Reply to Manno et al.

We have read the letter by Manno et al. with interest and would like to make some comments.

We agree that the experience using single-balloon enteroscopy (SBE) for investigation of the small bowel is much less in the study of Takano et al. compared with the experience using double-balloon enteroscopy (DBE). However, both techniques are push-and-pull techniques, which means that the principle of pleating the small bowel is similar. In the paper of Mehdizadeh et al., a learning period of 10 DBEs was calculated, but this was for endoscopists with no experience in any kind of balloon-assisted enteroscopy [1]. The lack of skill, especially for the SBE technique, might be the reason for a 0 % rate of complete enteroscopy for SBE in the Takano study [2]. Nevertheless, the results of the Takano study confirmed the results of our own comparative trial, which showed a three-fold higher complete rate of enteroscopy for DBE compared with SBE [3].

Regarding the Domagk study [4], I refer to my reply to another recent letter published in Endoscopy [5].

Finally, it should be pointed out that, of course, not all patients need a complete enteroscopy. This is necessary, in our experience, in only approximately 20 % – 25 % of all the patients with an indication for enteroscopy. Of course, good results can be achieved with all enteroscopy techniques, depending on the experience of the endoscopist. This was shown by the authors of the letter in their abstract published in Endoscopy. It will be interesting to read more details and information in the full paper.

Complete enteroscopy is a suitable parameter for studies from the scientific point of view, because it is an objective parameter – in contrast to measuring insertion depth. On the other hand, it is an expression of deep insertion and demonstrates the value of the second balloon if it is really needed, such as in difficult anatomy or if a very deep insertion or complete enteroscopy is mandatory.

• References

• 1 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
• 2 Takano N, Yamada A, Watabe H et al. Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial. Gastrointest Endosc 2011; 73: 734-739
• 3 May A, Färber M, Aschmoneit I et al. Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders. Am J Gastroenterol 2010; 105: 575-581
• 4 Domagk D, Mensink P, Aktas H et al. Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trial.. Endoscopy 2011; 43: 472-476
• 5 May A. Reply to Lenz et al. Endoscopy 2012; 44: 800