Double-balloon enteroscopy: beyond feasibility, what do we do now?

The small intestine has always been regarded as the most difficult area of the hollow gastrointestinal tract to evaluate, either radiologically or endoscopically. Capsule endoscopy provided a major breakthrough in the evaluation of the small bowel and has since established itself as the standard method for evaluating occult and obscure gastrointestinal bleeding and Crohn’s disease [1] [2] [3] [4]. However, this technique has several limitations, including its lack of facilities for obtaining tissue for diagnosis or for providing endoscopic interventions (such as polyp removal, dilation of strictures, or cauterization of angiodysplasia), and its inability to evaluate a lesion in a to-and-fro manner. The advent of double-balloon enteroscopy (DBE) has greatly increased our capability in the investigation and treatment of diseases of the small bowel [5] [6] [7] [8] [9] [10]. DBE was described by Yamamoto et al. in 2001 [5]. Although the initial experience in Japan was encouraging, it was not until May and colleagues in Germany further demonstrated the value and capabilities of this breakthrough endosopic method that its use became more acceptable and widespread [6]. The use of DBE in the pig and the Erlangen training model increased our understanding of the mechanics and intrumentalization of DBE [7]. Since then there have been several prospective and retrospective single- and multicenter studies demonstrating the clinical utility of DBE for the diagnosis and therapy of small-bowel disorders [8] [9] [10] [11] [12] [13] [14]. Nevertheless, there have been few studies investigating the clinical implications and therapeutic outcomes of DBE [9] [10].

In this issue the Endoscopy, Zhong et al. [15] from Shanghai present us with the largest published experience of DBE to date. The investigators set out not only to determine the diagnostic yield of DBE for various indications, but also to investigate the the impact of DBE results on therapeutic decisions and clinical outcomes in a distinct clinical setting. During a 26-month study period, 471 DBE procedures were performed in 378 patients, the principal indications being obscure gastrointestinal bleeding (n = 191), abdominal pain (n = 69), diarrhea (n = 63), and small-bowel obstruction (n = 48). Lesions were found in 247/378 patients (65.3 %). The diagnostic yield for each of the indications was 81 % for obscure gastrointestinal bleeding, 80 % for obstruction, 31 % for abdominal pain, and 30 % for diarrhea. Endoscopic interventions were performed in 20 patients during the DBE procedure. The complication rate was 1 %, with two cases of gastrointestinal bleeding, one perforation (treated conservatively), and two cases of abdominal pain with hyperamylasemia.

This study has several potential advantages over previously published studies. Firstly, the number of procedures performed is the largest reported from a single center. Secondly, the clinical outcomes were well evaluated. Even though the mean follow-up period was short, the clinical implications of DBE were apparent. Furthermore, the authors assessed outcomes separately in patients with positive DBE findings and in patients with negative findings on DBE. There seemed to be an outcome benefit in patients with positive findings compared with those with negative findings. Thirdly, the diagnostic yield and clinical outcome were further investigated with respect to the indication for the procedure. For example, the diagnostic yield was highest in patients investigated for occult gastrointestinal bleeding (80.6 %) or for obstruction (81.3 %). The authors conlcuded that the diagnostic yield in patients with chronic diarrhea and abdominal pain was “only” 30 %. Although this percentage may seem low when compared with other indications, we need to remember that it is very difficult to find the cause of abdominal pain and even of chronic diarrhea in a significant number of patients. Studies using capsule endoscopy for evaluation of abdominal pain and diarrhea have yielded much poorer results [16].

The Zhong et al. study has some limitations. First, the inherent limitation of retrospective studies should be taken into account when interpreting their data. Nonetheless, the data collection and follow-up appear thorough and give strength to their data. Secondly, some methodological information is missing: What was the mean duration of the procedure? How many individuals performed any given DBE procedure? Did the endoscopist have an assistant holding the overtube? Did the endoscopist perform the DBE alone? Did any patients have a previous work-up with capsule endoscopy or push-enteroscopy?

References

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