- Email: [email protected]
Double-Balloon Endoscopy
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2005;3:S27–S29
Double-Balloon Endoscopy HIRONORI YAMAMOTO Department of Gastroenterology, Jichi Medical School, Tochigi, Japan
In 1997, we devised a method of enteroscopy that uses 2 balloons, 1 balloon attached to the tip of the endoscope and the other balloon attached to the distal end of a soft overtube. We reported that endoscopic observation of the entire small intestine was possible with this method by using an endoscope of 200-cm working length. This double-balloon endoscopy system now is available commercially. We have experience with more than 250 cases of enteroscopy since September 2000 using the double-balloon endoscope including our experience with the prototype. Recently, a new therapeutic type of double-balloon endoscope was developed. The new type has an accessory channel of 2.8 mm, which is bigger than the 2.2-mm accessory channel of the standard double-balloon endoscope.
he double-balloon endoscopy system is composed of a thin endoscope (Fujinon EN-450P5/20; Fujinon Corporation, Saitama, Japan) with an 8.5-mm diameter and a 200-cm working length, a 145-cm soft overtube with an outer diameter of 12.2 mm, and a specifically designed pump (Figure 1A, B).1,2 A soft latex balloon attached to the tip of the endoscope can be inflated and deflated through an air channel in the endoscope by using the pump. The soft overtube also has a latex balloon at its tip that can be inflated and deflated. The pressure in both balloons is monitored accurately and regulated at 6 kPa. The new type of endoscope for therapeutic use (EN-450T5) has an outer diameter of 9.4 mm with a 2.8-mm accessory channel. The specifications of this system are listed in Table 1.
T
Procedure The overtube is backloaded onto the endoscope with both balloons collapsed. The endoscope is advanced into the duodenum and the balloon on the endoscope tip is inflated there. The overtube then is inserted into the duodenum, and the overtube balloons are inflated. After straightening the overtube and endoscope by gently withdrawing them, the endoscope balloon is deflated and the endoscope is inserted further. After the tip of the endoscope has been inserted beyond the angle of Treitz, the endoscope balloon is inflated and the overtube balloon is deflated, and the overtube is then advanced.
Gentle, simultaneous withdrawal of the overtube and endoscope with both balloons inflated causes pleating of the intestine onto the overtube. This sequence is repeated to advance further into the intestine. The pleating effect of the intestine over and onto the overtube allows for the insertion of the endoscope into the small intestine well beyond the physical length of the endoscope itself (Figure 2). The procedure is performed under fluoroscopic guidance whenever necessary. A retrograde (anal) approach also is performed using the same principle. The latex balloons can be inflated sufficiently to grip the colonic wall while advancing through the colon. Because the balloons are very elastic and balloon inflation is controlled by pressure instead of air volume, they can be used safely regardless of the intestinal diameter. After reaching the cecum, the endoscope is inserted into the ileum beyond the ileocecal valve; the overtube is also inserted into the ileum. A tip to remember when advancing the endoscope into the deep small intestine using the double-balloon method is to form concentric circles with the endoscope. Advancing the endoscope tip downward into the pelvis, forming an S shape with the endoscope shaft, should be avoided; forming a C or O shape is preferred (Figure 3).
Clinical Experience We have performed more than 250 cases of double-balloon enteroscopy using the Fujinon system since September 2000 when the first prototype of the Fujinon double-balloon system became available.2 Insertion beyond the ligament of Treitz and endoscopic observation of the jejunum or insertion of the endoscope beyond the ileocecal valve and observation of the ileum was achieved easily using this system. The average depth of insertion estimated from the number of pleating procedures and the fluoroscopic images of the small intestine and endoscope was approximately one half to two thirds of the entire length of the small intestine in either the anterograde or retrograde ap© 2005 by the American Gastroenterological Association
1542-3565/05/$30.00 PII: 10.1053/S1542-3565(05)00253-3
S28
HIRONORI YAMAMOTO
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 7
Table 1. Specifications of the Fujinon Double-Balloon System
Endoscope Outer diameter Total length Working length Accessory channel Overtube Outer diameter Inner diameter Total length Working length Pump controller (PB-10) Pressure setting range Maximum flow rate
EN-450P5/20
EN-450T5
8.5 mm 2300 mm 2000 mm 2.2 mm
9.4 mm 2300 mm 2000 mm 2.8 mm
12.2 mm 10 mm 1450 mm 1400 mm
13.2 mm 11 mm 1450 mm 1400 mm
5.6 ⫾ 2.0 kPa 170 mL/10 s
By using this system, we also performed endoscopic therapies in the small intestine such as hemostasis with electrocoagulation,4 polypectomy, endoscopic mucosal resection,5 balloon dilation,6 and stent placement. The new therapeutic double-balloon endoscope (EN-450T5) is useful especially for endoscopic therapies because bal-
Figure 1. Fujinon double-balloon endoscopy system. (A) The doubleballoon endoscope (EN-450P5/20), (B) the pump controller (PB-10).
proach. By combining both approaches, endoscopic observation of the entire small intestine is possible in more than 85% of cases.3 Total enteroscopy can be confirmed by reaching a mark from the opposite approach, which is made with India ink at the farthest point during the initial approach. Obscure gastrointestinal bleeding is the most frequent indication for double-balloon enteroscopy in our experience. Other major indications include obstructive symptoms and suspicion of an intestinal tumor. In a majority of cases, endoscopy successfully diagnosed lesions such as small-intestinal ulcer, tumor, and angiodysplasia.3
Figure 2. Sequential maneuvers of anterograde insertion of doubleballoon endoscopy.
July Supplement 2005
DOUBLE–BALLOON ENDOSCOPY
S29
the movement of the endoscope is controlled from the gripped point by the overtube balloon, which can be set at any point.
Discussion Both capsule endoscopy and double-balloon endoscopy can explore the entire small intestine with a high success rate. Capsule endoscopy is suitable for the initial work-up of nonobstructive small intestinal disorders because it is discomfort-free and does not require the patient to be confined to a medical facility. On the other hand, double-balloon endoscopy is more labor-intensive, but has distinct advantages which can complement the limitations of capsule endoscopy. Abnormal findings detected by a capsule can be confirmed by double-balloon endoscopy with biopsy examination, and endoscopic treatment can be performed in some cases. Small intestinal strictures, which are a contraindication for capsule endoscopy, can be explored by double-balloon endoscopy, and endoscopic balloon dilation can be performed in some cases. Moreover, in cases of capsule retention at a stricture, the capsule can be retrieved by doubleballoon endoscopy and the stricture can be dilated endoscopically.
References Figure 3. Sequential maneuvers of retrograde insertion of doubleballoon endoscopy.
loon dilators and clip devices can be used through the accessory channel.
Other Applications The double-balloon endoscopy system is not made exclusively for enteroscopy. It can be used in any part of the gastrointestinal tract. For example, we use the double-balloon endoscope as a colonoscope for technically difficult cases. We also use this system for endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis in which an endoscopic approach to the papilla of Vater is impossible with regular endoscopic insertion. A remarkable feature of double-balloon endoscopy is not only the excellent accessibility to the distal small intestine, but also the ability to control the endoscope tip in any part of the intestine. Precise control of the endoscope tip is possible at any point in the intestine because
1. Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001;53:216 –220. 2. Yamamoto H, Yano T, Kita H, et al. New system of double-balloon enteroscopy for diagnosis and treatment of small intestinal disorders. Gastroenterology 2003;125:1556 –1557. 3. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of doubleballoon endoscopy for the diagnosis and treatment of small intestinal diseases. Clin Gastroenterol Hepatol 2004;2:1010 –1016. 4. Nishimura M, Yamamoto H, Kita H, et al. A case of gastrointestinal stromal tumor in the jejunum; diagnosis and control of bleeding with electrocoagulation by using double-balloon enteroscopy. J Gastroenterol 2004;39:1001–1004. 5. Kuno A, Yamamoto H, Kita H, et al. Application of double-balloon enteroscopy through Roux-en-Y anastomosis for the endoscopic mucosal resection of an early carcinoma in the duodenal afferent limb. Gastrointest Endosc 2004;60:1032–1034. 6. Sunada K, Yamamoto H, Kita H, et al. Case report: successful treatment with balloon dilatation using a double-balloon enteroscope for a stricture in the small bowel of a patient with Crohn’s disease. Dig Endosc 2004;16:237–240.
Address requests for reprints to: Hironori Yamamoto, MD, Department of Gastroenterology, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi, Kawachi, Tochigi, 329-0498 Japan. e-mail: [email protected] or [email protected]; fax: (81) 285-44-8297.
Double-Balloon Endoscopy HIRONORI YAMAMOTO Department of Gastroenterology, Jichi Medical School, Tochigi, Japan
In 1997, we devised a method of enteroscopy that uses 2 balloons, 1 balloon attached to the tip of the endoscope and the other balloon attached to the distal end of a soft overtube. We reported that endoscopic observation of the entire small intestine was possible with this method by using an endoscope of 200-cm working length. This double-balloon endoscopy system now is available commercially. We have experience with more than 250 cases of enteroscopy since September 2000 using the double-balloon endoscope including our experience with the prototype. Recently, a new therapeutic type of double-balloon endoscope was developed. The new type has an accessory channel of 2.8 mm, which is bigger than the 2.2-mm accessory channel of the standard double-balloon endoscope.
he double-balloon endoscopy system is composed of a thin endoscope (Fujinon EN-450P5/20; Fujinon Corporation, Saitama, Japan) with an 8.5-mm diameter and a 200-cm working length, a 145-cm soft overtube with an outer diameter of 12.2 mm, and a specifically designed pump (Figure 1A, B).1,2 A soft latex balloon attached to the tip of the endoscope can be inflated and deflated through an air channel in the endoscope by using the pump. The soft overtube also has a latex balloon at its tip that can be inflated and deflated. The pressure in both balloons is monitored accurately and regulated at 6 kPa. The new type of endoscope for therapeutic use (EN-450T5) has an outer diameter of 9.4 mm with a 2.8-mm accessory channel. The specifications of this system are listed in Table 1.
T
Procedure The overtube is backloaded onto the endoscope with both balloons collapsed. The endoscope is advanced into the duodenum and the balloon on the endoscope tip is inflated there. The overtube then is inserted into the duodenum, and the overtube balloons are inflated. After straightening the overtube and endoscope by gently withdrawing them, the endoscope balloon is deflated and the endoscope is inserted further. After the tip of the endoscope has been inserted beyond the angle of Treitz, the endoscope balloon is inflated and the overtube balloon is deflated, and the overtube is then advanced.
Gentle, simultaneous withdrawal of the overtube and endoscope with both balloons inflated causes pleating of the intestine onto the overtube. This sequence is repeated to advance further into the intestine. The pleating effect of the intestine over and onto the overtube allows for the insertion of the endoscope into the small intestine well beyond the physical length of the endoscope itself (Figure 2). The procedure is performed under fluoroscopic guidance whenever necessary. A retrograde (anal) approach also is performed using the same principle. The latex balloons can be inflated sufficiently to grip the colonic wall while advancing through the colon. Because the balloons are very elastic and balloon inflation is controlled by pressure instead of air volume, they can be used safely regardless of the intestinal diameter. After reaching the cecum, the endoscope is inserted into the ileum beyond the ileocecal valve; the overtube is also inserted into the ileum. A tip to remember when advancing the endoscope into the deep small intestine using the double-balloon method is to form concentric circles with the endoscope. Advancing the endoscope tip downward into the pelvis, forming an S shape with the endoscope shaft, should be avoided; forming a C or O shape is preferred (Figure 3).
Clinical Experience We have performed more than 250 cases of double-balloon enteroscopy using the Fujinon system since September 2000 when the first prototype of the Fujinon double-balloon system became available.2 Insertion beyond the ligament of Treitz and endoscopic observation of the jejunum or insertion of the endoscope beyond the ileocecal valve and observation of the ileum was achieved easily using this system. The average depth of insertion estimated from the number of pleating procedures and the fluoroscopic images of the small intestine and endoscope was approximately one half to two thirds of the entire length of the small intestine in either the anterograde or retrograde ap© 2005 by the American Gastroenterological Association
1542-3565/05/$30.00 PII: 10.1053/S1542-3565(05)00253-3
S28
HIRONORI YAMAMOTO
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 7
Table 1. Specifications of the Fujinon Double-Balloon System
Endoscope Outer diameter Total length Working length Accessory channel Overtube Outer diameter Inner diameter Total length Working length Pump controller (PB-10) Pressure setting range Maximum flow rate
EN-450P5/20
EN-450T5
8.5 mm 2300 mm 2000 mm 2.2 mm
9.4 mm 2300 mm 2000 mm 2.8 mm
12.2 mm 10 mm 1450 mm 1400 mm
13.2 mm 11 mm 1450 mm 1400 mm
5.6 ⫾ 2.0 kPa 170 mL/10 s
By using this system, we also performed endoscopic therapies in the small intestine such as hemostasis with electrocoagulation,4 polypectomy, endoscopic mucosal resection,5 balloon dilation,6 and stent placement. The new therapeutic double-balloon endoscope (EN-450T5) is useful especially for endoscopic therapies because bal-
Figure 1. Fujinon double-balloon endoscopy system. (A) The doubleballoon endoscope (EN-450P5/20), (B) the pump controller (PB-10).
proach. By combining both approaches, endoscopic observation of the entire small intestine is possible in more than 85% of cases.3 Total enteroscopy can be confirmed by reaching a mark from the opposite approach, which is made with India ink at the farthest point during the initial approach. Obscure gastrointestinal bleeding is the most frequent indication for double-balloon enteroscopy in our experience. Other major indications include obstructive symptoms and suspicion of an intestinal tumor. In a majority of cases, endoscopy successfully diagnosed lesions such as small-intestinal ulcer, tumor, and angiodysplasia.3
Figure 2. Sequential maneuvers of anterograde insertion of doubleballoon endoscopy.
July Supplement 2005
DOUBLE–BALLOON ENDOSCOPY
S29
the movement of the endoscope is controlled from the gripped point by the overtube balloon, which can be set at any point.
Discussion Both capsule endoscopy and double-balloon endoscopy can explore the entire small intestine with a high success rate. Capsule endoscopy is suitable for the initial work-up of nonobstructive small intestinal disorders because it is discomfort-free and does not require the patient to be confined to a medical facility. On the other hand, double-balloon endoscopy is more labor-intensive, but has distinct advantages which can complement the limitations of capsule endoscopy. Abnormal findings detected by a capsule can be confirmed by double-balloon endoscopy with biopsy examination, and endoscopic treatment can be performed in some cases. Small intestinal strictures, which are a contraindication for capsule endoscopy, can be explored by double-balloon endoscopy, and endoscopic balloon dilation can be performed in some cases. Moreover, in cases of capsule retention at a stricture, the capsule can be retrieved by doubleballoon endoscopy and the stricture can be dilated endoscopically.
References Figure 3. Sequential maneuvers of retrograde insertion of doubleballoon endoscopy.
loon dilators and clip devices can be used through the accessory channel.
Other Applications The double-balloon endoscopy system is not made exclusively for enteroscopy. It can be used in any part of the gastrointestinal tract. For example, we use the double-balloon endoscope as a colonoscope for technically difficult cases. We also use this system for endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anastomosis in which an endoscopic approach to the papilla of Vater is impossible with regular endoscopic insertion. A remarkable feature of double-balloon endoscopy is not only the excellent accessibility to the distal small intestine, but also the ability to control the endoscope tip in any part of the intestine. Precise control of the endoscope tip is possible at any point in the intestine because
1. Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001;53:216 –220. 2. Yamamoto H, Yano T, Kita H, et al. New system of double-balloon enteroscopy for diagnosis and treatment of small intestinal disorders. Gastroenterology 2003;125:1556 –1557. 3. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of doubleballoon endoscopy for the diagnosis and treatment of small intestinal diseases. Clin Gastroenterol Hepatol 2004;2:1010 –1016. 4. Nishimura M, Yamamoto H, Kita H, et al. A case of gastrointestinal stromal tumor in the jejunum; diagnosis and control of bleeding with electrocoagulation by using double-balloon enteroscopy. J Gastroenterol 2004;39:1001–1004. 5. Kuno A, Yamamoto H, Kita H, et al. Application of double-balloon enteroscopy through Roux-en-Y anastomosis for the endoscopic mucosal resection of an early carcinoma in the duodenal afferent limb. Gastrointest Endosc 2004;60:1032–1034. 6. Sunada K, Yamamoto H, Kita H, et al. Case report: successful treatment with balloon dilatation using a double-balloon enteroscope for a stricture in the small bowel of a patient with Crohn’s disease. Dig Endosc 2004;16:237–240.
Address requests for reprints to: Hironori Yamamoto, MD, Department of Gastroenterology, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi, Kawachi, Tochigi, 329-0498 Japan. e-mail: [email protected] or [email protected]; fax: (81) 285-44-8297.