UMass Memorial is first in state to offer Double Balloon and
This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
|Gastroenterologists David Cave, MD, PhD, and Kanishka
Bhattacharya, MD, perform minimally invasive double balloon enterscopy and
spiral enteroscopy at UMass Memorial Medical
The small intestine often was
referred to as "the dark continent" because it remained largely unexplored, due
to the limitations of conventional endoscopes. Capsule endoscopy changed all
that in 2001, giving gastroenterologists a way to visualize this 20-foot portion
of the gastrointestinal tract and localize such small-bowel conditions as
obscure bleeding. Open surgery, however, was still required to treat most of
Now, two endoscopic innovations enable physicians at UMass Memorial Medical
Center to not only visualize the entire small bowel but also perform treatments
noninvasively. With double balloon enteroscopy (DBE) and spiral enteroscopy
(SE), gastroenterologists can perform biopsies, remove polyps, cauterize
bleeding, dilate strictures and remove foreign bodies (including trapped
capsules) - all without open surgery. And in cases in which a lesion is too
large to remove endoscopically, the enteroscope can be used to mark the area -
making surgery easier and more accurate.
A novel way to visualize the small intestine
"With these procedures, we have a novel means of getting into the small
intestine and localizing problems, particularly bleeding, which we could never
do before without operating," said David Cave, MD, PhD, director of clinical
gastroenterology research at UMass Memorial. He is one of the first physicians
in the United States to work with the double balloon enteroscope and has
performed more than 100 DBE procedures at UMass Memorial since 2005. In fact,
UMass Memorial was the first hospital in the state to offer DBE and remains the
only one in Central Massachusetts with this capability.
"We do screening with the video capsule and, if we find a target, then we go
after that with DBE or SE," Dr. Cave noted. "The preeminent use is to identify
causes of obscure GI bleeding, usually after upper endoscopy and colonoscopy
have not found a cause. Bleeding from angioectasia, tumors, ulcers - these are
the most common issues that we are asked to manage.
"In addition, the device is helpful in localizing small bowel tumors," he
said. "We can mark the lesion with an India ink tattoo so the surgeon can find
Dilation of strictures causing obstruction due to Crohn's disease, surgery or
medication, such as NSAIDs, is an additional indication. "And it's been
demonstrably helpful in treating polyposis syndromes, such as Peutz-Jeghers
syndrome and juvenile polyposis," Dr. Cave added. "We can often avoid operating
on these young patients."
How DBE and SE work
Double balloon enteroscopy - also called push-pull enteroscopy - uses two
balloons, one attached to the distal end of the scope and the second attached to
a transparent tube that slides over the scope. The scope and overtube are
inserted either through the mouth or the rectum, and passed in conventional
fashion into the small bowel. Then, the scope is advanced a small distance in
front of the overtube and the balloon at the end is inflated. When inflated with
air, the balloon "grips" a section of the intestinal wall and accordions it back
over the scope. The overtube balloon is then deployed, and the enteroscope
balloon is deflated. By deflating and inflating the balloons respectively, the
enteroscope can be advanced or withdrawn - pushed and pulled - until the entire
small bowel is sleeved over the scope, like a shower curtain on a rod. The
procedure takes about 90 minutes and is performed on an outpatient basis.
In spiral enteroscopy - using a device called the Spirus Endo-Ease
DiscoveryTM SB - an overtube with a raised spiral at the distal end
is used in conjunction with a 200 cm enteroscope. As the overtube is rotated,
the small bowel is "pleated" over the scope.
"The SE procedure is only performed through the mouth right now," explained
Kanishka Bhattacharya, MD, associate director of endoscopy at UMass Memorial. He
performed the first spiral enteroscopy in Massachusetts in May, when the
Endo-Ease device received FDA clearance. "Among most of us who do both DBE and
spiral enteroscopy, we tend to use DBE for the lower part of the small intestine
and spiral enteroscopy for the upper part," he said.
"The video capsule helps to identify where in the small bowel the area of
interest is so we can plan to do the upper or lower approach," added Dr. Cave.
For the SE procedure and DBE performed from the upper end, the patient must
take nothing by mouth after dinner the night before since general anesthesia is
used. DBE from the lower end requires the standard colonoscopy preparation and
is performed under conscious sedation.
A safe procedure
"Over the next six months, we'll be comparing the spiral enteroscopy device
with the double balloon enteroscope to help determine the optimal applications,"
said Dr. Cave. "We know that they're both pretty safe procedures, with a
complication rate that's about the same as conventional endoscopy."
There also is research underway using DBE in patients who have undergone
gastric bypass surgery, he noted. "Patients who have had the Roux-en-Y procedure
for control of obesity have had their GI tracts surgically modified, making it
hard to get to the ampulla of Vater with a standard endoscope," Dr. Cave said,
referring to the ampulla formed by the union of the pancreatic duct and the
common bile duct.
"Because of the length and maneuverability of the DBE scope, it provides an
opportunity to get to these ducts. And with the increasing prevalence of
bariatric surgery, this will be more of an issue."
Drs. Cave and Bhattacharya not only are among an elite group of experienced,
early adopters of DBE in Massachusetts, but they also are recognized
internationally for their expertise. Dr. Cave was organizer and cochair of the
recent Third International Conference on Double Balloon Endoscopy in Chicago. At
that same conference, Dr. Bhattacharya was involved in training other physicians
in the procedure.
"Dr. Cave is one of the top five physicians in the world doing DBE,"
concluded Dr. Bhattacharya.