Small-bowel neuroendocrine tumours (SB-NETs) are typically small and multifocal, often eluding detection on cross-sectional imaging, particularly when multiple and/or of diminutive size. Accurate localisation and assessment of disease extent are crucial for staging and optimal management, especially when surgery is being considered (1) . This study aimed to assess the contribution of double-balloon enteroscopy (DBE) to diagnosis, staging, lesion localisation and management-planning in patients evaluated for SB-NETs.

All DBE procedures performed between July 2023 and October 2025 for suspected, or known SB-NETs were retrospectively reviewed. Data collected included: demographics, surgical anatomy, multidisciplinary team (MDT) discussion, lesion detection, multifocality, tattoo marking, alternative diagnoses and subsequent management decisions.

Twenty-four patients were included. Median age was 59-years; 54.1% were women, and 29.1% had surgically-altered gastrointestinal anatomy. Pre-procedural MDT discussion occurred in 79.1% of cases. The retrograde route was used in 14 patients (58.3%). DBE identified lesions suspicious for SB-NET in 18/24 patients (75%). Multifocal disease was detected in 6/18 patients (33%). Tattoo marking was performed in 16/18 lesions (88.9%). DBE findings led to surgical referral and definitive management in 12/24 patients (50%). In 3/24 patients (12.5%), DBE identified benign or alternative pathology (lipoma, leiomyoma, primary paraganglioma) rather than NET. In patients investigated for small-bowel bleeding, DBE distinguished NET-related bleeding from unrelated sources in those with a history of SB-NET.

DBE added significant value in the assessment and diagnosis of SB-NETs by enabling direct lesion visualisation, targeted tissue sampling, confirmation and extent of multifocality and the detection of additional lesions not identified on imaging. It further supported management by providing precise preoperative localization through tattoo marking and subsequent mapping disease extent. DBE refined diagnosis when imaging was inconclusive and avoided misclassification when benign alternative pathology was present. By informing MDT discussions and guiding surgical strategy in half of the cases, DBE served as an integral element of the SB-NET diagnostic and management pathway.