How to approach the small bowel with flexible enteroscopy

Nowadays, 5 nonsurgical flexible endoscopic techniques are available for small bowel endoscopy: push enteroscopy (PE), balloon-assisted enteroscopy using 2 balloons (double-balloon enteroscopy [DBE]) or 1 balloon (single-balloon enteroscopy [SBE]), balloon-guided enteroscopy (BGE), and spiral enteroscopy (SE). PE is a cost-saving, easy, and fast procedure for the examination of the proximal jejunum, but for a deep small bowel endoscopy, the other flexible enteroscopic techniques are required. BGE does not play a considerable role in deep small bowel endoscopy. DBE is the oldest flexible enteroscopic technique. Actually, the balloon-assisted enteroscopy (BAE) techniques with one balloon (SBE) or two balloons (DBE) are the mainly used techniques. DBE has become established throughout the world for diagnostic and therapeutic examinations of the small bowel and is now used universally in clinical routine work. DBE is still regarded as the gold standard nonsurgical procedure for deep small bowel endoscopy, because it provides the highest rates of complete enteroscopy, which becomes increasingly useful. The recently introduced SE technique represents a promising method but still needs technical improvement. Larger prospective studies on SE and prospective studies comparing the 3 systems (DBE, SBE, SE) are awaited before conclusive assessments can be made.