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Device assisted enteroscopy
Small bowel is 17feet (5-6Metres) long and large bowel is 5feet (1.5Metre) long
Double balloon enteroscopy (DBE) is a new diagnostic and therapeutic modality originally described by Yamamoto et al in 2001 that allows high resolution visualisation, diagnostic and therapeutic interventions in all segments of the small intestine. It came almost the same time as Video capsule endoscopy and at one point was thought to be each other competitors. However with more widespread use of VCE it is expected that roughly 10% of those patients will need enteroscopy for further evaluation or imparting therapy.
The double balloon enteroscope comprises a 145 cm overtube back loaded on a 200 cm enteroscope and a latex balloon attached to each end.
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Technical details
Indications
The main indications are
Other indications for DBE include an evaluation of suspected small-bowel diarrhoea, abdominal pain, the removal of small-bowel polyps, treatment for angiodysplasias (APC) or small intestinal bleeding ( Endoclip) ,the retrieval of tissue samples/ stuck capsule and accessing ampulla for ERCP in Roux-en-Y anastomoses, post bariatric surgery, small intestinal stricture dilatation/ stenting, tattooing to assist laparoscopic small bowel resection. Difficult colonoscopy is another indication when rectal approach is used.
One important point is if APC is used to treat any telangiectasia in small bowel – Argon flow is to be reduced to 1.5 litres/minute (normally 2 litres/minute) and energy reduced to A30 (normally A65 for Stomach/duodenum). Also avoid physical contact of the small bowel wall with the tip of APC catheter as suddenly the wall can be blown up with the gas. Also to inflate CO2 should be preferentially used.
Limitations
The limitations of DBE include the long procedural time and the patient discomfort and increased need for sedation.
Complications
Diagnostic DBE has an overall complication rate of 1.7% (perforation 0.3%, bleeding 0.8%, pancreatitis 0.3%). The cause of pancreatitis is uncertain. Therapeutic DBE has a relatively high complication rate of 4.3% (polypectomy bleeding 3.3%, argon plasma coagulation perforation 1.2%, dilation perforation 2.9%) (2).
Single balloon enteroscopy
Single balloon enteroscopy (SBE) is similar to DBE except that SBE utilizes a single balloon on the overtube and a hyper flexible endoscope tip. Rather than the balloon at the tip of the endoscope fixing the endoscope when overtube is advanced- the intestine is fixed by hooking the flexible distal tip (J manoeuvre).
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This decreases set-up time and also no assistant is needed. The single balloon enteroscope is also stiffer that may facilitate one-to-one advancement in the small bowel and improve success rates for ileal intubation from the anal approach. In the initial clinical experience using SBE, average depth of insertion (270 cm) and diagnostic yield (54%) were similar to those with DBE (3).Procedure time was somewhat shorter. There are no comparison studies between DBE and SBE with regard to complete enteroscopy rates.
Previously Enteroscopy was done either by Push Enteroscopy or Sonde enteroscopy
Push Enteroscopy
Push enteroscopy is an endoscopic procedure whereby a longer endoscope is inserted into the jejunum through the mouth to evaluate a larger segment of the small bowel. The diagnostic yield of push enteroscopy is approximately 40% to 65%.
Push enteroscopy is normally done with a paediatric colonoscope +/- overtube. The main disadvantage is the fact that small bowel is too long and being supported on a mobile mesentery, the endoscope tends to accentuate the natural curvature and makes complete examination almost impossible.
Sonde enteroscopy
Sonde enteroscopy involves the use of a long, flexible, fiberoptic instrument propelled through the small bowel by peristalsis; this procedure may allow for viewing the remainder of the small bowel. Sonde instruments rely on a balloon placed at the instrument’s tip. Peristalsis then advances the long flexible endoscope to the distal small bowel, and the endoscopic examination is performed during withdrawal. In contrast to push enteroscopy, this instrument has no biopsy or therapeutic capability.
References
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