Spirals and balloons: a new chapter in deep enteroscopy?

Seung Min Hong; Dong Hoon Baek

doi:10.5946/ce.2025.133

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Editorial Spirals and balloons: a new chapter in deep enteroscopy?: Seung Min Hong, Dong Hoon Baek; DOI: https://doi.org/10.5946/ce.2025.133
Published online: July 4, 2025

Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea

Correspondence: Dong Hoon Baek Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea E-mail: dhbeak77@gmail.com

• Received: April 28, 2025 • Revised: May 10, 2025 • Accepted: May 17, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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REFERENCES

See the article "Double-balloon is equal to motor-spiral-enteroscopy in a german prospective, randomized trial".

Motorized spiral enteroscopy (mSPE) has emerged as an innovative approach aimed at addressing the procedural challenges inherent to balloon-assisted enteroscopy (BAE), offering potential advantages in terms of procedural speed and operator convenience. Although the concept of mSPE was introduced over a decade ago,¹ its integration into routine clinical practice remains relatively limited, and ongoing studies continue to refine our understanding of its safety profile and clinical efficacy.²

In this issue of Clinical Endoscopy, Knabe et al.³ reported the results of the first prospective randomized study comparing mSPE and double-balloon enteroscopy (DBE) in a real-world setting. The study evaluated the performance and safety of both modalities in 48 patients (DBE, n=25; mSPE, n=23) who underwent small bowel enteroscopy. The overall mean procedure time was 59 minutes, with no significant difference between the DBE and mSPE groups (63 minutes vs. 54 minutes, respectively; p=0.212). The complete enteroscopy rates were comparable—41.7% of DBE cases and 41.1% of mSPE cases—when evaluated among patients who were planned to undergo complete enteroscopy. Although mSPE allowed a shorter time to achieve a diagnosis (mean, 19.4 vs. 33.4 minutes), DBE yielded a significantly higher diagnostic rate (68% vs. 35%). Therapeutic success rates were uniformly high across both modalities. The safety profiles were comparable, with one perforation reported in the mSPE group and minor mucosal injuries observed in both groups. Prior abdominal surgery did not significantly affect the outcomes. These findings are consistent with those of previous reports, including a case-matched study by Chan et al.,⁴ which demonstrated no significant differences in technical (DBE 98.4% vs. mSPE 96.8%, p=0.62) or therapeutic success rates (DBE, 62.8% vs. mSPE, 52.9%; p=0.62). Similarly, a recent systematic review and meta-analysis reported comparable technical and therapeutic outcomes between the two modalities, with both showing low rates of serious adverse events.⁵ Collectively, these findings support the notion that mSPE can achieve clinical outcomes similar to those of the well-established DBE, reinforcing its role as a viable and effective alternative for deep small bowel evaluation.

Previous studies assessing mSPE have predominantly focused on insertion times rather than on the precise time to achieve a diagnosis. In a single-center prospective trial, Beyna et al.⁶ reported a median antegrade insertion time of 26 minutes (range, 15–110 minutes), whereas a separate feasibility study demonstrated a median insertion time to maximal depth of 25 minutes (range, 3–122 minutes).⁷ Although these findings indicate that rapid small bowel advancement is achievable with mSPE, none of the available studies have directly measured the time from scope insertion to a definitive diagnosis. As such, insertion time serves only as a surrogate marker of procedural efficiency rather than a diagnostic confirmation. Similarly, for cases in which an initial diagnosis was not achieved, the endpoint of the time to complete enteroscopy was not directly assessed in prior literature. Instead, performance was evaluated based on complete enteroscopy rates. In an early feasibility trial, complete enteroscopy was achieved in approximately 70% of patients when both antegrade and retrograde approaches were combined, whereas the success rate via the antegrade route alone was substantially lower at approximately 10.6%.⁷ In contrast, the current randomized trial provides valuable new data by evaluating diagnostic efficiency as a primary endpoint rather than merely procedural speed, thereby offering a clinically more relevant comparison between mSPE and DBE.³ While the study by Knabe et al.³ offers valuable comparative data between mSPE and DBE, its single-center design and small sample size limit the generalizability of its findings. Potential differences in operator expertise and diagnostic criteria may also affect interpretation. Future multicenter trials and subgroup analyses based on lesion characteristics or surgical histories are essential to further define the role of mSPE in clinical practice.

While an earlier feasibility study by Beyna et al.⁷ demonstrated a high diagnostic yield of 74.2% and rapid insertion times across a cohort of patients without prior abdominal surgery, the present randomized trial by Knabe et al.³ revealed a markedly lower diagnostic yield for mSPE (35%) than for DBE (68%). This discrepancy likely reflects the inclusion of a more complex patient population, including individuals who had previously undergone abdominal surgeries and those with diagnostically challenging small bowel pathologies, as well as those who underwent procedures performed at tertiary referral centers. Several factors may explain the superior performance of DBE, including its balloon-assisted stability, enabling meticulous mucosal inspection; the extensive experience of participating endoscopists with DBE; and the high proportion of patients with prior abdominal surgeries complicating small bowel advancement.⁸ Taken together, these considerations likely contributed to the higher diagnostic yield observed with DBE in this trial. Clinically, DBE should remain the preferred modality for diagnostic evaluation of the small bowel in complex cases, whereas mSPE, despite its procedural advantages such as faster insertion times, may be better suited for selected, less complex cases.

Safety considerations remain paramount as the mSPE technology continues to evolve.⁹ While DBE has an extensively validated safety profile supported by more than 1,400 peer-reviewed publications, the safety profile of mSPE remains to be fully established. However, the study by Knabe et al.³ demonstrated that mSPE maintained an acceptable safety profile with only one serious adverse event observed. Reflecting the critical importance of safety in small bowel endoscopy, the European Society of Gastrointestinal Endoscopy has established benchmark adverse event rates at ≤1% for purely diagnostic BAE and ≤5% for BAE with therapeutic interventions.¹⁰ Although the first-generation mSPE system was withdrawn from the global market in 2023 following a fatal complication during overtube retrieval, Knabe et al.³ reported only one conservatively managed perforation, thereby supporting the continued use of mSPE with appropriate refinement and safety measures.

In conclusion, the first head-to-head randomized trial comparing mSPE and DBE highlights that both techniques are effective for deep small bowel evaluation, each offering distinct strengths. Individualized selection based on patient characteristics, procedural goals, and institutional expertise is crucial. As technology matures and real-world experience expands, mSPE may assume a complementary role alongside the established balloon-assisted techniques in the evolving landscape of deep enteroscopy.

Conflicts of Interest

Dong Hoon Baek is currently serving as a member of the publication committee for Clinical Endoscopy. He was not involved in peer reviewer selection, evaluation, or the decision process for this article. Seung Min Hong has no potential conflicts of interest to declare.

Funding

None.

Author Contributions

Conceptualization: BDH; Data curation: all authors; Formal analysis: all authors; Investigation: all authors; Methodology: SMH; Project administration: all authors; Resources: SMH; Supervision: BDH; Validation: all authors; Visualization: all authors; Writing–original draft: SMH; Writing–review & editing: all authors.

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