European Society of Gastrointestinal Endoscopy (ESGE) Guidelines: flexible enteroscopy for diagnosis and treatment of small-bowel diseases.

Until recently, large parts of the small bowel were not accessible with nonsurgical endoscopic techniques. In this scenario, the advent of video capsule endoscopy and balloon−assisted ente− roscopy represented a major breakthrough. Although capsule endoscopy is a safe method that may provide imaging of the entire small bowel, major drawbacks are that biopsy sampling and endoscopic treatment cannot be performed; moreover, in many cases interpretation of nonspe− cific findings remains a concern. In contrast to capsule endoscopy, flexible enteroscopy with push enteroscopy or balloon−assis− ted enteroscopy is labour−intensive and more invasive but allows real−time−controlled observa− tion with the option for tissue sampling and endoscopic treatment. Push enteroscopy was established during the 1980 s but due to excessive loop formation it allows only limited visua− lization of the small intestine. This limitation has been overcome by the invention of balloon− assisted enteroscopy, which may permit imaging of the entire small bowel by threading it onto the overtube, thereby minimizing looping and maximizing insertion. Initially, a double balloon enteroscopy (DBE) system was developed by Yamamoto and colleagues in 2001 [1]. This system has rapidly gained an established role in small−bowel investigation and therapy and is widely applied in clinical practice. Importantly, besides small−bowel endoscopy the DBE technique can be applied for additional indications, for example difficult colonoscopies, for gaining access to the pancreatic and biliary tract in patients with a surgically modified gastrointestinal tract, and access to the stomach in patients after bariatric surgery. Very recently, another balloon−assis− ted enteroscopy device with only one balloon at the tip of the overtube was introduced as the single balloon enteroscopy (SBE) system. The present report constitutes a guide to the clinical application of flexible enteroscopy sys− tems (push enteroscopy, DBE, and SBE) in the small bowel, based on published findings as well as personal experience of the authors (l" Table 1). Recommendations concerning DBE are partially derived from a consensus that was developed during the 2nd International Conference on DBE in Berlin, 14 ±15 June 2007.