What is the learning curve associated with double-balloon enteroscopy? Technical details and early experience in 6 U.S. tertiary care centers

Background Double-balloon enteroscopy (DBE) allows therapeutic maneuvers in previously unreachable segments of the small bowel. Performance parameters for this new endoscopic procedure have not been described in the United States. The purpose of this study was to determine the learning curve in 6 U.S. tertiary centers. Methods We collected data from DBE procedures performed between August 2004 and 2005. Performance parameters from each center's initial 10 cases were compared with subsequent examinations. Results A total of 237 DBE procedures were performed on 188 patients. A total of 130 patients (69%) presented with obscure GI bleeding. DBE was introduced by mouth in 149 cases (63%), by rectum in 77 cases (33%), and through a stoma in 6 patients (2.5%). The mean duration and standard deviation was 109.1 ± 44.6 minutes for the first 10 cases and 92.4 ± 37.6 minutes for subsequent cases ( P = .005), but this did not change when rectal DBE procedures were analyzed. There was no change in mean depth of insertion, but the mean fluoroscopy time declined significantly ( P = .025). DBE led to a diagnosis in 81 patients (43%), including 7 with biopsy-proven small-bowel tumors. Of the patients, 78% had prior capsule endoscopy (CE), with significant agreement between DBE and CE (k = 0.74). Diagnostic and therapeutic maneuvers were performed in 64% of cases. One perforation occurred (0.4%). Per-rectal cases failed to reach the small bowel in 24 cases (31%). Conclusions There was a significant decline in overall procedural time and fluoroscopy time after the initial 10 DBE cases. There was no improvement in performance parameters when DBE was performed via the rectal approach, despite increased, but limited, operator experience. DBE appears to be reasonably safe and effective in evaluating and treating small-bowel diseases.