Therapeutic double-balloon endoscopy (DBE) has changed management of some small bowel diseases. Using DBE, precise control of the endoscope is possible even in the deep segment of the small intestine because the intestine can be stabilized by the overtube balloon. Endoscopic therapies used in the colon are now available in the small intestine. In this lecture, I will explain how to perform safe and effective therapeutic procedures in the small intestine focusing on three procedures, namely, hemostasis, polyp strangulation and balloon dilation.
The choice of bowel preparation and the selection of endoscopic insertion route are important for successful hemostasis of active bleeding in the small intestine. We select oral insertion without bowel preparation for active ongoing bleeding. There is almost no regurgitation of blood in the small intestine, and the blood flows to the anal side. Therefore, if the endoscope is inserted orally without bowel preparation, the bleeding point is identified near the first appearance of blood. Underwater observation is useful for identifying a bleeding point, but gel immersion endoscopy is more useful in case of rather massive bleeding.
DBE has enabled endoscopic treatment of small intestinal polyps with Peutz-Jeghers syndrome, but standard polypectomy carries the risk of bleeding and perforation, and polypectomies for many small intestinal polyps require a long procedure time and increase the risk of complications. Therefore, we introduced the crossed-clip method for strangulation of the polyps as a safer and more convenient method.
Repeated surgical resection for small intestinal strictures in Crohn's disease can lead to short bowel syndrome. Endoscopic balloon dilation is useful to avoid frequent surgical resections. We devised and commercialized the CAST hood as a device to safely and efficiently perform endoscopic balloon dilation for small intestinal strictures. I will explain how to perform endoscopic balloon dilation using the CAST hood.