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Original article Clinical endoscopy: Editorial| Volume 77, ISSUE 2, P252-254, February 2013

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Spiral enteroscopy versus double-balloon enteroscopy: choosing the right tool for the job

      Abbreviations:

      DBE (double-balloon enteroscopy), SE (spiral enteroscopy)
      The article in this journal by Messer et al
      • Messer I.
      • May A.
      • Manner H.
      • et al.
      Prospective, randomized, single-center trial comparing double-balloon enteroscopy and spiral enteroscopy in patients with suspected small-bowel disorders.
      comparing spiral enterosocopy (SE) with double-balloon enteroscopy (DBE) is a welcome addition to the knowledge base for the deep small-bowel endoscopist. The study is a prospective randomized study comparing both methods, and is a narrowly focused small study from a single center. The primary endpoint was complete small-bowel examination comparing peroral with anal enteroscopy by use of SE or DBE.
      The SE technique uses a screw to pleat the small bowel on the endoscope. The screw is one of the 6 classical machines defined by the Renaissance scientists to provide mechanical advantage (leverage). A simple machine changes the direction and magnitude of a force. In this case, the screw converts rotational force into linear force. When this force is applied to the small bowel, the mobile small bowel is pleated on the endoscope. Conceptually, SE uses the spiral to pleat the small bowel on the endoscope in a manner similar to a curtain being pleated on a curtain rod.
      In this study, 13 patients were prospectively and randomly assigned to either bidirectional DBE or SE. The primary endpoint was total small-bowel visualization with secondary endpoints of time of procedure, estimated insertion depths, complications, and diagnostic and therapeutic efficacy. Bidirectional DBE was significantly more successful at total enteroscopy, with a success rate of 92% compared with 8% for SE. The SE bidirectional procedure times were statistically significantly superior to those of DBE, with shorter peroral and per anal time of procedures. The diagnostic and therapeutic diagnostic outcomes were not statistically significantly different. The depth of insertion was statistically significantly greater for DBE than for SE in both the peroral and anal approaches. There were no complications in the peroral approach in the SE or DBE groups. The anal approach had 1 perforation of the terminal ileum in the SE group.
      The primary limitations of the study are the small sample size from a single center. Thirty-two patients were initially enrolled in the study, and 6 dropped out of the study, primarily because of lack of need to proceed to an anal approach once a definitive diagnosis had been made. This dropout rate did not seem to affect the study negatively. The procedures were performed by an endoscopist highly experienced in DBE and less experienced in SE. The depth of intubation of the small bowel was measured in 2 different ways. For DBE, the depth was measured with an estimated advancement per push-and-pull procedure. The SE depth of intubation was visually measured on withdrawal. Accurate measurement of the depth of intubation of the small bowel had been a vexing point for enteroscopists attempting to compare techniques and operators. In this study, the comparison of 2 estimates differently arrived at is a weakness of the study.
      There are clear benefits of total enteroscopy as described in this article. Knowing that you have seen the entire GI tract endoscopically can obviate additional studies and help plan future treatment. As stated in the article, the majority of patients who undergo deep enteroscopy do not need a complete enteroscopy. In addition, the total enteroscopy success rate of 92% would be exceptional and indeed is not the norm in most DBE centers in the United States. In this country, the total enteroscopy rates in a 6-center study of the DBE learning curve, including from bidirectional enteroscopy, was 5%.

      Mehdizadeh S, Ross A, Gerson L, et al. Gastrointest Endosc 2006;64:740-50.

      If the success rate at other institutions for DBE at total enteroscopy is low, then the proclaimed superiority of DBE over SE would be diminished, with the SE having a lower procedure time with similar diagnostic and therapeutic efficacy.
      Deep enteroscopy performed with DBE or SE is an advanced procedure that is best suited for the experienced endoscopist. The authors are highly experienced experts in DBE. For the highly experienced endoscopist, SE has been suggested to have a relatively short learning curve of 5 procedures.
      • Judah J.R.
      • Draganov P.V.
      • Lam Y.
      • et al.
      Spiral enteroscopy is safe and effective for an elderly United States population of patients with numerous comorbidities.
      The authors suggest in their discussion that it “seems that SE is easier to learn than DBE.” Although this may be true, it is this endoscopist's experience that SE is a procedure with significant subtlety that is mastered only after considerable experience.
      In this study there were no statistically significant differences in severe complications. There was a demonstrated increase in mucosal trauma in the SE group compared with the DBE group. Mucosal trauma did not seem to have a clinical effect on patient complaints, diagnostic or therapeutic efficacy, or time of procedure. The serious complication rate for SE in 1 retrospective registry study was 0.34% and a perforation rate of 0.27% in a study of 1750 patients.
      • Akerman P.
      Severe complicatons of spiral enteroscopy in the first 1750 patients [abstract].
      In a prospective study of 61 elderly patients with 51% class 3 ASA, there were no serious complications when SE was used; the procedure was successful in 93% of patients.
      • Judah J.R.
      • Draganov P.V.
      • Lam Y.
      • et al.
      Spiral enteroscopy is safe and effective for an elderly United States population of patients with numerous comorbidities.
      In the first 850 cases reported in the literature with SE there were no serious complications.
      • Akerman P.A.
      • Haniff M.
      Spiral enteroscopy: prime time or for the happy few?.
      Overall, this study and others have demonstrated no statistically significant difference in complications between DBE and SE. Interestingly, there appears to be a lower pancreatitis rate with SE than DBE (0.06% vs 1%).
      • Messer I.
      • May A.
      • Manner H.
      • et al.
      Prospective, randomized, single-center trial comparing double-balloon enteroscopy and spiral enteroscopy in patients with suspected small-bowel disorders.
      • Judah J.R.
      • Draganov P.V.
      • Lam Y.
      • et al.
      Spiral enteroscopy is safe and effective for an elderly United States population of patients with numerous comorbidities.
      In this study, diagnostic and therapeutic efficacy were not statistically significantly different. Similar results have been found by several other investigators.
      • Khashab M.A.
      • Lennon A.M.
      • Dunbar K.B.
      • et al.
      A comparative evaluation of single balloon enteroscopy and spiral enteroscopy for patients with mid gut disorders.
      • Schembre D.S.
      • Ross A.M.
      Yield of antegrade double balloon versus spiral enteroscopy for obscure bleeding.
      • Esmail S.
      • Ostradici E.
      • Mallatt D.
      • et al.
      A single center retrospective review of spiral enteroscopy versus double balloon enteroscopy.
      Although this study suggests that DBE accomplishes deeper small-bowel intubation, there was not a demonstrated difference in diagnostic or therapeutic outcomes. Of note, the methods of measuring depth of intubation were different in each group. This makes the oral deep enterosocopy comparison particularly difficult to interpret. Prior prospective and retrospective comparative studies that used similar techniques to estimate depth of intubation of the small bowel comparing DBE and SE did not show a significant difference in depth of intubation when the oral approach was used.
      • Khashab M.A.
      • Lennon A.M.
      • Dunbar K.B.
      • et al.
      A comparative evaluation of single balloon enteroscopy and spiral enteroscopy for patients with mid gut disorders.
      • Schembre D.S.
      • Ross A.M.
      Yield of antegrade double balloon versus spiral enteroscopy for obscure bleeding.
      • Esmail S.
      • Ostradici E.
      • Mallatt D.
      • et al.
      A single center retrospective review of spiral enteroscopy versus double balloon enteroscopy.
      These studies also showed no difference in diagnostic or therapeutic outcomes. SE has consistently been shown to have a shorter time of procedure than DBE, although those times have varied considerably. The studies to date therefore suggest no difference in therapeutic or diagnostic yield with a shorter time of procedure with SE.
      Spiral enteroscopy has demonstrated advantages of decreased time of procedure with no significant difference in therapeutic or diagnostic efficacy. It may also offer a superior platform for therapy, with improved control on withdrawal and the ability to easily remove and reintroduce the enteroscope through the spiral overtube. The spiral overtube is considerably shorter than the DBE overtube: 118 cm versus 145 cm, respectively. This allows more of the enteroscope to be pushed through the overtube and can be useful in the performance of endoscopic therapy. For the experienced endoscopist, the learning curve for successful SE training has been suggested to be as few as 5 procedures,
      • Buscaglia J.M.
      • Dunbar K.B.
      • Okolo 3rd, P.I.
      • et al.
      The spiral enteroscopy training initiative: results of a prospective study evaluating the Discovery SB overtube device during small bowel enteroscopy (with video).
      and in this article the authors suggest that SE “is easier to conduct and learn” than DBE.
      The disadvantages of SE are the bigger and more rigid overtube, the 2-person technique, and the challenge of accomplishing retrograde SE when a combined bidirectional enteroscopy is performed. In this author's experience, retrograde SE can be difficult to achieve. In this study the retrograde approach to bidirectional enteroscopy significantly underperformed in comparison with DBE, likely because the SE overtube is significantly shorter at 118 cm. When the handles are subtracted, the functional length of the spiral overtube is 95 cm. The spiral is on the distal 21 cm of the overtube. Therefore, complete insertion of the overtube would require a “short” colon position for the performance of SE from the retrograde approach. A future study to see the total enteroscopy rate by combining the faster SE oral enteroscopy route with the anal DBE approach would be interesting.
      Bidirectional DBE enteroscopy is clearly superior to bidirectional SE for total enteroscopy at this single center. How this superiority translates to other centers likely depends on the total enteroscopy rates at those centers. If DBE is not available, this study supports other studies in demonstrating no difference in diagnostic and therapeutic efficacy. This study by Messer et al once again demonstrates the decreased procedure time of SE compared with DBE, and according to the take-home message, SE “is easier to conduct and learn.” SE may have some advantages for therapy with controlled withdrawal and ease of removal of the endoscope through the overtube for polyp retrieval. Future developments for motorized SE are quite promising, with 1 study demonstrating 23 consecutive single-session total bidirectional enteroscopies by a single operator with a 160-cm endoscope in less than 1 hour total time, and 4 consecutive patients had a total peroral enteroscopy reaching the cecum in an average time of 22 minutes.
      • Akerman P.A.
      • Demarco D.
      • et al.
      Endoscopic visualization of the entire small intestine in 27 consecutive patients using a novel spiral endoscope.
      In conclusion, this study supports the current literature that each of the current deep enteroscopy techniques has strengths and weaknesses. Choosing the right tool for the job is important for maximizing patient care. Further improvements in the technology of deep small bowel enteroscopy are still needed so that the goal of endoscopic access to the entire GI tract with full therapeutic and diagnostic capabilities easily and rapidly is realized and a “best” technique can be declared. This article and the current literature are evidence that SE is a safe and effective technique for deep small-bowel investigation and can be the right tool for the job in the care of our patients.

      Disclosure

      The author has disclosed a financial relationship relevant to this publication: consultant to the Olympus Co. and stockholder in the Spirus Medical Corp.

      References

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        • May A.
        • Manner H.
        • et al.
        Prospective, randomized, single-center trial comparing double-balloon enteroscopy and spiral enteroscopy in patients with suspected small-bowel disorders.
        Gastrointest Endosc. 2013; 77: 241-249
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        • Dunbar K.B.
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        • et al.
        The spiral enteroscopy training initiative: results of a prospective study evaluating the Discovery SB overtube device during small bowel enteroscopy (with video).
        Endoscopy. 2009; 41: 194-199
        • Akerman P.
        Severe complicatons of spiral enteroscopy in the first 1750 patients [abstract].
        Gastrointest Endosc. 2009; 69: 127-128
        • Judah J.R.
        • Draganov P.V.
        • Lam Y.
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        Spiral enteroscopy is safe and effective for an elderly United States population of patients with numerous comorbidities.
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        Spiral enteroscopy: prime time or for the happy few?.
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        • Lennon A.M.
        • Dunbar K.B.
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        A comparative evaluation of single balloon enteroscopy and spiral enteroscopy for patients with mid gut disorders.
        Gastrointest Endosc. 2010; 72: 766-772
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        • Ross A.M.
        Yield of antegrade double balloon versus spiral enteroscopy for obscure bleeding.
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        • Ostradici E.
        • Mallatt D.
        • et al.
        A single center retrospective review of spiral enteroscopy versus double balloon enteroscopy.
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        Endoscopic visualization of the entire small intestine in 27 consecutive patients using a novel spiral endoscope.
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