Double-balloon enteroscopy (DBE) is an essential modality for diagnosing and managing small-bowel disorders, offering advantages over other investigations through direct visualisation, targeted biopsy, endotherapy and marking of lesions in need of further management. With rising small-bowel referrals and increasing case complexity, understanding real-world DBE performance is key to optimising service delivery and guiding clinical pathways. This study aimed to describe patient characteristics, procedural indications, diagnostic findings and clinical outcomes of DBE performed within a large tertiary small-bowel unit.

All DBE procedures performed at the Royal Free Unit for Endoscopy between July 2023 and October 2025 were analyzed through a prospectively maintained consecutive database. Patient demographics, indications, procedural parameters, diagnostic findings and clinical outcomes were recorded. Descriptive statistics were used to summarize the cohort.

Across the study period, 359 DBE procedures were performed in 262 patients. Median age was 64-years (IQR 51–72); 148 patients were women (41.2%). The most common American Society of Anaesthesiologists (ASA) classification score was 2 (56.5%), followed by ASA 3 (19.2%); 80.5% of the procedures were performed under conscious sedation with median doses of midazolam and fentanyl  5mg and 100mcg, respectively. The main indications for DBE were small-bowel bleeding/iron-deficiency anemia (49.6%), small-bowel tumors or polyps (31.5%), suspected or established Crohn’s disease (8.4%), stricture dilatation (5.6%), and foreign-body retrieval (2.8%). Over one-third of patients (34.8%) were on anticoagulant or antiplatelet therapy; surgically altered anatomy was present in 73 patients (20.3%). A preceding small-bowel investigation—CT/MR enterography or capsule endoscopy—had been performed in 90.6% of cases. Most referrals originated from other centers or outpatient specialty clinics (74.4%).

The insertion route was anterograde in 72.1% and retrograde in 27.9%. DBE was completed as intended in 95.8% cases, and a clinical impression explaining the patient’s presentation was achieved in 96.4%. Small-bowel lesions were detected in 79.4% of procedures, and therapeutic intervention was required in 60.2%, with a high technical success rate (98.6%). Repeat DBE was required in 19.5% of cases. A total of 13.4% of patients required subsequent enteroscopy via the alternative route, and among these, pan-enteroscopy was achieved in 33.3%. Overall pan-enteroscopy was achieved in 9.2% of all procedures. The overall complication rate was 0.8% (3/359). Trainee involvement occurred in 92.8% of procedures.

This two-year cohort demonstrates that DBE is employed across a broad clinical spectrum, with small-bowel bleeding and suspected neoplastic pathology representing the leading indications. Technical success and diagnostic yield was high, and the vast majority of procedures resulted in a clear clinical impression, underscoring the role of DBE as an effective problem-solving instrument, particularly following capsule endoscopy or cross-sectional imaging. Therapeutic intervention was frequently required and was highly successful, while complication rates remained low. These findings highlight the central role of DBE within a structured, multidisciplinary small-bowel service and its substantial contribution to both diagnosis and treatment in complex small-bowel disease.