See “Diagnostic and Therapeutic Utility of Double-Balloon Enteroscopy in Children” by Urs et al on page 206.
In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Urs et al present their experience in double-balloon enteroscopy from a third-line pediatric endoscopy unit (1). One may question the novelty of a case series of 58 patients undergoing double-balloon enteroscopy, because this technique has been available for approximately a decade and resulted in >700 publications in a PubMed search in 2013. Nevertheless, as has been the case for all of the other endoscopic procedures, pediatric endoscopy has always been behind other disciplines in adopting new developments. Several reasons may explain this delay, the most important being the understandable hesitation to subject children to invasive endoscopic procedures. The reticence to perform endoscopy in children leads to fewer indications, fewer pediatricians trained in endoscopy, fewer prospective endoscopy studies in children, and fewer pediatric-specific endoscopy developments. Therefore, advanced endoscopy in the pediatric population is often performed by endoscopists who usually work on adults; however, children cannot be considered small adults. They differ not only in size but also in anatomical changes, and different pathologies occur (2–4). Endoscopy in children should be performed by pediatricians trained in pediatric endoscopy, with additional help from adult endoscopists for advanced therapeutic endoscopy.
The small bowel has long been considered the “black box” of the digestive tract because it is difficult to access by endoscope, even in adults. In recent years, wireless video capsule (WCE) endoscopy and balloon-assisted enteroscopy (BAE), including single- and double-balloon systems, have evolved and also have been used in children from the age of 1 and 3 years old, respectively (4,5). WCE allows noninvasive visualization of the entire small bowel, and BAE combines excellent visualization of, in theory, the entire small bowel, with the possibility of performing biopsy sampling and therapeutic interventions (6). The time has come for pediatric endoscopists to adopt this technique. Urs et al are not the first to report on double-balloon enteroscopy in children. Even the first reported case series, by its spiritual father Hironori Yamamoto, in 2004, mentions children as young as 8 years (7).
Then why does the article by Urs et al deserve special attention? It is the first case series with a considerable number of patients from a dedicated pediatric endoscopy unit. It highlights differences between adult and pediatric enteroscopy. When indicated, total enteroscopy in their pediatric population was achieved in 30%, which resembles Western success rates, in contrast to the much higher “Eastern” completion rates. Complications described in this article highlight the concept that children with surgically altered anatomy and poor general condition are at higher risk of complications irrespective of the therapeutic nature of the procedure. In contrast, postenteroscopy pancreatitis was absent, whereas it is a well-known complication in adults undergoing antegrade BAE.
Although indications to perform enteroscopy in children resemble those in adults, pathological entities such as the blue rubber bleb nevus syndrome are restricted to the pediatric practice. On the contrary, endoscopic removal of swallowed foreign bodies that have migrated to the small intestine does not appear to be an indication for double-balloon enteroscopy, although foreign body removal is a major indication for upper gastrointestinal endoscopy in children (2,8).
Finally, the study by Urs et al overcomes one of the major limitations of previously published articles. It is a study that combines the evaluation using WCE before BAE in all of the patients with the possibility of comparing the diagnostic yield of these 2 techniques. This important detail in the study design could contribute significantly to the definition of a diagnostic and therapeutic algorithm for the management of small bowel disease in pediatric clinical practice. Therefore, in conjunction with adult recommendations, the authors suggested that WCE be performed before BAE in children because of the less invasive nature of the capsule procedure and its usefulness in directing an antegrade or a retrograde approach to double-balloon enteroscopy. Future trials should also include a cost-effectiveness analysis of this combined approach.
The article by Urs et al illustrates the need for an update of the 1996 NASPGN position paper on the indications for pediatric gastrointestinal endoscopy, which lacked information on enteroscopy, whereas BAE is included as a level 3 advanced procedure in the latest NASPGHAN training guidelines (8,9).
1. Urs A, Martinelli M, Rao P, et al. Diagnostic and therapeutic utility of double-balloon enteroscopy in children. J Pediatr Gastroenterol Nutr
2. Lee KK, Anderson MA, Baron TH, et al. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc
3. Barth BA, Banerjee S, Bhat YM, et al. Equipment for pediatric endoscopy. Gastrointest Endosc
4. de Ridder L, Tabbers MM, Escher JC. Small bowel endoscopy in children. Best Pract Res Clin Gastroenterol
5. Di Nardo G, de Ridder L, Oliva S, et al. Enteroscopy in paediatric Crohn's disease. Dig Liver Dis
6. Moreels TG. History of endoscopic devices for the exploration of the small bowel. Acta Gastroenterol Belg
7. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol
8. Squires RH, Colletti RB. Indications for pediatric gastrointestinal endoscopy: a medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr
9. Leichtner AL, Gillis LA, Gupta S, et al. NASPGHAN guidelines for training in pediatric gastroenterology. J Pediatr Gastroenterol Nutr
2013; 56 (suppl I):S1–S38.