Small bowel endoscopy:: Have we conquered the final frontier?

With a functional instrument channel and the capacity to visualize most of the small bowel, the true value of the DBE is finally being realized. The current issue of The American Journal of Gastroenterology features an article that summarizes the therapeutic experience of double-balloon enteroscopy (DBE) by Andrea May and colleagues. Virtually all therapeutic devices used with the conventional endoscopes are now available for use through the DBE scopes. Polypectomy, hemostasis therapy, intestinal stenting, foreign body removal, mucosectomy, direct jejunostomy, and ERCP in Roux-en-Y anatomy are now all realistically possible to perform. But behind the very positive data are many technical problems that the authors and those interested in performing DBE have to overcome. Passage of accessories is difficult through the small working channel. Approaching a lesion from a proper angle is a particularly daunting task when the endoscope is situated in the deeper parts of the intestine. The current report of 3.4% of severe complications is well within the range reported previously and is acceptable in light of potential problems encountered with alternative treatment modalities. An important observation of these authors is the particularly high rate of complication associated with polypectomy. Now that we have established the strong diagnostic and therapeutic values of DBE, we need to make it more available and safer for our patients.