American Journal of Gastroenterology ISSN 0002-9270 C  2007 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2007.01063.x Published by Blackwell Publishing Endoscopic Interventions in the Small Bowel Using Double Balloon Enteroscopy: Feasibility and Limitations Andrea May, M.D., Ph.D., Lars Nachbar, M.D., J¨ urgen Pohl, M.D., Ph.D., and Christian Ell, M.D., Ph.D. Department of Internal Medicine II, HSK Wiesbaden, Teaching Hospital of the University of Mainz, Wiesbaden, Germany BACKGROUND: Double-balloon enteroscopy (DBE) is a new endoscopic tool that not only allows diagnostic workup of small bowel diseases, but also makes it possible to carry out therapeutic interventions. However, for a variety of reasons, endoscopic therapy appears to be more difficult to carry out deep in the small bowel than in the upper or lower gastrointestinal tract. AIM: The purpose of this study was to evaluate the acute technical success and acute complication rate of DBE. PATIENTS: Between June 2003 and July 2006, 353 patients (152 women, 201 men; mean age 60.3 ± 17.1 yr) with suspected or known small bowel disease underwent 635 consecutive DBE procedures. The majority of the patients were suffering from midgastrointestinal bleeding (N = 210, 60%). The overall diagnostic yield was 75% (265/353) for relevant lesions in the small bowel. The overall therapeutic yield was 67% (236/353). METHODS: Endoscopic therapy was performed in 59% of these patients (139/236). All therapeutic interventions were done in an inpatient manner. The majority of the procedures were carried out with the patients under conscious sedation (N = 130, 73%); sedation with propofol was administered in 37 (20.8%) and with a combination of propofol and meperidine in 11 (6.2%) investigations. RESULTS: A total of 178 therapeutic procedures was carried out. A median of 270 cm of the small bowel was visualized using the oral route and a median of 150 cm using the anal route. The investigation time averaged 78 ± 30 minutes. The endoscopic treatments included argon plasma coagulation (APC, 102 treatment sessions), injection therapy (N = 2), a combination of APC and injection (N = 6), polypectomies (N = 46), dilation therapy (N = 18), and foreign-body extraction (N = 3). In 6/178 cases (3.4%), polypectomy (N = 2), dilation (N = 3), and implantation of a self-expanding metal stent (N = 1) could not be performed successfully for technical or anatomical reasons. Severe treatment-associated complications occurred in six of the 178 therapeutic procedures (3.4%) and 4/139 patients (2.9%), consisting of bleeding (N = 2) and perforation (N = 3) during and after polypectomy of large polyps (>3 cm in size), as well as one case of segmental enteritis after APC. CONCLUSIONS: Endoscopic therapeutic interventions can be performed safely even in the more difficult conditions of the small bowel in the majority of patients. Polypectomy of large polyps appears to be the procedure associated with the highest risk. (Am J Gastroenterol 2007;102:527–535) INTRODUCTION Intraoperative enteroscopy was for a long period the gold standard for the detection and treatment of lesions in the small bowel, with a diagnostic yield of 70–80% (1–5). Even after the introduction of wireless capsule endoscopy, intra- operative enteroscopy continued to be the method of choice for the treatment of lesions in the deep small bowel that were not accessible using push enteroscopy. However, intraopera- tive enteroscopy requires considerable time, staff, and costs and is associated with a substantial risk of complications and mortality (1–6). The new technique of double-balloon en- teroscopy (DBE), also known as push-and-pull enteroscopy (DBE)—which was introduced in 2001 by Yamamoto et al. (7), followed by our own group in Germany in 2003 (8)—has made it possible not only to inspect small bowel diseases, but also to carry out endoscopic therapeutic interventions deep in the small bowel without the need for laparotomy or la- parascopy (9–13). Only limited data have been reported to date regarding the risk of complications in DBE. Perforation and pancreatitis can occur during diagnostic DBE procedures (9–14), and two case reports have described a perforation after 527