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      Does Single Balloon Enteroscopy Have Similar Efficacy and Endoscopic Performance Compared with Double Balloon Enteroscopy?

      Gut and Liver

      Editorial Office of Gut and Liver

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          Abstract

          The small bowel had been considered unobservable area for gastrointestinal endoscopy, as most of the small bowel was inaccessible with conventional endoscopy. The advent of capsule endoscopy and balloon-assisted enteroscopy during the last decade revolutionized the diagnosis and management of small bowel diseases. Capsule endoscopy, developed in 2001, has been evolved as the main technique for the endoscopic evaluation of small bowel disorders because it is a noninvasive and safe technique for complete small bowel visualization. However, it has several major limitations, lack of therapeutic capabilities and movement control. Yamamoto et al.1 described the double balloon enteroscopy (DBE) technique visualizing small intestine and capable of therapeutic procedures in 2001. DBE has one latex balloon to the tip of enteroscope and the other on the tip of overtube. The balloon of the tip of enteroscope and one of the overtube are alternatively inflated or deflated with air from a pressure-controlled pump unit of the DBE system. The mechanism of DBE was based on the concept that stretching of the small bowel during the insertion of endoscope prevents further endoscopic advancement, and that the usage of two balloons of enteroscope tip and overtube would hold the intestinal wall and prevent subsequent loop formation and make further advancement of enteroscopy.1 In 2007, single balloon enteroscopy (SBE) technique was developed, in which a latex-free balloon is attached to the tip of the silicon overtube and is inflated or deflated with air controlled by a balloon control system.2 Preparation and operation of DBE are more time-consuming and cumbersome, manually applying a latex balloon to enteroscope tip as well as inflation and deflation of two balloons than one of SBE. SBE may provide a quicker procedure with shorter procedure time.3 However SBE may have some difficulties to perform deep insertion of enteroscopy due to the absence of a balloon of enteroscope tip to prevent small bowel getting free. A randomized controlled trial reported that total enteroscopy rate of DBE is higher than one of SBE.4 Despite of lower rate of total enteroscopy, recent studies demonstrated that SBE and DBE have similar diagnostic, therapeutic yields and insertion depth in the patients with suspected small bowel diseases.5,6 There are two meta-analyses about diagnostic and therapeutic yields, and endoscopic performance of DBE and SBE, which also reported that both DBE and SBE have similar diagnostic and therapeutic yields.5,6 In this issue of Gut and Liver, Kim et al.7 reported the retrospective analysis of SBE and DBE data by a single enteroscopist of a single center and meta-analysis of the efficacy and safety of SBE and DBE. From a prospective balloon-assisted enteroscopy registry, a total of 65 enteroscopic procedures in 44 patients with SBE and 73 procedures in 69 patients with DBE were included. The results of this issue reported that there were no significant differences in diagnostic yields, therapeutic yields and complication rate between DBE and SBE in their enteroscopy registry.7 Kim et al. also analyzed the meta-analysis including four small-scale randomized-controlled trials and three observational studies. This meta-analysis also demonstrated that there were no significant differences in the pooled relative risk and odds ratio for diagnostic and therapeutic yield and complication between SBE and DBE.7 Previous meta-analyses including four randomized controlled studies reported similar results to this issue.5,6 Meta-analysis of this issue included three large-scale of observations studies as well as four randomized controlled studies. The author suggested the large-scale of observational studies might reflect real practice of DBE and SBE.7 There are some limitations of this issue. This study is a retrospective study of comparison between SBE and DBE which might have some bias. The results might be dependent on which one was that the endoscopists had the experiences to overcome learning curve at the first time if the endoscopists do not have the same volume of experiences on DBE and SBE. Although there are some limitations, it seems that SBE shows similar diagnostic, therapeutic yields and complication rate to DBE. Either DBE or SBE can be used for the diagnosis or treatment of small intestinal diseases depending on the available endoscopic system in the hospital on the basis of this result. Well-designed randomized controlled trials of large sample size to compare these techniques are still needed to demonstrate the efficacy of both enteroscopy.

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          Most cited references 7

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          Total enteroscopy with a nonsurgical steerable double-balloon method

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            Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial.

            Balloon endoscopy has been accepted as an effective tool for examining the small intestine. Two types of balloon endoscopy, single and double, are commercially available. The difference in performance between these 2 types of balloon endoscopy has not yet been elucidated. To compare the yield of single-balloon endoscopy (SBE) and double-balloon endoscopy (DBE). Single-center, randomized, controlled trial. University hospital in Tokyo, Japan. Patients with suspected small-bowel disease. SBE and DBE. Outcomes were the total enteroscopy rate, diagnostic yield, complication rate, and clinical outcomes. Analysis was done by intent to treat. The study started in April 2008 and was terminated in April 2010 because of an obvious disadvantage for the SBE group. Thirty-eight patients were enrolled in the study; 18 patients were assigned to the SBE group and 20 to the DBE group. The total enteroscopy rate was 0% in the SBE group and 57.1% in the DBE group (P = .002). In terms of complications, the DBE group had 1 patient with Mallory-Weiss syndrome, and the SBE group had 1 patient with hyperamylasemia. There was no difference in the overall diagnosis rate between the SBE and DBE groups (61.1% vs 50.0%, P = .49). There was no difference in therapeutic outcome between the SBE and DBE groups (27.8% vs 35.0%, P = .63). Relatively small number of study patients. Total enteroscopy is more easily performed with DBE than with SBE. Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.
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              Clinical evaluation of a newly developed single-balloon enteroscope.

              Double-balloon enteroscopy (DBE) is a useful and epoch-making technique for small-bowel diseases. The single-balloon enteroscope (SBE) is a new instrument introduced by Olympus. To evaluate a prototype of the SBE. A prospective case series. Kyoto Second Red Cross Hospital, between April 2006 and July 2007. We used the SBE system to perform 37 enteroscopic examinations on 27 patients, including 22 oral and 15 anal approaches. The rate of whole small-bowel visualization, mean time necessary for the investigation, discovery rate of lesions, and complications. We observed the entire small intestine in 1 of 8 cases (12.5%) that we examined. The mean (+/-SD) time necessary for the oral approach was 83 +/- 38 minutes and that for the anal approach was 90 +/- 32 minutes. The preparation time was less than 5 minutes in both approaches. Small-intestinal lesions were detected in 11 of the 27 patients (40.7%). Perforation occurred in one case as a complication, but the injury healed without surgical intervention. This was a single-center study. Use of the SBE system in the endoscopic study of the small intestine makes it possible to observe the entire small intestine and to diagnose lesions; thus, the SBE system is a useful instrument for small-bowel diseases. However, the rate of whole small-bowel visualization was inferior to the DBE system.
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                Author and article information

                Journal
                Gut Liver
                Gut Liver
                Gut and Liver
                Editorial Office of Gut and Liver
                1976-2283
                2005-1212
                July 2017
                15 July 2017
                : 11
                : 4
                : 451-452
                Affiliations
                Department of Internal Medicine, Hallym University School of Medicine, Hwasung, Korea
                Author notes
                Correspondence to: Hyun Joo Jang, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym University School of Medicine, 7 Keunjaebong-gil, Hwaseong 18450, Korea, Tel: +82-31-8086-2450, Fax: +82-31-8086-2029, E-mail: jhj1229@ 123456hallym.or.kr
                Article
                gnl-11-451
                10.5009/gnl17225
                5491077
                28647954
                Copyright © 2017 by The Korean Society of Gastroenterology, the Korean Society of Gastrointestinal Endoscopy, the Korean Society of Neurogastroenterology and Motility, Korean College of Helicobacter and Upper Gastrointestinal Research, Korean Association the Study of Intestinal Diseases, the Korean Association for the Study of the Liver, Korean Pancreatobiliary Association, and Korean Society of Gastrointestinal Cancer.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Gastroenterology & Hepatology

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