Safety of single-balloon enteroscopy: our experience of 72 procedures

We read with great interest the article by Aktas et al. [1] on the complications of single-balloon enteroscopy (SBE). The authors performed 166 SBE procedures (105 by the oral approach and 61 by the anal approach) in 105 patients. No complications were reported in the 145 diagnostic SBE procedures. There was only one perforation in the 21 therapeutic SBE procedures, which occurred during dilation of a stricture in the distal ileum and was not related to the SBE technique. Moreover, although 13 patients had post-SBE hyperamylasemia, none had clinical acute pancreatitis.

Here we report our experience with the SBE system (Olympus Co., Ltd., Tokyo, Japan). Between March 2008 and April 2010, we performed a total of 72 procedures in 67 patients (57 by the oral approach and 15 by the anal approach). The mean procedure times were 62.5 ± 23.4 minutes for the oral approach and 67.5 ± 16.9 minutes for the anal approach. The mean insertion depths were 229.0 ± 59.5 cm beyond the ligament of Treitz and 125.0 ± 69.4 cm beyond the ileocecal valve. A total of 60 procedures (56 oral and 4 anal) were performed under general anesthesia, and the remaining 12 (1 oral and 11 anal) were done under conscious sedation. Therapeutic interventions were included in 22 procedures (30.6 %): argon plasma coagulation in 19 (86.4 % of interventions), balloon dilation in 1 (4.5 %), positioning of clip in 1 (4.5 %), and injection therapy in 1 (4.5 %). Within 30 days after SBE, no complications had occurred following either the 50 diagnostic SBE procedures or the 22 therapeutic SBE procedures.

Among the 412 SBE procedures published to date [1] [2] [3] [4], only one perforation (0.24 %) was related to the SBE technique, which occurred in a postoperative case of ulcerative colitis where the sliding tube may have caught on an anastomotic region when it was inserted. In the remaining two perforations published, one was a mucosal tear (no free air was seen on abdominal computed tomography) [3], and the other one was related to balloon dilation and not to the SBE technique. Moreover, the overall risk of perforation decreases if we include our data in the analysis (one perforation in 484 SBE procedures, i. e. 0.21 %). Finally, the incidence of perforation during SBE is comparable to that reported during double-balloon enteroscopy (DBE) (0.30 %) [5]. However, scrupulous care is required when passing a small-intestinal lesion or in patients with known adhesions or strictures.

In contrast to per oral DBE, no acute pancreatitis has been reported following SBE. We agree with the hypothesized mechanisms of onset of acute pancreatitis according to Aktas et al.: inflation of two balloons in the duodenum results in an increase of intraluminal pressure, leading to reflux of duodenal fluids into the pancreatic duct, and the repeated ‘push-and-pull’ with stretching of the small intestine. However, we think that the lowered incidence of this complication after SBE is mainly due to the differences in SBE and DBE techniques. In the proposed SBE technique, after passing the enteroscope into the third duodenal portion, the overtube is advanced, the sliding tube goes along the enteroscope, and the balloon is inflated away from the papilla in order to fix the tube to the intestinal wall. Inflating the balloon too near to the papilla may obstruct the pancreatic duct, either directly or due to post-traumatic edema, resulting in the onset of pancreatitis.

In conclusion, we agree with Aktas et al. and confirm the safety of SBE, which nonetheless requires a careful approach and a skilled endoscopist.

Competing interests: None

References

• 1 Aktas H, de Ridder L, Haringsma J. et al . Complications of single-balloon enteroscopy: a prospective evaluation of 166 procedures.  Endoscopy. 2010;  42 365-368
• 2 Tsujikawa T, Saitoh Y, Andoh A. et al . Novel single-balloon enteroscopy for diagnosis and treatment of the small intestine: preliminary experiences.  Endoscopy. 2008;  40 11-15
• 3 Kawamura T, Yasuda K, Tanaka K. et al . Clinical evaluation of a newly developed single-balloon enteroscope.  Gastrointest Endosc. 2008;  68 1112-1116
• 4 Ramchandani M, Reddy D N, Gupta R. et al . Diagnostic yield and therapeutic impact of single-balloon enteroscopy: series of 106 cases.  J Gastroenterol Hepatol. 2009;  24 1631-1638
• 5 Mensink P B, Haringsma J, Kucharzik T. et al . Complications of double balloon enteroscopy: a multicenter survey.  Endoscopy. 2007;  39 613-615