ABSTRACT
In double-ballon enteroscopy, loop formation may hinder deep penetration and consequently the identification and treatment of a lesion. After a failed attempt of identifying the source of bleeding with a standard double-balloon anterograde enteroscopy in a 69-year-old woman with several episodes of gastrointestinal bleeding, we decided to employ a novel magnetic balloon anchoring system, Conformité Européenne Marked for use in colonoscopies and enteroscopies and US FDA approved for use in the large bowel, to reduce looping and obtain deeper penetration. This “triple balloon” approach enabled identification and treatment of a 2-mm nonbleeding vascular lesion (Yano-Yamamoto type IIb) of the mid-small bowel.
KEYWORDS: enteroscopy, small bowel bleeding, magnetic anchoring system
INTRODUCTION
Double-balloon enteroscopy, introduced for the first time in 2001,1 enables exploration of the small bowel and endoscopic treatment or sampling of lesions without the need of surgery.2 Its main indications are small bowel bleeding, Crohn's disease, or suspect of neoplasia.2,3 Small bowel length and loop configuration represent the major difficulties in trying to achieve a total enteroscopy4; as a result, a complete small bowel exploration can be achieved only in about 44% of the cases, mainly with a combined anterograde and retrograde approach, therefore limiting the detection rate.3 A possible improvement could be represented by Endorail (Endostart srl, Certaldo, Firenze, Italy), a CE Marked magnetic balloon anchoring system composed by a permanent magnet and a through-the scope balloon catheter filled with a water-based iron powder dispersion. This system has already been approved by US FDA for use in the large intestine during difficult colonoscopies, where it allows loop resolution and easier cecal intubation, and it might be a useful on-demand tool also in enteroscopy when deeper penetration is needed, effectively establishing a new endoscopic procedure: the triple-balloon enteroscopy.
CASE REPORT
A 69-year-old woman was referred to our endoscopy unit for a history of chronic iron-deficiency anemia (hemoglobin 6.8 g/dL) requiring multiple transfusions and suspected gastrointestinal bleeding. Upper endoscopy revealed a gastric antral vascular ectasia, treated with argon plasma coagulation (APC) without any significant clinical improvement. Lower endoscopy identified two 3-mm Yano-Yamamoto Type Ib angiodysplasia in the cecum, treated with APC but without clinical success. Capsule endoscopy was performed, revealing active bleeding in the distal jejunum (Figure 1). A device-assisted anterograde enteroscopy using a short double-balloon enteroscope (Fujifilm—155 cm length, 3.2 mm working channel) was performed under fluoroscopic guidance by an experienced endoscopist (>20 enteroscopies/year over 5 years); the scope was advanced for approximately 170 cm in the small bowel, but the lesion could not be reached due to loop formation, which prevented deeper penetration.
Figure 1.
Evidence of jejunal bleeding at capsule endoscopy, causing accelerated proximal small bowel transit (duodenal intubation time at 00:16:42, small bowel transit time 28%).
To address this limitation, we employed a novel magnetic balloon anchoring system, which consists of a through-the-scope balloon catheter filled with ferromagnetic fluid and anchored via an external abdominal magnet (Figures 2 and 3). This setup improves the endoscope stability and allows effective loop resolution through retraction and straightening, thereby minimizing scope slippage.
Figure 2.
Iron powder, prefilled syringe and balloon catheter. Syringe liquid is mixed with the iron powder creating a ferromagnetic water dispersion, which is subsequently injected into the through-the-scope catheter to inflate the balloon.
Figure 3.
Permanent magnet. After inflation of the balloon with the ferromagnetic fluid, the magnet is positioned on the abdomen to achieve effective anchoring.
We performed a second anterograde enteroscopy using the same scope and the magnetic balloon anchoring system. The scope was advanced using the standard double-balloon technique. Upon loop formation, the magnetic balloon was inflated under fluoroscopic guidance and magnetically anchored to the abdominal wall, in conjunction with the overtube and scope balloons, applying the external magnet under fluoroscopy over the abdominal projection of the magnetic balloon, to minimize the distance between them; effective magnetic interaction was confirmed by a decrease in homogeneity of the ferromagnetic fluid within the balloon.
This triple-anchoring approach enabled a more efficient loop resolution through retraction and straightening. After loop resolution, the magnetic balloon was deflated and removed, and the scope advanced using standard techniques. This sequence (Figures 4 and 5) was repeated 7 times, with a penetration of about 250 cm into the small bowel in just 75 minutes. We identified and treated with APC a 2-mm nonbleeding vascular lesion (Yano-Yamamoto type IIb) (Figure 6). At 2-week follow-up, hemoglobin level was stable at about 9 g/dL without any sign of gastrointestinal bleeding.
Figure 4.
Fluoroscopic view of the sequence. (A) Loop formation; (B) balloon catheter insertion and filling with ferromagnetic fluid; (C) magnet anchoring; and (D) loop resolution.
Figure 5.
Endoscopic view of the through-the-scope catheter before (A) and after (B) balloon inflation.
Figure 6.
A 2-mm type IIb Yano-Yamamoto lesion.
DISCUSSION
To our knowledge, this is the first reported case of a double-balloon enteroscopy enhanced by a magnetic balloon anchoring system—the “triple balloon enteroscopy.” The main advantages of this triple-balloon approach are rapid and repeated loop resolution, resulting in a reduction in procedure time and a deeper and more efficient small bowel exploration, and improvement of scope stability, particularly during argon plasma coagulation. Furthermore, the use of a short enteroscope facilitated technical maneuvers during the procedure.
The main contraindications are the presence of permanently or semi-permanently implanted active medical devices (e.g., orthopedic implants, cardiac pacemakers or defibrillators, drug pumps, neurostimulators, cochlear implants) or presence of ferromagnetic implanted medical devices (e.g., vascular stents, aneurysm clips) or foreign bodies; the main limitation is severe obesity, as a thicker subcutaneous tissue reduces the effect of the transabdominal magnetic field.
Considering that this new technique requires only 2 additional steps compared with standard double-balloon enteroscopy—ballon inflation with ferromagnetic fluid and external abdominal magnet anchoring—we believe that an experienced endoscopist could use this device effectively after approximately 5 procedures.
This case supports the clinical potential of magnetic balloon technology in enteroscopy, particularly in complex or incomplete procedures, improving both diagnostic and therapeutic outcomes and leading to optimization of procedure time and overall cost reduction.
In conclusion, we described a potential identification of a new and innovative technique for diagnosis and treatment of small bowel diseases, but more studies are needed to assess advantages and limitations of this newborn endoscopic procedure: the triple balloon enteroscopy.
DISCLOSURES
Author contributions: P. Minerba: conception and drafting of the manuscript. G. Rossi, C. Rosa, MI Parzanese: drafting and critical revision of the manuscript. C. Alvisi: identification of the case, critical revision of the manuscript for important intellectual content. All authors gave final approval of the version to be published and agree to be held accountable for the integrity of the work. C. Alvisi is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Previous presentation: This case report was presented as a poster at the ACG 2025, Phoenix (AZ), October 24–29, 2025.
ABBREVIATIONS:
- APC
Argon Plasma Coagulation
- CE
Coformité Européenne
- FDA
Food and Drug Administration
- SBTT
Small Bowel Transit Time
- US
United States of America
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