The endoscopic revolution

Written by: Dr Edward John Despott
Edited by: Cal Murphy

The small bowel is an 8 m long, floppy tube, which makes managing problems challenging. However, new endoscopic techniques are changing this. Top gastroenterologist Dr Edward Despott, a specialist in double balloon enteroscopy, is here to explain:

What are endoscopic procedures?

Endoscopy is a technique used by doctors to examine the inside of the body, particularly the digestive system. A long, thin tube called an endoscope, with a camera and a light source attached, is passed into the patient’s body via the mouth, the anus, or through an incision made by the surgeon, depending on the part of the digestive tract that needs to be examined. Endoscopes may be used simply to view the patient’s digestive tract, or to take biopsies or even perform minimally invasive procedures using attachments on the endoscope.


New endoscopic options

Until recently, the only endoscopic options available for small bowel disease included the intrinsically limited ‘push’ enteroscopy, which only allows examination of the first metre of the bowel, and the significantly invasive intra-operative enteroscopy (IOE), which carries the risks of major surgery. In recent years, the development of wireless small bowel capsule endoscopy (SBCE) and double-balloon enteroscopy (DBE) have revolutionised endoscopic investigation and management of small bowel disease by facilitating visualisation of the entire SB without the need for surgery.

These two procedures are complementary. SBCE has a diagnostic role, limited to capturing images. It is used as an image ‘scout’ to guide DBE, which in turn offers tissue biopsy as well as therapeutic options.

Double balloon enteroscopy

DBE overcomes the challenges of the small bowel’s anatomy by employing a 200cm long enteroscope, 2 balloons and a 145 cm stabilising plastic overtube. The balloons inflate and deflate in an alternating pattern, folding the intestine wall around the overtube in a ‘push-and-pull’ manoeuvre to allow the enteroscope to pass deep into the digestive tract. It can be inserted orally or rectally, facilitating complete enteroscopy. A minimally invasive alternative to IOE, it allows surgeons administer endotherapy, such as argon plasma coagulation (APC), clipping and injection therapy of vascular lesions, dilatation of strictures, polypectomy and direct percutaneous endoscopic jejunostomy (DPEJ) placement for enteral nutrition.

What are the risks of double balloon enteroscopy?

DBE is a safe and effective procedure (with overall complication rates of <1%); in appropriate cases, the endotherapy it offers has also been shown to avoid the need for operative surgery.

It is nonetheless a complex, advanced endoscopic procedure which requires years of dedicated training to be performed effectively and is only available in a handful of specialist centres in the UK and currently only three NHS centres and only one private centre in London (The Royal Free Private Patients Unit). The Royal Free DBE service is currently the most advanced and busiest DBE service in the UK with its lead clinicians (who underwent dedicated training in DBE in Japan) having over 11 years of experience in the performance of this complex procedure.


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By Dr Edward John Despott

Dr Edward Despott is a London-based consultant gastroenterologist, gastrointestinal (GI) endoscopist and trust-wide clinical lead at the Royal Free Unit for Endoscopy, Royal Free London NHS Foundation Trust. He serves as an honorary senior lecturer at the University College London Institute for Liver and Digestive Health (Royal Free Campus). His specialist interests include device-assisted enteroscopy (double-balloon enteroscopy in particular), capsule endoscopy, therapeutic colonoscopy (especially complex polypectomy, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)) and transnasal upper GI endoscopy. He is also interested in the diagnosis and management of inflammatory bowel disease (IBD) and endoscopic management of IBD-related complications (such as dilatation of small bowel and colonic strictures).

Dr Despott underwent specialist and sub-specialist GI and advanced GI endoscopy training in the North East Thames training rotation of the London Deanery School of Medicine, at the Wolfson Unit for Endoscopy, St Mark’s Hospital, and in Japan. He has received several national and international scholarships and bursaries relating to advanced GI endoscopy and has also been awarded MD(Res) (Imperial College London) for his thesis on research in this field.

Dr Despott has an on-going interest in academic GI endoscopy, authoring numerous peer-reviewed publications and book chapters and reviews and is a referee for several international GI endoscopy journals of high impact. He is also regularly invited as a speaker, live endoscopy demonstrator and hands-on trainer at national and international conferences and meetings and is a member of numerous international endoscopy guideline and education committees. He is the co-organiser of the internationally renowned Royal Free Advanced Endoscopy Masterclass, which attracts experts from around the world as a major educational event.

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