Clinical aspects and treatment possibilities of single balloon enteroscopy

Lars Aabakken, Chief of GI Endoscopy
Rikshospitalet University Hospital
Oslo, Norway

The almost coinciding introduction of capsule endoscopy (CE) and device-assisted enteroscopy (DAE) proved to be an extremely valuable combination of technologies to explore the endoluminal aspect of the small bowel, which previously was confined to indirect imaging by x‑ray and contrast, or cross-sectional imaging with limited mucosal delineation and no therapeutic options.

Most clinical algorithms favour CE for initial mapping of the small bowel, to detect pathology, and to make an estimation of the likely location. Based on this information, DAE may or may not be indicated, but even negative CE studies may well indicate a subsequent DAE if the index of suspicion is high. If pathology is seen, closer characterization and sampling, as well as endoscopic therapy may be DAE options. If the lesion needs surgical care, endoscopic tattooing can greatly simplify th eprocedure, particularly for laparoscopic resections.

Despite the long and winding (and narrow) road of the DAE channel, a range of adapted therapeutic options are available, not too different from the armamentarium of gastroscopy and colonoscopy. For angiectesias, the most frequent indication in many materials, APC is the preferred modality, while more focused lesions may benefit from clipping with or without injection therapy. Snares are available for polypectomy, and injection needles for submucosal injection facilitates resection of flat lesions. Standard needles may however deform and malfunction, and a reinforced sheath is recommendable. Endoloops are available in sufficient lengths and is sometimes warranted e. g. for removal of large pedunculated peutz-jæghers polyps.

Surgically altered anatomy has created yet another are o finterest for the DAE method. ERCP may be indicated in various variants of roux-loops or other alterations where access to the biliary or pancreatic ducts is no longer available with the duodenoscope. Even Billroth II surgery, which can usually be managed with traditional instruments, are simpler and more safely approached with the balloon enterscope. Gastric bypass surgery creates substantial challenges for the endoscopist, for intubation, as well as for papillary cannulation, but the past the learning curve, the results warrant consideration of this method as a less invasive alternative to transhepatic or surgically- assisted access routes. However, the accessories are still suboptimal, and adapted instuments with shorter intubation tubes and wider working channels, as well as a tip elevator, would greatly facilitate these procedures. Tips and techniques for navigating and negotiating the altered anatomy will be demonstrated.