Carbon dioxide insufflation improves depth of insertion particularly from the upper approach [38••]. India ink tattooing is helpful to mark the deepest site of insertion when complete enteroscopy is desired and to mark lesions for minimally invasive surgical resection. Laparoscopic-assisted DBE can be useful for polyp removal in Peutz-Jeghers syndrome  and when DBE alone cannot reach small bowel bleeding lesions for technical reasons (personal experience).
Availability of tools that fit both the pediatric (2.2 mm) and therapeutic (2.8 mm) double balloon enteroscope channel is improving. More needs to be known about optimal settings for thermal therapy in the small bowel. Therapeutic capacity has increased particularly in the use of the double balloon technique to allow ERCP in individuals with Roux-en-Y anastomoses. In such cases, the overtube acts as a pliable, straightening device around tight bowel angulations allowing advancement into fairly long limbs.
Abdominal pain is common following DBE and can be lessened by the use of carbon dioxide insufflation. Diagnostic DBE has an overall complication rate of 1.7% (perforation 0.3%, bleeding 0.8%, pancreatitis 0.3%) [41•]. The cause of pancreatitis is uncertain. Advancing the overtube and enteroscope into the jejunum before inflating balloons and avoiding excessive tension on the mesentery during push–pull cycles may limit this risk. 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%) [41•].
Gastroenterologists and other healthcare providers need to be trained. What is most desired is the need for randomized, prospective studies to compare technologies and long-term outcomes, particularly in small bowel bleeding. Certainly, the past 8 years have been a remarkable start.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 165–166).
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