THE FELLOWS’ CORNER Navigating beyond the ligament of Treitz: an introduction to learning enteroscopy Gastroenterologists are often faced with the task of introducing new techniques and technology. Various ad- vances in technology have brought the diagnosis and treatment of small-bowel disease within our reach and into everyday practice. In this month’s Fellows’ Corner, Drs. Michael Schafer and Simon K. Lo have shared some advice for fellows (and those in practice) wanting to train in advancing the endoscope beyond the ligament of Treitz. Juan Carlos Bucobo, MD Fellows’ Corner Editor Interventional Endoscopy Fellow Cedars-Sinai Medical Center Los Angeles, California USA Since the introduction of fiberoptic instruments in the 1970s, endoscopic examination of the esophagus, stomach, duodenum, and colon have become cornerstones in the diagnostic and therapeutic armamentarium of gastroenterol- ogists. Training gastroenterology fellows in the indications, techniques, and possible complications of GI endoscopy make up a large portion of the fellowship experience. Until recently, however, examination of the small intestine beyond the reach of a diagnostic gastroscope was limited to only rudimentary diagnostic (primarily radiologic) tests that of- fered very few therapeutic options. Wireless capsule endoscopy, introduced in 2001, enabled the gastroenterologist to explore the small bowel with pre- viously unheard-of accuracy. Although truly a breakthrough technology, capsule endoscopy remains a purely diagnostic entity, limiting its role. Newer techniques and technologies, including single- balloon enteroscopy (SBE) and double-balloon enteroscopy (DBE) as well as spiral enteroscopy, have allowed us to examine the small intestine first hand. For the first time, gastroenterologists not only can diagnose, but can treat pa- thology that was previously only accessible to the surgeon. With the introduction of any new technology, the ques- tion of who should implement these techniques and use these new tools is often a cause of much debate. Our GI societies are delegated with the task of establishing practice guidelines in the proper use and credentialing of these tech- niques. How should these technologies be implemented? Which patients should be treated? Perhaps most importantly, who should perform the procedures and how should they be trained? These are questions that are still being answered. EXAMINATION OF THE SMALL BOWEL Small-intestinal bleeding is the most common indication for examination of the small intestine. 1 In fact, as many as 5% of patients presenting with GI bleeding will have a source beyond the ligament of Treitz. 2 Obscure GI bleeding, abnor- mal small-bowel radiographic findings, abnormal capsule endoscopy results, refractory celiac disease, retained foreign bodies, and Crohn’s disease are other major indications for enteroscopy. 3 PUSH ENTEROSCOPY Most endoscopists’ experience with enteroscopy is lim- ited to push enteroscopy. Because there is no need for specialized equipment (either a pediatric colonoscope or standard enteroscope can be used), the technique is ac- cessible to almost all gastroenterologists. Most experi- enced endoscopists are capable of reaching the proximal jejunum, but the examination rarely reaches the mid- jejunum. 4 Gastroenterologists are typically trained in push enteroscopy as a part of a general fellowship, as an ex- Copyright © 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.02.045 Key Points ● Enteroscopy skill sets are more difficult to acquire than standard endoscopy, requiring additional specialized training. ● Training in enteroscopy may be best integrated into a fourth-year endoscopy fellowship. ● No longer viewed as a fringe procedure, capsule enteroscopy requires a high-level of proficiency and accuracy in its reading and interpretation. www.giejournal.org Volume 71, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY 1029