endoscopic and histologic confirmation [9].

In established Crohn’s disease, in which small-bowel disease activity is suspected and other modalities do not reveal significant findings, VCE can be considered in patients without suspected stenosis [27] [28] and DBE might be performed if strictures cannot be ruled out. In any case, possible findings should significantly change clinical management before either VCE or DBE are performed. Further outcome studies need to show the possible role of DBE for endoscopic mucosal evaluation, for example in discriminating between fibrostenotic and active inflammatory strictures [11] [12], evaluating unexplained symptoms in Crohn’s disease, or - if deemed necessary from a clinical standpoint or within studies - in assessing small-bowel healing after medical or surgical therapy.

Endoscopic balloon dilation appears to be a safe and effective procedure in short-segment fibro-stenotic strictures [11] [12]. However, the outcome of these procedures should be evaluated in large prospective multicenter trials.

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Polyposis syndromes

In the opinion of the conference participants, in case of familial adenomatous polyposis (FAP), Peutz-Jeghers Syndrome (PJS) and other polyposis syndromes, VCE and/or other imaging modalities (e. g. magnetic resonance imaging [MRI] ) should be used for screening. If clinically relevant polyps are detected, DBE should be the first therapeutic step if polypectomy is considered.

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Celiac disease

In case of refractory celiac disease, DBE might be the first step because of the option for biopsy sampling [29]. The value of small-bowel imaging and biopsy beyond the duodenum by both capsule endoscopy and DBE has not been clarified.

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Gastrointestinal lymphoma

For staging of gastrointestinal lymphoma beyond the stomach, DBE is the first choice because of the ability to take biopsies for histologic confirmation.

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Technical considerations

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Bowel preparation

  • For DBE using the retrograde approach patients should have a full bowel preparation with 4 L of standard polyethylene glycol (PEG) + electrolyte solution. Splitting the solution (2 L in the evening before and 2 L in the morning of the day of the procedure) might optimize preparation.

  • There are insufficient data concerning the value of bowel preparation for DBE from the oral route. However, an arbitrary minimum of 10 hours fasting is warranted (small amounts of clear fluids are allowed until 4 hours before the procedure).

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Preparation of devices

  • Dedicated nurses, who prepare the scope, overtube, pump controller, and accessories, should be assigned to DBE.

  • There should be an established unit protocol and check list.

  • There should be a full and wide variety of accessories available, as in any potentially therapeutic case.

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Medication and monitoring

  • There is a wide range of sedation options, and selection is related to local conditions and policies.

  • In most cases of anterograde or retrograde DBE, conscious sedation (i. e. with midazolam, pethidine, and/or fentanyl) was considered sufficient by the consensus participants.

  • For anterograde DBE that may last for more than an hour, deep monitored sedation (e. g. with propofol) or general anesthesia with intubation is widely accepted.

  • For retrograde DBE as for colonoscopy, conscious sedation is sufficient in most cases. However, deep monitored anesthesia with propofol can be used as well as no sedation in selected cases.

  • Unpublished data indicate that bowel insufflation with CO2 instead of air enhances patient comfort and decreases the need for sedation. Peer-reviewed publications are needed before a general recommendation can be made.

  • The application of conscious sedation, deep sedation, or general anesthesia necessitates automated monitoring of blood pressure, pulse oximetry, and/or electrocardiography. Postprocedure monitoring follows good clinical practice rules in the recovery area.

  • There are no convincing data concerning the value of spasmolytics (glucagon or N-butyl-scopolamine) during insertion of the device. Spasmolytics might be helpful in advancing the device against peristalsis (e. g. retrograde approach/ERCP). Spasmolytics might improve visualization of the small-bowel mucosa during withdrawal of the device and during therapeutic interventions by reducing motility of the small bowel.

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Specific indications for use of different DBE scopes

To date there are no comparable data available comparing the diagnostic and therapeutic efficiencies of the available scopes listed in [Table 1] with their specifications. As mentioned above, the role of single balloon enteroscopy can not be assessed as yet.

Table 1 Specification of enteroscopes and overtubes
EN-450P5 EN-450T5 EC-450BI5
Working length of the scope, cm 200 200 152
Outer diameter of the scope, mm 8.5 9.4 9.4
Diameter of working channel, mm 2.2 2.8 2.8
Outer diameter of overtube, mm 12.2 13.2 13.2
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Determination of the primary insertion route

The choice of either anal or oral route for the primary procedure depends on the suspected location of pathology within the small bowel. As mentioned above, VCE may be used to guide insertion (oral or anal insertion with 2/3 vs. 1/3 time span measured on VCE during small-bowel transit) [26].

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Measurement of insertion depth

The insertion depth of the endoscope into the small bowel can be estimated by recording the “net” advancement of the endoscope for each push and pull maneuver on a standardized documentation sheet. At the end of the examination, the distances are summed and the length of small bowel that has been visualized can be estimated. This method was validated in an ex vivo pig model [30], and enables rough estimation of insertion depth and an approximate location of pathologic findings seen during enteroscopy, but has not been tested and validated in patients.

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Procedural issues

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Fluoroscopy in DBE

  • Fluoroscopy appears to be used by most DBE endoscopists, when no further progress can be made.

  • Less fluoroscopy is used with increasing experience [6]. Some centers report application of fluoroscopy in less than 10 % of the DBE procedures. Published data concerning the real impact of fluoroscopy are not yet available.

  • Transendoscopic enteroclysis might be useful in special situations for documentation and therapeutic considerations.

  • For some patients with surgically modified anatomy and during therapeutic procedures such as ERCP or dilations, DBE usually requires fluoroscopic guidance.

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Performance of complete enteroscopy

  • Total enteroscopy has been reserved for selected cases in all publications, accounting only for a minority of examined cases. Precise criteria have not been elucidated.

  • Although total enteroscopy via the anterograde approach alone can only be performed in the minority of patients, complete enteroscopy by a combination of the anterograde and retrograde may be achieved in 40 % - 80 % of cases [3] [5] [7] [9].

  • When the combination of anterograde and retrograde procedures is planned, it is recommended that a tattoo and/or marking-clip is placed at the deepest point of insertion as a mark for assisting in confirming total enteroscopy during the subsequent procedure from the opposite direction.

  • Unless an emergency dictates otherwise, the procedure from the opposite direction should ideally be performed one or a few days later because of concerns about residual air in the intestinal lumen.

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Endoscopic resection in the small bowel

  • For large polyps with a broad base or thick stalk, piecemeal resection is in general recommended to lower the complication risk.

  • Prior to endoscopic resection submucosal injection may be helpful [12]. The majority of endoscopists use a diluted epinephrine-saline solution. However, no data exist on the real value of injection prior to endoscopic resection in the small bowel. As emergency re-endoscopy (e. g. for bleeding after polypectomy) is more complicated and competence at present may not be widespread in the endoscopy emergency team, measures of bleeding prevention may be considered more liberally as for upper and lower gastrointestinal endoscopy; evidence is however missing.

  • For a scheduled endoscopic resection, it may be helpful to use the T-type overtube and the P-type enteroscope to facilitate specimen retrieval. The larger internal diameter overtube offers the advantage that for removal of resected specimen the endoscope can be pulled back through the positioned overtube, with the overtube balloon inflated to maintain a stable position. After the specimen has been removed, the scope can then be easily and quickly inserted through the overtube again to continue the procedure.

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Small-bowel bleeding: devices for hemostasis

Argon plasma coagulation (APC), metal clips, and injection have all been used successfully for endoscopic hemostasis. Whereas the respective devices can be introduced through the working channel of both available scopes, metal clips at present can only be used with the larger working channel (see above, Specific indications for use of different DBE scopes).

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Complications of DBE

  • Complications are divided into two main categories, those directly attributed to the procedure and those secondary to anesthesia or conscious sedation.

  • The complication rate of diagnostic procedures is low (0.4 % - 0.8 %) [31] [32].

  • In diagnostic procedures from via the anterograde approach, pancreatitis is the most severe complication [31] [32] [33].

  • The overall complication rate of therapeutic DBE is about 3 % - 4 % (perforation, bleeding). However, difficult therapeutic endoscopic procedures (e. g. resection of large polyps) may increase the risk up to 10 % [31,32].

  • The most common complications secondary to anesthesia or conscious sedation are respiratory depression, aspiration, and pneumonia, with a frequency of less than 1 %.

#

DBE for difficult colonoscopy

  • DBE colonoscopy appears to be useful in selected difficult colonoscopies, even if colonoscopy with a pediatric colonoscope failed; published success rates range from 88 % - 100 % [19] [20] [21] [22].

  • Preliminary data have been published on DBE colonoscopy using a special DBE colonoscope device [34], however there are no comparative studies with DBE colonoscope versus standard colonoscope.

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DBE for ERCP in patients with postoperative anatomy

For ERCP, use of instruments with larger working channels that allow stent placement (7F) are recommended. The DBE colonoscope device (EC-450BI5) ([Table 1]) has a working length of 152 cm, and therefore allows application of standard accessories for ERCP. Clinical data concerning DBE-ERCP are still very limited [16]. In the presence of a Roux-en-Y, it is useful to mark the afferent limb with India ink to make a re-examination faster and easier.

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Role of endoscopic ultrasonography in DBE

Although the proof of principle for DBE based endoscopic ultrasonography (EUS, using miniprobes) in the small bowel has been successfully obtained [35], further studies are needed to determine which lesions found by DBE should undergo EUS examination and how the information obtained by EUS may impact patient management.

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Training programs: how to acquire competence in DBE?

Participants agreed on the following statements.

  • Training is required before starting DBE in patients.

  • Lectures, videos, and simulators are useful initial steps.

  • Animal models and live procedures are the main components of training.

  • Fresh ex vivo animal models should be preferred.

  • Only advanced endoscopists should perform DBE in patients after appropriate training.

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DBE in pediatric patients

The small diameter of the DBE scope has been applied in pediatric patients [36]. Preliminary data suggest that it is safe and efficient, and that diagnostic yield, insertion depth, and procedure duration appear to be similar to DBE in adults. Until larger series of DBE in children are reported, the age limit that qualifies for DBE depends on clinical judgement on an individual basis.

Competing interests: None

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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
    Search in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Pérez-Cuadrado E, Latorre R, Carballo F. et al . Training and new indications for double balloon endoscopy.  Gastrointest Endosc. 2007;  66 39-46
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 19 May A, Nachbar L, Ell C. Push-and-Pull Enteroscopy using a single-balloon technique for difficult colonoscopy.  Endoscopy. 2006;  38 395-398
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 31 Mensink P, Haringsma J, Kucharzik T F. et al . Complications of double balloon enteroscopy: a multicenter survey.  Endoscopy. 2007;  39 613-615
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 34 Gay G, Delvaux M. Double-balloon colonoscopy after failed conventional colonoscopy: A pilot series with a new instrument.  Endoscopy. 2007;  39 788-792
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar

J. Pohl, MD, PhD

Dr. Horst Schmidt Klinik
Internal Medicine II

Ludwig-Erhard-Str. 100
65199 Wiesbaden
Germany

Fax: +49-611-432418

Email: pohljuergen@web.de

#

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
    Search in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Pérez-Cuadrado E, Latorre R, Carballo F. et al . Training and new indications for double balloon endoscopy.  Gastrointest Endosc. 2007;  66 39-46
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 19 May A, Nachbar L, Ell C. Push-and-Pull Enteroscopy using a single-balloon technique for difficult colonoscopy.  Endoscopy. 2006;  38 395-398
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 31 Mensink P, Haringsma J, Kucharzik T F. et al . Complications of double balloon enteroscopy: a multicenter survey.  Endoscopy. 2007;  39 613-615
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar
  • 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
    Thieme ConnectPubMedSearch in Google Scholar
  • 34 Gay G, Delvaux M. Double-balloon colonoscopy after failed conventional colonoscopy: A pilot series with a new instrument.  Endoscopy. 2007;  39 788-792
    Thieme ConnectPubMedSearch in Google Scholar
  • 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
    CrossrefPubMedSearch in Google Scholar
  • 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
    PubMedSearch in Google Scholar

J. Pohl, MD, PhD

Dr. Horst Schmidt Klinik
Internal Medicine II

Ludwig-Erhard-Str. 100
65199 Wiesbaden
Germany

Fax: +49-611-432418

Email: pohljuergen@web.de

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