2. Small-bowel tumors(SBTs) – relatively rare - 3~5% of all GI tumors - difficult access before the introduction of capsule endoscopy in 2000 Obscure GI bleeding(OGIB) or other indications 으로 CE 를 하는 환자의 3~9% 에서 SBTs 발견 Capsule Endoscopy(CE) 의 contraindication - Stenotic symptoms Introductions

3. First introduced by Yamamoto et al in 2001 access to the entire small bowel endoscopic intervention  APC, polypectomy, and balloon dilatation More indication including stenotic symptoms

4. Retrospective analysis of cross-sectional case series In 2005, 7 major Japanese institutions established the Japanese Study Group for Double-Balloon Endoscopy(JSG-DBE) The JSG-DBE was organized by the following 7 institutions: Division of Gastroenterology, Jichi Medical School, Tochigi Division of Gastroenterology, Nippon Medical School, Tokyo Department of Gastroenterology, Nagoya University Hospital, Nagoya Department of Gastroenterology, Kyoto University Hospital, Kyoto Department of Gastroenterology, Hiroshima University Hospital, Hiroshima Department of Gastroenterology, Fukuoka University Hospital, Fukuoka Department of Internal Medicine, Kyushu University Hospital, Fukuoka

5. DBE Using 2 high-resolution video endoscopes Fujinon EN-450P5/20 Fujinon EN-450T5 Both with flesible 145cm overtubes

7. Suspected presence of SBTs - Peutz-Jeghers syndrome - familial adenomatous polyposis - malignant lymphoma - radiographic exam or CE suggested the presence of an SBTs Others - abnormal bowel habits

13. SBTs were found in 144 of 1035 subjects (13.9%) - 62 malignant tumors (43.1%) + 82 benign tumors (56.9%) Much higher than recent CE studies Why? 1.our database includes 119 patients diagnosed as having intestinal ds. ; tumors, such as PJS and FAP 2. differences in indications for small-bowel examination ; also included 124 subjects with stenotic symptoms 3. the most common indication was OGIB ; in present study, SBT was found in 8.5% who underwent DBE for OGIB evaluation

14. The most common tumor found in the present study ; malignant lymphoma (21.5%) > GIST (18.8%) > PJS (15.3%) > FAP (9.7%) > carcinoma (9.7%) > metastasis and/or invasion (9.0%) > carcinoid (2.8%). This distribution does not correlate well with SBT studies conducted by CE. The largest study from 29 centers in 10 European countries among 124 SBTs found ; GIST (32.1%) > adenocarcinoma(20.5%) > carcinoid (15.2%) Why the distribution is different? 1. differences in the indications for each procedure 2. differences in ethnic group  The largest database until now, 1260 SBTs reported between 1980 and 2000 in the Connecticut Tumor Registry, carcinoid (417 cases [33%]) > adenocarcinoma (341 cases [27%]) > lymphoma(205 cases [16.3%]) Although carcinoid seems fairly predominant among SBTs in white patients, it was not so in our database in Japan

15. Complications 3 times higher than other investigators Why? 1.Biopsies or therapeutic procedures 2.Counted minor events such as mucosal injuries and hyperventilation 3.Includes every single case since the first introduction of DBE

16. Conclusion 144 of all 1035 patients who underwent DBE had SBTs (13.9%). In most of these cases, diagnosis was made through DBE, and, in some cases, treatment was performed directly. There is no doubt that DBE is one of the most appropriate devices to approach a suspected SBT