Children’s Mercy is preparing to become one of the few institutions in the country to perform a procedure known as “Double Balloon Enteroscopy” (DBE) for children with small bowel disorders.
Listen in as Thomas Attard, MD, FAAP, FACG, Medical Director of Endoscopy Services-Division of Gastroenterology, has shared that DBE provides a more complete evaluation of the small intestine because the instrument used allows access to areas beyond the reach of conventional endoscopes.
The DBE scope provides sharp, clear, high-definition images; it can be used to biopsy tumors, remove small lesions and mark an area with dye for future surgical localization, helping a surgeon know exactly where to go.
Gastrointestinal bleeding, abdominal pain, chronic diarrhea, polyps and tumors are among the conditions that can be evaluated and treated with DBE technology.
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Double Balloon Enteroscopy
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Learn more about Thomas M. Attard, MD
Thomas M. Attard, MD
Dr. Attard is a pediatric gastroenterologist and medical director for endoscopy services at Children’s Mercy Kansas City. He received his medical degree from University of Malta Medical School and completed his residency in pediatrics from Creighton University in 1998. He completed his fellowship in pediatric gastroenterology in 1999 and then also completed a research fellow for pediatric gastroenterology and nutrition in 2001 from The John Hopkins University School of Medicine. Dr. Attard is certified in pediatrics and pediatric gastroenterology.Learn more about Thomas M. Attard, MD
Transcription:
Double Balloon Enteroscopy
Dr. Michael Smith (Host): Our topic today is double balloon enteroscopy. My guest is Dr. Thomas Attard. Dr. Attard is a pediatric gastroenterologist and medical director for endoscopy services at Children’s Mercy Kansas City. Dr. Attard, welcome to the show.
Dr. Thomas Attard (Guest): Hi. Thanks for having me here, Dr. Mike.
Dr. Smith: Sure. Let’s first talk about some of the basics of what we’re going to call “DBE”. Double balloon enteroscopy. What exactly is it and how does it work?
Dr. Attard: As you’re definitely familiar, we have been doing endoscopy, upper endoscopy meaning what we call EGD’s or esophageal gastro endoscopy, as well as lower endoscopy which we call colonoscopies, for many years in adults and, certainly, in kids. There’s always been this frustration about being able to get in the bowel that’s between how far we get from above and how far in we get from below. So, most people forget the small bowel is actually about 17 feet in length and if, you think about it, we’re only looking about maybe the first half foot from the top part and maybe a half foot from the lower part leaving you 16 feet of bowel which can have quite a bit of pathology that we never actually get to or, in any other way, look at. Through the years, as most people are aware, we’ve been doing barium studies and then we moved on to having CT scans and MR studies and then, more recently, we’ve been doing what I’ve been calling “capsule enteroscopies”. So, you swallow a pill cam. You’re probably familiar with that technique and then, the physician, the gastroenterologist, actually sees a video feed of the whole small bowel. That’s all great but it doesn’t allow you to get biopsies from whatever you’ve seen. So, the double balloon enteroscopy is really kind of the state of the art of endoscopic techniques to be able to go into the small bowel, to sample tissue that you’re interested in that may look abnormal on other studies, and to actually intervene and cure some of the conditions we deal with. For example, with [inaudible] syndrome, we get small bowel polyps that can actually transform into neoplastic from malignant polyps later on that we can actually go ahead and take out before they cause too much trouble. Double balloon enteroscopy is quite sophisticated. It’s a very long procedure compared to most other endoscopies but this kind of allows us to get into areas in which we haven’t gone there before at least.
Dr. Smith: Obviously, you have the advantage or the benefit of being able to visualize more bowel. Are there any other advantages to doing DBE?
Dr. Attard: As I said, you visualize it but you can also intervene upon it. So, you’ll know exactly where you’re going in terms of the scope. You know how far in the pathology is. If there’s something, for example, that you see but you can’t do anything about endoscopically, then you’re actually going to help the surgeon considerably by actually tattooing the area so we can actually inject some dye into the wall of the bowel and that allows the surgeon, at a later date, to actually find, at a later date, whatever lesion you are interested in on the inside to isolate it and probably resect it sooner. It does allow you a lot more, certainly a ton more, exits than conventional endoscopy used to and better diagnostic capabilities than capsule endoscopy does, at this point in time at least.
Dr. Smith: Do you see, Dr. Attard, that DBE is going to be pretty much the gold standard approach for endoscopy or are there ideal patients for this?
Dr. Attard: There are both. It definitely is the gold standard. There’s no comparison of any degree of radiologic or even real time images even true capsuled to being able to biopsy and identify a lesion. So, there’s no question that it represents the ultimate test of what’s going on. The problem is, however, that being so invasive, I don’t see it as replacing any of the other techniques. I see it as the obvious and the natural plug in to what we already are doing. So, instead of kind of quitting on finding out what’s going on after we have images or x-rays or MRI scans, we can now go a step further short of surgery, still fairly invasive of course, it is a procedure under general anesthesia and it has significant risks more than a regular endoscopy, but it allows us to kind of complete the gamut of that diagnostic work up that we are offering these patients. If they’re the ideal patient, yes, exactly as was implied by the answer is, the patient who has been worked up for what we call obscure upper GI bleeding, negative endoscopies, meaning endoscopies that failed to find a cause for bleeding in the gastrointestinal tract, perhaps negative also either MRI or capsule endoscopy or maybe difficult to interpret results. So, when you’re at your wits end, basically, with all the other studies, that’s when DBE kind of wraps it up and tells you what’s going on in the small intestine. So, the ideal patient is the one who has failed far less invasive and traditional techniques.
Dr. Smith: Children’s Mercy is still one of the few institutions that does DBE on a regular basis, correct? What’s been your experience as a clinician overall with it?
Dr. Attard: I trained in Sheffield in the U.K. with Dr. Mike Thompson to do some of these. In the United States there are, I was asked how many exactly at one point, and I don’t know exactly how many centers do this, but I’m imagining not more than five or six centers. I could be off, maybe, by one or two but I don’t think so. It is ultimately a test which I don’t think should be perhaps attempted at every center because not a lot of centers have a huge volume of patients and this is something that is clearly very operator dependent. It’s not a very straightforward procedure. It does require a fair amount of skill and that skill has to be maintained. So, if a center commits itself to doing them it’s actually doing quite a few. I do think it’s just something that fits very well with when Children’s wants to do in endoscopy. We want to be able to offer all the services and we certainly have the volume that actually made us want to develop DBE so that we can deliver better care. We also get all the unusual diagnostic challenges rather than just the straightforward issues and that does, then, require us to then go the extra mile with finding new techniques that perhaps aren’t available all over the place.
Dr. Smith: So, DBE will be a procedure that will probably stay in the hands of the highly-trained specialists at the very specialized hospitals. Is that right?
Dr. Attard: Yes. I can’t imagine it any other way.
Dr. Smith: Well, Dr. Attard, I want to thank you so much for coming on the show. And thank you for all the work that you’re doing.
Dr. Attard: Oh, thank you.
Dr. Smith: You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to ChildrensMercy.org. That’s ChildrensMercy.org. I’m Dr. Michael Smith. Thanks for listening.
Double Balloon Enteroscopy
Dr. Michael Smith (Host): Our topic today is double balloon enteroscopy. My guest is Dr. Thomas Attard. Dr. Attard is a pediatric gastroenterologist and medical director for endoscopy services at Children’s Mercy Kansas City. Dr. Attard, welcome to the show.
Dr. Thomas Attard (Guest): Hi. Thanks for having me here, Dr. Mike.
Dr. Smith: Sure. Let’s first talk about some of the basics of what we’re going to call “DBE”. Double balloon enteroscopy. What exactly is it and how does it work?
Dr. Attard: As you’re definitely familiar, we have been doing endoscopy, upper endoscopy meaning what we call EGD’s or esophageal gastro endoscopy, as well as lower endoscopy which we call colonoscopies, for many years in adults and, certainly, in kids. There’s always been this frustration about being able to get in the bowel that’s between how far we get from above and how far in we get from below. So, most people forget the small bowel is actually about 17 feet in length and if, you think about it, we’re only looking about maybe the first half foot from the top part and maybe a half foot from the lower part leaving you 16 feet of bowel which can have quite a bit of pathology that we never actually get to or, in any other way, look at. Through the years, as most people are aware, we’ve been doing barium studies and then we moved on to having CT scans and MR studies and then, more recently, we’ve been doing what I’ve been calling “capsule enteroscopies”. So, you swallow a pill cam. You’re probably familiar with that technique and then, the physician, the gastroenterologist, actually sees a video feed of the whole small bowel. That’s all great but it doesn’t allow you to get biopsies from whatever you’ve seen. So, the double balloon enteroscopy is really kind of the state of the art of endoscopic techniques to be able to go into the small bowel, to sample tissue that you’re interested in that may look abnormal on other studies, and to actually intervene and cure some of the conditions we deal with. For example, with [inaudible] syndrome, we get small bowel polyps that can actually transform into neoplastic from malignant polyps later on that we can actually go ahead and take out before they cause too much trouble. Double balloon enteroscopy is quite sophisticated. It’s a very long procedure compared to most other endoscopies but this kind of allows us to get into areas in which we haven’t gone there before at least.
Dr. Smith: Obviously, you have the advantage or the benefit of being able to visualize more bowel. Are there any other advantages to doing DBE?
Dr. Attard: As I said, you visualize it but you can also intervene upon it. So, you’ll know exactly where you’re going in terms of the scope. You know how far in the pathology is. If there’s something, for example, that you see but you can’t do anything about endoscopically, then you’re actually going to help the surgeon considerably by actually tattooing the area so we can actually inject some dye into the wall of the bowel and that allows the surgeon, at a later date, to actually find, at a later date, whatever lesion you are interested in on the inside to isolate it and probably resect it sooner. It does allow you a lot more, certainly a ton more, exits than conventional endoscopy used to and better diagnostic capabilities than capsule endoscopy does, at this point in time at least.
Dr. Smith: Do you see, Dr. Attard, that DBE is going to be pretty much the gold standard approach for endoscopy or are there ideal patients for this?
Dr. Attard: There are both. It definitely is the gold standard. There’s no comparison of any degree of radiologic or even real time images even true capsuled to being able to biopsy and identify a lesion. So, there’s no question that it represents the ultimate test of what’s going on. The problem is, however, that being so invasive, I don’t see it as replacing any of the other techniques. I see it as the obvious and the natural plug in to what we already are doing. So, instead of kind of quitting on finding out what’s going on after we have images or x-rays or MRI scans, we can now go a step further short of surgery, still fairly invasive of course, it is a procedure under general anesthesia and it has significant risks more than a regular endoscopy, but it allows us to kind of complete the gamut of that diagnostic work up that we are offering these patients. If they’re the ideal patient, yes, exactly as was implied by the answer is, the patient who has been worked up for what we call obscure upper GI bleeding, negative endoscopies, meaning endoscopies that failed to find a cause for bleeding in the gastrointestinal tract, perhaps negative also either MRI or capsule endoscopy or maybe difficult to interpret results. So, when you’re at your wits end, basically, with all the other studies, that’s when DBE kind of wraps it up and tells you what’s going on in the small intestine. So, the ideal patient is the one who has failed far less invasive and traditional techniques.
Dr. Smith: Children’s Mercy is still one of the few institutions that does DBE on a regular basis, correct? What’s been your experience as a clinician overall with it?
Dr. Attard: I trained in Sheffield in the U.K. with Dr. Mike Thompson to do some of these. In the United States there are, I was asked how many exactly at one point, and I don’t know exactly how many centers do this, but I’m imagining not more than five or six centers. I could be off, maybe, by one or two but I don’t think so. It is ultimately a test which I don’t think should be perhaps attempted at every center because not a lot of centers have a huge volume of patients and this is something that is clearly very operator dependent. It’s not a very straightforward procedure. It does require a fair amount of skill and that skill has to be maintained. So, if a center commits itself to doing them it’s actually doing quite a few. I do think it’s just something that fits very well with when Children’s wants to do in endoscopy. We want to be able to offer all the services and we certainly have the volume that actually made us want to develop DBE so that we can deliver better care. We also get all the unusual diagnostic challenges rather than just the straightforward issues and that does, then, require us to then go the extra mile with finding new techniques that perhaps aren’t available all over the place.
Dr. Smith: So, DBE will be a procedure that will probably stay in the hands of the highly-trained specialists at the very specialized hospitals. Is that right?
Dr. Attard: Yes. I can’t imagine it any other way.
Dr. Smith: Well, Dr. Attard, I want to thank you so much for coming on the show. And thank you for all the work that you’re doing.
Dr. Attard: Oh, thank you.
Dr. Smith: You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to ChildrensMercy.org. That’s ChildrensMercy.org. I’m Dr. Michael Smith. Thanks for listening.