Title: Which route should we select when performing double-balloon enteroscopy?
Abstract: To the Editor: We read with great interest the article by Kaffes et al1Kaffes A.J. Siah C. Koo J.H. Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy.Gastrointest Endosc. 2007; 66: 304-309Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar on the effectiveness of double-balloon enteroscopy (DBE) in patients with obscure GI bleeding (OGIB) and a previously positive finding on capsule endoscopy (CE).2Nakamura M. Niwa Y. Ohmiya N. et al.Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding.Endoscopy. 2006; 38: 59-66Crossref PubMed Scopus (245) Google Scholar Performing DBE after a positive CE supports the appropriateness of the algorithm for OGIB.3Pennazio M. Eisen G. Goldfarb N. ICCE Consensus for obscure gastrointestinal bleeding.Endoscopy. 2005; 37: 1046-1050Crossref PubMed Scopus (154) Google Scholar However, the question remains: How is the information obtained from CE applied to DBE? The location of the lesion as found by CE is sometimes difficult to precisely apply to the DBE procedure. Because the effectiveness of therapeutic DBE is not shown until the proper route for the first DBE has been chosen, the selection technique is important. Use of the proper route will lead to earlier patient recovery, effective management, and lower costs. Kaffes et al1Kaffes A.J. Siah C. Koo J.H. Clinical outcomes after double-balloon enteroscopy in patients with obscure GI bleeding and a positive capsule endoscopy.Gastrointest Endosc. 2007; 66: 304-309Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar stated that antegrade DBE was used when the lesion was within the proximal two thirds, as determined by small-bowel transit time. Gay et al4Gay G. Delvaux M. Fassler I. Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy.Endoscopy. 2006; 38: 49-58Crossref PubMed Scopus (232) Google Scholar recommended antegrade DBE when the lesion was within three quarters of the oral side. However, DBE via the antegrade approach causes more complications. Moreover, with continuing active bleeding, CE may advance more rapidly after passing the bleeding lesion, and thus the ratio between the time to the lesion and small-bowel transit time may be skewed. Furthermore, when CE cannot reach the cecum within the test time, the location of the lesion is more difficult to identify because the time-ratio method is not helpful. In such cases, we often utilize the localization map in the workstation, the computer system, to interpret CE images. Figure 1 shows that when the lesion is in the yellow dotted circle, the antegrade approach is considered, and when it is in the red, the opposite route is preferred. However, no standard method for choosing the DBE route exists to date, and further study, exploring the precise location of lesions by CE, will be required.