Curriculum for small-bowel capsule endoscopy and device-assisted enteroscopy training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Reena Sidhu; Stefania Chetcuti Zammit; Peter Baltes; Cristina Carretero; Edward J. Despott; Alberto Murino; Xavier Dray; David S. Sanders; Martin Keuchel; Evelien Dekker; James E. East; Gavin Johnson; Pedro Pimentel-Nunes; Marianna Arvanitakis; Thierry Ponchon; Mario Dinis-Ribeiro; Raf Bisschops

doi:10.1055/a-1185-1289

Endoscopy, Table of Contents

Endoscopy 2020; 52(08): 669-686
DOI: 10.1055/a-1185-1289

Position Statement

Curriculum for small-bowel capsule endoscopy and device-assisted enteroscopy training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Authors

Reena Sidhu

¹Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
Stefania Chetcuti Zammit

¹Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
Peter Baltes

²Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
Cristina Carretero

³Gastroenterology Department, University of Navarra Clinic, Pamplona, Spain
Edward J. Despott

⁴Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health Hampstead Campus, London, UK
Alberto Murino

⁴Royal Free Unit for Endoscopy, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health Hampstead Campus, London, UK
Xavier Dray

⁵Endoscopy Unit, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris and Sorbonne Université, Paris, France
David S. Sanders

¹Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
Martin Keuchel

²Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
Evelien Dekker

⁶Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
James E. East

⁷Translational Gastroenterology Unit, Nuffield Department of Medicine, Experimental Medicine Division, John Radcliffe Hospital, University of Oxford, Oxford, UK

⁸Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
Gavin Johnson

⁹University College London Hospitals, London, UK
Pedro Pimentel-Nunes

¹⁰Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal

¹¹Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal

¹²Surgery and Physiology Department, Faculty of Medicine, University of Porto, Porto, Portugal
Marianna Arvanitakis

¹³Department of Gastroenterology, Hepato-pancreatology and Digestive Oncology Erasme University Hospital, Brussels, Belgium
Thierry Ponchon

¹⁴Gastroenterology Division, Hôpital Edouard Herriot, Lyon, France
Mario Dinis-Ribeiro

¹⁰Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal

¹¹Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
Raf Bisschops

¹⁵Department of Gastroenterology and Hepatology, Catholic University of Leuven (KUL), TARGID, University Hospitals Leuven, Leuven, Belgium

Abstract

Main Recommendations

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize training in small-bowel endoscopy across European centers. The following criteria and framework for training in small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE), which aim to provide uniform and high quality training to ensure that small-bowel endoscopists are competent to operate independently, are based on the current literature and experience of experts in the field. Three main areas are covered: skills required prior to commencing training in small-bowel endoscopy; structured training for trainees to become independent endoscopists; and ways of ensuring competence is achieved.

1 Centers providing training in SBCE should perform a minimum of 75 – 100 SBCEs/year.

2 Experience in bidirectional endoscopies is desirable for structured training in SBCE.

3 SBCE courses should consist of at least 50 % hands-on training and cover information on technology, indications and contraindications for SBCE, pathologies that can be encountered on SBCE, and standard terminology that should be used during reporting of SBCE. An SBCE course should be completed prior to achieving competence in SBCE reporting.

4 Competence in SBCE can be assessed by considering a minimum of 30 SBCEs. Direct Observation of Procedural Skills, short SBCE videos, and multiple-choice questions can be useful to assess improvement in the skills of trainees.

5 Centers offering training in DAE should aim to carry out at least 75 DAEs/year, should have direct links with an SBCE service, and should allow regular discussion of cases at a radiology small-bowel MDT. Training centers with lower numbers are encouraged to offer training by “buddying-up” with other centers, or using mentoring systems.

6 DAE trainees must be independent in bidirectional endoscopies and have experience in level 1 polypectomy prior to commencement of training. They should also be competent in reviewing SBCEs.

7 Training in DAE should be structured with a minimum of 75 procedures, including 35 retrograde DAEs, with therapeutic procedures undertaken in at least 50 % of the DAEs performed. Training should cover the indications, contraindications, complications including prevention, and technicalities of the DAE procedure; formal evaluation should follow. DAE trainees must acquire skills to independently manage and advise on small-bowel pathology following DAE procedures.

8 It is highly recommended that international societies develop online modules and courses on DAE, which are currently lacking across Europe.

Full Text

References

References
1 Bisschops R, Dekker E, East JE. et al. European Society of Gastrointestinal Endoscopy (ESGE) curricula development for postgraduate training in advanced endoscopic procedures: rationale and methodology. Endoscopy 2019; 51: 976-979
2 Hijaz NM, Septer SS, Attard TM. Present standard in pediatric gastroenterology fellowship training in the interpretation of capsule endoscopy. J Pediatr Gastroenterol Nutr 2015; 61: 421-423
3 Read AJ, Rice MD, Conjeevaram HS. et al. A deeper look at the small bowel: training pathways in video capsule endoscopy and device-assisted enteroscopy. Dig Dis Sci 2018; 63: 2210-2219
4 Sidhu R, Sakellariou P, McAlindon ME. et al. Is formal training necessary for capsule endoscopy? The largest gastroenterology trainee study with controls.. Dig Liver Dis 2008; 40: 298-302
5 Pennazio M, Spada C, Eliakim R. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2015; 47: 352-376
6 McAlindon ME, Parker CE, Hendy P. et al. Provision of service and training for small bowel endoscopy in the UK. Frontline Gastroenterol 2012; 3: 98-103
7 Postgate A, Haycock A, Fitzpatrick A. et al. How should we train capsule endoscopy? A pilot study of performance changes during a structured capsule endoscopy training program.. Dig Dis Sci 2009; 54: 1672-1679
8 Rajan E, Iyer PG, Oxentenko AS. et al. Training in small-bowel capsule endoscopy: assessing and defining competency. Gastrointest Endosc 2013; 78: 617-622
9 Yamamoto H, Sekine Y, Sato Y. et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53: 216-220
10 Riccioni ME, Urgesi R, Cianci R. et al. Single-balloon push-and-pull enteroscopy system: does it work? A single-center, 3-year experience.. Surg Endosc 2011; 25: 3050-3056
11 Buscaglia JM, Dunbar KB, Okolo PI. et al. The spiral enteroscopy training initiative: results of a prospective study evaluating the Discovery SB overtube device during small bowel enteroscopy (with video). Endoscopy 2009; 41: 194-199
12 Rutter MD, Senore C, Bisschops R. et al. The European Society of Gastrointestinal Endoscopy Quality Improvement Initiative: developing performance measures. United European Gastroenterol J 2016; 4: 30-41
13 Albert JG, Humbla O, McAlindon ME. et al. A simple evaluation tool (ET-CET) indicates increase of diagnostic skills from small bowel capsule endoscopy training courses: a prospective observational European multicenter study. Medicine (Baltimore) 2015; 94: e1941
14 Postgate A, Tekkis P, Fitzpatrick A. et al. The impact of experience on polyp detection and sizing accuracy at capsule endoscopy: implications for training from an animal model study. Endoscopy 2008; 40: 496-501
15 Alakkari A, El-Sherif O, Dobson M. et al. Is focused training adequate or is prior endoscopy experience needed for reliable capsule endoscopy reporting?. J Gastroenterol Hepatol Res 2013; 2: 628-631
16 Graepler F, Wolter M, Vonthein R. et al. Accuracy of the size estimation in wireless capsule endoscopy: calibrating the M2A PillCam (with video). Gastrointest Endosc 2008; 67: 924-931
17 Spada C, McNamara D, Despott EJ. et al. Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2019; 51: 574-598
18 The Joint Advisory Group on GI Endoscopy. Formative video capsule endoscopy - Patency capsule DOPS. 2016 Available from (accessed: 29 April 2020): https://www.thejag.org.uk/AboutUs/DownloadCentre.aspx
19 Fernandez-Urien I, Panter S, Carretero C. et al. International core curriculum for capsule endoscopy training courses. Endosc Int Open 2017; 5: E526-E538
20 Korman LY, Delvaux M, Gay G. et al. Capsule endoscopy structured terminology (CEST): proposal of a standardized and structured terminology for reporting capsule endoscopy procedures. Endoscopy 2005; 37: 951-959
21 Jang BI, Lee SH, Moon JS. et al. Inter-observer agreement on the interpretation of capsule endoscopy findings based on capsule endoscopy structured terminology: a multicenter study by the Korean Gut Image Study Group. Scand J Gastroenterol 2010; 45: 370-374
22 Petroniene R, Dubcenco E, Baker JP. et al. Given capsule endoscopy in celiac disease: evaluation of diagnostic accuracy and interobserver agreement. Am J Gastroenterol 2005; 100: 685-694
23 Zheng Y, Hawkins L, Wolff J. et al. Detection of lesions during capsule endoscopy: physician performance is disappointing. Am J Gastroenterol 2012; 107: 554-560
24 Yung DE, Fernandez-Urien I, Douglas S. et al. Systematic review and meta-analysis of the performance of nurses in small bowel capsule endoscopy reading. United European Gastroenterol J 2017; 5: 1061-1072
25 Rondonotti E, Spada C, Adler S. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2018; 50: 423-446
26 Jirapinyo P, Imaeda AB, Thompson CC. Endoscopic training in gastroenterology fellowship: adherence to core curriculum guidelines. Surg Endosc 2015; 29: 3570-3578
27 Rajan EA, Pais SA, Degregorio BT. et al. ASGE Training Committee – Small-bowel endoscopy core curriculum. Gastrointest Endosc 2013; 77: 1-6
28 eIntegrity Healthcare. 2014 Available from (accessed: 13 May 2020): https://www.eintegrity.org
29 Lim YJ, Joo YS, Jung DY. et al. Learning curve of capsule endoscopy. Clin Endosc 2013; 46: 633-636
30 Rajan E, Martinez M, Gorospe E. et al. Prospective multicenter study to evaluate capsule endoscopy competency using a validated assessment tool. Gastrointest Endosc 2020; 91: 1140-1145
31 The European Section and Board of Gastroenterology and Hepatology. Speciality Training Programme and Curriculum for Gastroenterology and Hepatology. The Blue Book; 2017 Available from (accessed: 29 April 2020): http://www.euboghorg/blue-book/
32 Kassenärztliche Bundesvereinigung - Vereinbarung von Qualitätssicherungsmaßnahmen nach § 135 Abs. 2 SGB V für die Dünndarm-Kapselendoskopie zur Abklärung obskurer gastrointestinaler Blutungen (Qualitätssicherungsvereinbarung Dünndarm-Kapselendoskopie). 2014 Available from (accessed: 13 May 2020): https://www.kbv.de/media/sp/Duenndarm_Kapselendoskopie.pdf
33 Postgate A, Haycock A, Thomas-Gibson S. et al. Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability. Gastrointest Endosc 2009; 70: 310-316
34 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
35 Li X, Chen H, Dai J. et al. Predictive role of capsule endoscopy on the insertion route of double-balloon enteroscopy. Endoscopy 2009; 41: 762-766
36 Römmele C, Ebigbo A, Schrempf M. et al. Detection rate and clinical relevance of ink tattooing during balloon-assisted enteroscopy. Gastroenterol Res Pract 2017; 2017: 4969814
37 Pasha SF, Leighton JA, Das A. et al. Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis. Clin Gastroenterol Hepatol 2008; 6: 671-676
38 Teshima CW, Kuipers EJ, van Zanten SV. et al. Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: an updated meta-analysis. J Gastroenterol Hepatol 2011; 26: 796-801
39 Mensink PB, Haringsma J, Kucharzik T. et al. Complications of double balloon enteroscopy: a multicenter survey. Endoscopy 2007; 39: 613-615
40 Gerson LB, Tokar J, Chiorean M. et al. Complications associated with double balloon enteroscopy at nine US centers. Clin Gastroenterol Hepatol 2009; 7: 1177-1182, 1182.e1171–e1173
41 Möschler O, May A, Müller MK. et al. Complications in and performance of double-balloon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy 2011; 43: 484-489
42 Despott EJ, Murino A, Hughes S. et al. Mo1583 Second report of the UK multicenter DBE registry: furthering the international DBE experience. Gastrointest Endosc 2011; 73: AB394
43 Rondonotti E, Sunada K, Yano T. et al. Double-balloon endoscopy in clinical practice: where are we now?. Dig Endosc 2012; 24: 209-219
44 Moeschler O, Mueller MK. Deep enteroscopy - indications, diagnostic yield and complications. World J Gastroenterol 2015; 21: 1385-1393
45 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
46 Hirai F, Beppu T, Sou S. et al. Endoscopic balloon dilatation using double-balloon endoscopy is a useful and safe treatment for small intestinal strictures in Crohn's disease. Dig Endosc 2010; 22: 200-204
47 Xin L, Liao Z, Jiang YP. et al. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic double-balloon endoscopy: a systematic review of data over the first decade of use. Gastrointest Endosc 2011; 74: 563-570
48 Möschler O, May AD, Müller MK. et al. Complications in double-balloon-enteroscopy: results of the German DBE register. Z Gastroenterol 2008; 46: 266-270
49 Yamamoto H, Yano T, Ohmiya N. et al. Double-balloon endoscopy is safe and effective for the diagnosis and treatment of small-bowel disorders: prospective multicenter study carried out by expert and non-expert endoscopists in Japan. Dig Endosc 2015; 27: 331-337
50 Lipka S, Rabbanifard R, Kumar A. et al. Single versus double balloon enteroscopy for small bowel diagnostics: a systematic review and meta-analysis. J Clin Gastroenterol 2015; 49: 177-184
51 Lenz P, Roggel M, Domagk D. Double- vs. single-balloon enteroscopy: single center experience with emphasis on procedural performance. Int J Colorectal Dis 2013; 28: 1239-1246
52 Zepeda-Gómez S, Barreto-Zuñiga R, Ponce-de-León S. et al. Risk of hyperamylasemia and acute pancreatitis after double-balloon enteroscopy: a prospective study. Endoscopy 2011; 43: 766-770
53 Tsujikawa T, Bamba S, Inatomi O. et al. Factors affecting pancreatic hyperamylasemia in patients undergoing peroral single-balloon enteroscopy. Dig Endosc 2015; 27: 674-678
54 Kopacova M, Tacheci I, Rejchrt S. et al. Double balloon enteroscopy and acute pancreatitis. World J Gastroenterol 2010; 16: 2331-2340
55 Pata C, Akyüz U, Erzin Y. et al. Post-procedure elevated amylase and lipase levels after double-balloon enteroscopy: relations with the double-balloon technique. Dig Dis Sci 2010; 55: 1982-1988
56 Nakayama S, Tominaga K, Obayashi T. et al. The prevalence of adverse events associated with double-balloon enteroscopy from a single-centre dataset in Japan. Dig Liver Dis 2014; 46: 706-709
57 Rabeneck L, Paszat LF, Hilsden RJ. et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008; 135: 1899-1906, 1906.e1891
58 Chukmaitov A, Bradley CJ, Dahman B. et al. Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications. Gastrointest Endosc 2013; 77: 436-446
59 Singh H, Penfold RB, De Coster C. et al. Predictors of serious complications associated with lower gastrointestinal endoscopy in a major city-wide health region. Can J Gastroenterol 2010; 24: 425-430
60 Lorenzo-Zúñiga V, Moreno de Vega V, Doménech E. et al. Endoscopist experience as a risk factor for colonoscopic complications. Colorectal Dis 2010; 12: e273-e277
61 Saito Y, Uraoka T, Yamaguchi Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217-1225
62 Kim J. Training in Endoscopy: Enteroscopy. Clin Endosc 2017; 50: 328-333
63 DiMaio CJ, Mishra G, McHenry L. et al. EUS core curriculum. Gastrointest Endosc 2012; 76: 476-481
64 Jorgensen J, Kubiliun N, Law JK. et al. Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum. Gastrointest Endosc 2016; 83: 279-289
65 Van Dam J, Brady PG, Freeman M. et al. Guidelines for training in electronic ultrasound: guidelines for clinical application. From the ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1999; 49: 829-833
66 Williams EJ, Taylor S, Fairclough P. et al. Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice.. Gut 2007; 56: 821-829
67 Pohl J, Blancas JM, Cave D. et al. Consensus report of the 2nd International Conference on double balloon endoscopy. Endoscopy 2008; 40: 156-160
68 Tun GS, Rattehalli D, Sanders DS. et al. Clinical utility of double-balloon enteroscopy in suspected Crohn's disease: a single-centre experience. Eur J Gastroenterol Hepatol 2016; 28: 820-825
69 Keren D, Madi H, Matter I. et al. Feasibility and importance of enteroscopy after gastric bypass. Obes Surg 2017; 27: 1309-1315
70 Kashani A, Abboud G, Lo SK. et al. Double balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in Roux-en-Y gastric bypass anatomy: expert vs. novice experience. Endosc Int Open 2018; 6: E885-E891
71 Ali MF, Modayil R, Gurram KC. et al. Spiral enteroscopy-assisted ERCP in bariatric-length Roux-en-Y anatomy: a large single-center series and review of the literature (with video). Gastrointest Endosc 2018; 87: 1241-1247
72 Shao XD, Qi XS, Guo XZ. Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: A meta-analysis. Saudi J Gastroenterol 2017; 23: 150-160
73 Yane K, Katanuma A, Maguchi H. et al. Short-type single-balloon enteroscope-assisted ERCP in postsurgical altered anatomy: potential factors affecting procedural failure. Endoscopy 2017; 49: 69-74
74 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
75 Mehdizadeh S, Han NJ, Cheng DW. et al. Success rate of retrograde double-balloon enteroscopy. Gastrointest Endosc 2007; 65: 633-639
76 Tee HP, How SH, Kaffes AJ. Learning curve for double-balloon enteroscopy: Findings from an analysis of 282 procedures. World J Gastrointest Endosc 2012; 4: 368-372
77 James PD, Antonova L, Martel M. et al. Measures of trainee performance in advanced endoscopy: A systematic review. Best Pract Res Clin Gastroenterol 2016; 30: 421-452
78 Eisen GM, Dominitz JA, Faigel DO. et al. Guidelines for credentialing and granting privileges for endoscopic ultrasound. Gastrointest Endosc 2001; 54: 811-814
79 Biau DJ, Williams SM, Schlup MM. et al. Quantitative and individualized assessment of the learning curve using LC-CUSUM. Br J Surg 2008; 95: 925-929
80 Domagk D, Oppong KW, Aabakken L. et al. Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. United European Gastroenterol J 2018; 6: 1448-1460
81 Marshall JB. Technical proficiency of trainees performing colonoscopy: a learning curve. Gastrointest Endosc 1995; 42: 287-291
82 Rondonotti E, Koulaouzidis A, Georgiou J. et al. Small bowel tumours: update in diagnosis and management. Curr Opin Gastroenterol 2018; 34: 159-164
83 Dionisio PM, Gurudu SR, Leighton JA. et al. Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis. Am J Gastroenterol 2010; 105: 1240-1248; quiz 1249
84 Kopylov U, Yung DE, Engel T. et al. Diagnostic yield of capsule endoscopy versus magnetic resonance enterography and small bowel contrast ultrasound in the evaluation of small bowel Crohn's disease: Systematic review and meta-analysis. Dig Liver Dis 2017; 49: 854-863
85 Ethun CG, Postlewait LM, Baptiste GG. et al. Small bowel neuroendocrine tumors: A critical analysis of diagnostic work-up and operative approach. J Surg Oncol 2016; 114: 671-676
86 Manguso N, Gangi A, Johnson J. et al. The role of pre-operative imaging and double balloon enteroscopy in the surgical management of small bowel neuroendocrine tumors: Is it necessary?. J Surg Oncol 2018; 117: 207-212
87 Axe K, Hawkes E, Turner J. et al. PWE-433 A qualitative assessment of cognitive framework development in novice endoscopists: implications for programmed lesion recognition training. Gut 2015; 64 (Suppl. 01) A400
88 Neumann M, Hahn C, Horbach T. et al. Score card endoscopy: a multicenter study to evaluate learning curves in 1-week courses using the Erlangen Endo-Trainer. Endoscopy 2003; 35: 515-520
89 Fisher L, Ormonde DG, Riley RH. et al. Endoscopic skills training in a simulated clinical setting. Simul Healthc 2010; 5: 232-237
90 Hochberger J, Euler K, Naegel A. et al. The compact Erlangen Active Simulator for Interventional Endoscopy: a prospective comparison in structured team-training courses on "endoscopic hemostasis" for doctors and nurses to the "Endo-Trainer" model. Scand J Gastroenterol 2004; 39: 895-902
91 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
92 Maiss J, Diebel H, Naegel A. et al. A novel model for training in ERCP with double-balloon enteroscopy after abdominal surgery. Endoscopy 2007; 39: 1072-1075
93 Khan R, Plahouras J, Johnston BC. et al. Virtual reality simulation training in endoscopy: a Cochrane review and meta-analysis. Endoscopy 2019; 51: 653-664
94 Hartmann D, Eickhoff A, Tamm R. et al. Balloon-assisted enteroscopy using a single-balloon technique. Endoscopy 2007; 39 (Suppl. 01) E276
95 Moran RA, Barola S, Law JK. et al. A randomized controlled trial comparing the depth of maximal insertion between anterograde single-balloon versus spiral enteroscopy. Clin Med Insights Gastroenterol 2018; 11: 1179552218754881
96 García-Correa JJE, Ramírez-García JJ, García-Contreras LF. et al. Double-balloon enteroscopy: Indications, approaches, diagnostic and therapeutic yield, and safety. Early experience at a single center. Rev Gastroenterol Mex 2018; 83: 31-40
97 Lu Z, Qi Y, Weng J. et al. Efficacy and safety of single-balloon versus double-balloon enteroscopy: a single-center retrospective analysis. Med Sci Monit 2017; 23: 1933-1939
98 Holleran G, Valerii G, Tortora A. et al. The use of single balloon enteroscopy in Crohn's disease and its impact on clinical outcome. Scand J Gastroenterol 2018; 53: 925-929
99 Khashab MA, Lennon AM, Dunbar KB. et al. A comparative evaluation of single-balloon enteroscopy and spiral enteroscopy for patients with mid-gut disorders. Gastrointest Endosc 2010; 72: 766-772
100 Schneider M, Höllerich J, Beyna T. Device-assisted enteroscopy: A review of available techniques and upcoming new technologies. World J Gastroenterol 2019; 25: 3538-3545
101 Despott EJ, Murino A, Bourikas L. et al. A prospective comparison of performance during back-to-back, anterograde manual spiral enteroscopy and double-balloon enteroscopy. Dig Liver Dis 2015; 47: 395-400
102 May A, Manner H, Aschmoneit I. et al. Prospective, cross-over, single-center trial comparing oral double-balloon enteroscopy and oral spiral enteroscopy in patients with suspected small-bowel vascular malformations. Endoscopy 2011; 43: 477-483
103 Neuhaus H, Beyna T, Schneider M. et al. Novel motorized spiral enteroscopy: first clinical case. VideoGIE 2016; 1: 32-33
104 Mans L, Arvanitakis M, Neuhaus H. et al. Motorized spiral enteroscopy for occult bleeding. Dig Dis 2018; 36: 325-327
105 Beyna T, Arvanitakis M, Schneider M. et al. Motorised spiral enteroscopy: first prospective clinical feasibility study. Gut 2020;
106 Aquino JCM, Bernardo WM, de Moura DTH. et al. Carbon dioxide versus air insufflation enteroscopy: a systematic review and meta-analysis based on randomized controlled trials. Endosc Int Open 2018; 6: E637-E645
107 Shiani A, Lipka S, Lai A. et al. Carbon dioxide versus room air insufflation during balloon-assisted enteroscopy: A systematic review with meta-analysis. Endosc Int Open 2017; 5: E67-E75
108 Ching HL, Branchi F, Sanders DS. et al. Paradigm shift: should the elderly undergo propofol sedation for DBE? A prospective cohort study. Frontline Gastroenterol 2018; 9: 192-199
109 Jensen JT, Hornslet P, Konge L. et al. High efficacy with deep nurse-administered propofol sedation for advanced gastroenterologic endoscopic procedures. Endosc Int Open 2016; 4: E107-E111
110 Sidhu R, Turnball D, Newton M. et al. Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA). Frontline Gastroenterol 2019; 10: 141-147
111 Rodrigues JP, Pinho R, Rodrigues A. et al. Diagnostic and therapeutic yields of urgent balloon-assisted enteroscopy in overt obscure gastrointestinal bleeding. Eur J Gastroenterol Hepatol 2018; 30: 1304-1308
112 Tomba C, Sidhu R, Sanders DS. et al. Celiac disease and double-balloon enteroscopy: what can we achieve? The experience of 2 European tertiary referral centers.. J Clin Gastroenterol 2016; 50: 313-317
113 Baars JE, Theyventhiran R, Aepli P. et al. Double-balloon enteroscopy-assisted dilatation avoids surgery for small bowel strictures: A systematic review. World J Gastroenterol 2017; 23: 8073-8081
114 Makipour K, Modiri AN, Ehrlich A. et al. Double balloon enteroscopy: effective and minimally invasive method for removal of retained video capsules. Dig Endosc 2014; 26: 646-649
115 Mitsui K, Fujimori S, Tanaka S. et al. Retrieval of retained capsule endoscopy at small bowel stricture by double-balloon endoscopy significantly decreases surgical treatment. J Clin Gastroenterol 2016; 50: 141-146
116 Belsha D, Urs A, Attard T. et al. Effectiveness of double-balloon enteroscopy-facilitated polypectomy in pediatric patients with Peutz-Jeghers syndrome. J Pediatr Gastroenterol Nutr 2017; 65: 500-502
117 Goverde A, Korsse SE, Wagner A. et al. Small-bowel surveillance in patients with Peutz-Jeghers syndrome: comparing magnetic resonance enteroclysis and double balloon enteroscopy. J Clin Gastroenterol 2017; 51: e27-e33
118 Buscaglia JM, Okolo PI. Deep enteroscopy: training, indications, and the endoscopic technique. Gastrointest Endosc 2011; 73: 1023-1028
119 Barton JR, Corbett S, van der Vleuten CP. et al. The validity and reliability of a Direct Observation of Procedural Skills assessment tool: assessing colonoscopic skills of senior endoscopists. Gastrointest Endosc 2012; 75: 591-597
120 Rees CJ, Thomas Gibson S, Rutter MD. et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016; 65: 1923-1929
121 American Society for Gastrointestinal Endoscopy. Position statement. Maintaining competency in endoscopic skills. Gastrointest Endosc 1995; 42: 620-621
122 Morgan D, Upchurch B, Draganov P. et al. Spiral enteroscopy: prospective U.S. multicenter study in patients with small-bowel disorders. Gastrointest Endosc 2010; 72: 992-998
123 Siau K, Crossley J, Dunckley P. et al. Direct observation of procedural skills (DOPS) assessment in diagnostic gastroscopy: nationwide evidence of validity and competency development during training. Surg Endosc 2020; 34: 105-114
124 Siau K, Dunckley P, Valori R. et al. Changes in scoring of Direct Observation of Procedural Skills (DOPS) forms and the impact on competence assessment. Endoscopy 2018; 50: 770-778
125 The Joint Advisory Group on GI Endoscopy. Formative DOPS: Endoscopic retrograde cholangiopancreatography (ERCP). 2016 Available from (accessed: 29 April 2020): https://www.thejag.org.uk/AboutUs/DownloadCentre.aspx
126 Arribas Anta J, Zaera de la Fuente C, Martín Mateos R. et al. Evaluation of the efficacy of therapeutic endoscopy in gastrointestinal bleeding secondary to angiodysplasias. Rev Gastroenterol Mex 2017; 82: 26-31
127 Fan GW, Chen TH, Lin WP. et al. Angiodysplasia and bleeding in the small intestine treated by balloon-assisted enteroscopy. J Dig Dis 2013; 14: 113-116
128 Chen WC, Bartel M, Kroner T. et al. Double balloon enteroscopy is a safe and effective procedure in removing entrapped foreign objects in the small bowel for up to 3 months. J Laparoendosc Adv Surg Tech A 2015; 25: 392-395
129 Kanamori A, Sugaya T, Tominaga K. et al. Endoscopic balloon dilation for stenotic lesions in Crohn's disease. Turk J Gastroenterol 2017; 28: 117-124
130 Despott EJ, Gupta A, Burling D. et al. Effective dilation of small-bowel strictures by double-balloon enteroscopy in patients with symptomatic Crohn's disease (with video). Gastrointest Endosc 2009; 70: 1030-1036
131 Al-Bawardy B, Gorospe EC, Alexander JA. et al. Outcomes of double-balloon enteroscopy-assisted direct percutaneous endoscopic jejunostomy tube placement. Endoscopy 2016; 48: 552-556
132 Bernardes C, Pinho R, Rodrigues A. et al. Direct percutaneous endoscopic jejunostomy using single-balloon enteroscopy without fluoroscopy: a case series. Rev Esp Enferm Dig 2017; 109: 679-683
133 Despott EJ, Gabe S, Tripoli E. et al. Enteral access by double-balloon enteroscopy: an alternative method of direct percutaneous endoscopic jejunostomy placement. Dig Dis Sci 2011; 56: 494-498
134 Serrano M, Mão-de-Ferro S, Pinho R. et al. Double-balloon enteroscopy in the management of patients with Peutz-Jeghers syndrome: a retrospective cohort multicenter study. Rev Esp Enferm Dig 2013; 105: 594-599
135 Rahmi G, Samaha E, Vahedi K. et al. Multicenter comparison of double-balloon enteroscopy and spiral enteroscopy. J Gastroenterol Hepatol 2013; 28: 992-998
136 Wadhwa V, Sethi S, Tewani S. et al. A meta-analysis on efficacy and safety: single-balloon vs. double-balloon enteroscopy. Gastroenterol Rep (Oxf) 2015; 3: 148-155
137 Williamson JB, Judah JR, Gaidos JK. et al. Prospective evaluation of the long-term outcomes after deep small-bowel spiral enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc 2012; 76: 771-778
138 Aktas H, Mensink PB, Haringsma J. et al. Low incidence of hyperamylasemia after proximal double-balloon enteroscopy: has the insertion technique improved?. Endoscopy 2009; 41: 670-673
139 Chen WG, Shan GD, Zhang H. et al. Double-balloon enteroscopy in small bowel diseases: Eight years single-center experience in China. Medicine (Baltimore) 2016; 95: e5104
140 Gill RS, Kaffes AJ. Small bowel stricture characterization and outcomes of dilatation by double-balloon enteroscopy: a single-centre experience. Therap Adv Gastroenterol 2014; 7: 108-114
141 Holleran G, Hall B, Breslin N. et al. Long-acting somatostatin analogues provide significant beneficial effect in patients with refractory small bowel angiodysplasia: Results from a proof of concept open label mono-centre trial. United European Gastroenterol J 2016; 4: 70-76
142 Chetcuti Zammit S, Sidhu R, Sanders D. Refractory anaemia secondary to small bowel angioectasias - comparison between endotherapy alone versus combination with somatostatin analogues. J Gastrointestin Liver Dis 2017; 26: 369-374
143 Robles EP, Delgado PE, Conesa PB. et al. Role of double-balloon enteroscopy in malignant small bowel tumors. World J Gastrointest Endosc 2015; 7: 652-658
144 Ding NS, Yip WM, Choi CH. et al. Endoscopic dilatation of Crohn's anastomotic strictures is effective in the long term, and escalation of medical therapy improves outcomes in the biologic era. J Crohns Colitis 2016; 10: 1172-1178
145 Bettenworth D, Gustavsson A, Atreja A. et al. A pooled analysis of efficacy, safety, and long-term outcome of endoscopic balloon dilation therapy for patients with stricturing Crohn's disease. Inflamm Bowel Dis 2017; 23: 133-142
146 Tsuboi A, Oka S, Aoyama K. et al. Artificial intelligence using a convolutional neural network for automatic detection of small-bowel angioectasia in capsule endoscopy images. Dig Endosc 2020; 32: 382-390
147 Ding Z, Shi H, Zhang H. et al. Gastroenterologist-level identification of small-bowel diseases and normal variants by capsule endoscopy using a deep-learning model. Gastroenterology 2019; 157: 1044-1054 e1045
148 Dumonceau JM, Hassan C, Riphaus A. et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline Development Policy. Endoscopy 2012; 44: 626-629