Since its introduction in 2001, double-balloon enteroscopy has radically changed the approach to small bowel lesions, allowing endoscopic treatment and sampling without the need for a surgical approach [1, 2]. The most common indications for enteroscopy are small bowel bleeding, Crohn’s Disease or tumors [2, 3]. Anyway, a complete small bowel exploration can be achieved in only less than a half cases [3], and mainly with a combined anterograde and retrograde approach, due its noticeable length and loop configuration which often hinder deeper insertion [4]. As a result, the detection rate is limited, and patients frequently undergo multiple endoscopic procedures with considerable distress.
A possible improvement could be represented by a novel magnetic balloon anchoring system which consists of a permanent magnet and a through-the scope balloon catheter filled with a water-based iron powder dispersion. This system has already been approved for use during difficult colonoscopies, where it allows loop resolution and easier cecal intubation. This setup improves stability, allows easier loop resolution through retraction and straightening and minimize scope slippage. Upon loop formation, the magnetic balloon is inserted and inflated under fluoroscopic guidance and then magnetically anchored to the abdominal wall, in conjunction with overtube and scope balloons; at this point, loop resolution through retraction and straightening can be performed. After loop resolution, the magnetic balloon is deflated and removed, and the scope advanced using standard techniques. The sequence can be repeated multiple times.
We successfully employed this technique with a short enteroscope (155 cm length, 3.2 mm working channel) in two cases so far. In the first one, a 69-year-old woman with recurrent gastrointestinal bleeding underwent standard anterograde double-balloon enteroscopy but loop formation prevented the reaching of the lesion. A second anterograde approach was performed with the assistance of the magnetic anchoring system, allowing deeper penetration and treatment of a 2 mm Yano-Yamamoto type 2b non-bleeding lesion of the mid-small bowel.
In the second case, after a non-diagnostic standard anterograde double-balloon anterograde enteroscopy in a 71-year-old man with chronic iron-deficiency anaemia and a 15 mm ulcerative lesion of the proximal ileum at capsule endoscopy, this triple balloon approach allowed insertion approximately 100 cm deeper than in the previous standard procedure and biopsy of the lesion.
The magnetic ballon anchoring system might be a useful on-demand device in enteroscopy when deeper penetration is needed. It may be particularly useful in combination with a short enteroscope, which allows better manoeuvrability and stability and requires fewer medical and nursing staff. This could lead to better patient outcomes, optimization of procedure time and overall cost reduction.
The main contraindication is the presence of permanently or semi-permanently implanted active medical devices (e.g., orthopaedic implants, cardiac pacemakers or defibrillators, drug pumps, neurostimulators, cochlear implants), ferromagnetic implanted medical devices (e.g. vascular stents, aneurysm clips) or foreign bodies; a limitation is severe obesity, due to the reduction of the transabdominal magnetic field caused by a thicker subcutaneous tissue.
Our positive experiences could pave the way for a new and innovative technique for diagnosis and treatment of small bowel diseases: the “Triple Balloon Enteroscopy”. Anyway, more studies are needed to assess advantages and limitations of this new procedure.