multiple carcinoid tumors of the small intestine are rare and are very difficult to detect preoperatively . a 75-year - old woman in whom the bleeding focus could not be found by upper and lower endoscopy and abdominal ct was admitted for evaluation of anemia . we examined the patient with total double - balloon endoscopy ( dbe ) and located multiple submucosal tumors . we report a case of a successful laparoscopic operation for multiple carcinoid tumors in the small intestine without intraoperative endoscopy . total digestive tract observation using dbe tumors of the small intestine account for 1% to 2% of all gastrointestinal neoplasms ( only 0.3% of all neoplasms ) . however , the incidence of small intestine cancer has increased dramatically over the past 30 years , and the increase in carcinoid tumors has been largely responsible . carcinoids of the ileum account for 15.4% of all gastrointestinal carcinoids   and are multicentric in 2030% of patients . the lack of signs and symptoms , lack of definitive preoperative diagnostic tests , and the variable efficacy of available tests make small intestine tumors difficult to diagnose . the recent development of capsule endoscopy ( ce ) and double balloon endoscopy ( dbe ) has improved diagnostic capabilities for the small intestine . we report the first case of multiple carcinoid tumors of the small intestine preoperatively diagnosed by dbe and treated with laparoscopic surgery . a 75-year - old woman was referred to our hospital with melena and severe anemia ( hemoglobin ( hb ) 7.2 g / dl ) . she had a history of stroke at age 59 years , and was being treated with antiplatelet therapy at the time of admission to the referring hospital . at that hospital , the source of gi bleeding was not revealed by upper and lower gastrointestinal endoscopy examination , abdominal computed tomography ( ct ) , or ultrasound ( us ) . through radiological enteroclysis , an elevated lesion was found in the ileum , which was suspected to be a submucosal tumor and measured 15 mm in diameter . after 2 months at the referring hospital , she was admitted to our hospital for a thorough investigation of the small intestine . physical examination revealed her abdomen to be soft and flat without any pain or tenderness . results of blood tests were as follows : hb 11.3 g / dl ( normal : 11.115.2 g / dl ) , red blood cell count 418 10/ml ( normal : 380540 10/ml ) , and hematocrit 35.3% ( normal : 35.645.4% ) . we then examined the patient with peroral dbe ( en-450p5 : fujifilm medical co. , ltd . , a tumor was located about 250 cm from the ligament of treitz and measured 8 mm in diameter ( figure 1 ) . histologic examination of the biopsy sample obtained by endoscopy confirmed the diagnosis of a carcinoid tumor . the tumor was composed of small uniform epithelial cells , which stained positively for chromogranin a and synaptophysin . another tumor detected through peranal dbe was located about 110 cm from the ileocecal valve and measured 15 mm in diameter . also , other small tumors were detected that measured 3 mm and 5 mm in diameter and had a relatively smooth surface , similar to a submucosal tumor . these small tumors were diagnosed as carcinoid tumors by endoscopic findings , whereas histologic examination could not make this diagnosis . the largest tumor had ulcerations , which could account for the gi bleeding ( figure 2 ) . the patient underwent partial resection of the small intestine by laparoscopic surgery ( resected portion : 23.8 cm ) . she had already undergone a preoperative total small intestinal examination using dbe ; therefore , it was not necessary to perform intraoperative endoscopy . the resected specimen contained tumors measuring 1410 mm , with central ulceration ( figure 3 ) , 2.86 mm and a tumor 3 mm in diameter . microscopically , the tumors were composed of small uniform epithelial cells ( figure 4b ) , which stained positively for chromogranin a and synaptophysin ( figure 5 ) . no metastases were found in the regional lymph nodes , and the surgical margins were negative for tumor cells . follow - up dbe was performed 18 months later , and there was no sign of recurrence in the small intestine . this is the first report of laparoscopic surgery without the use of intraoperative endoscopy for multiple carcinoid tumors of the small intestine , which was possible because the tumors were diagnosed before surgery by dbe . carcinoid is the second most common malignancy , accounting for approximately 2025% of all small intestine lesions . carcinoid tumors are more common in the ileum ( most within 60 cm of the ileocecal valve ) than in the jejunum or duodenum , and lesions may be multiple and/or metastatic ( liver and lungs ) at the time of diagnosis because one fourth of carcinoid tumors in the small intestine are multiple . on the guideline , by far the majority of small intestinal neuroendocrine tumors ( nets , including carcinoid ) are malignant in nature . whether liver metastases are present or not , resection of the primary tumor is appropriate to cure or to delay progression that would otherwise endanger the small bowel . carcinoids of the rectum , stomach , and duodenum generally are found by endoscopy at an early stage , whereas carcinoid tumors of the small intestine usually are discovered after resection of the small intestine for symptoms of obstruction or during exploration of the small intestine in search of a primary tumor after distant metastases have been found [ 2,912 ] . through conventional imaging techniques ( e.g. , ct , us , double contrast barium study ) , few tumors of a small diameter are identified . currently , with advancement in methods of ce , small intestine tumors can be located . ce had a high diagnostic yield of 45% for identification of primary small intestinal carcinoid tumors . however , it remains purely a diagnostic procedure at present because it is not suitable for histological diagnosis and procedures . for this reason , if laparoscopic surgery is performed in a patient who was diagnosed as having multiple carcinoid tumors of the small intestine , it is usually necessary to perform intraoperative endoscopy to confirm that the lesion is a carcinoid tumor . it is notable that in reporting the results of their study , m. bellutti et al . suggested that intraoperative endoscopy is a potential gold standard for nets . on the other hand a submucosal tumor of the ileum or the jejunum was detected by dbe in 7 of 12 patients ( 58% ) with suspected carcinoid syndrome . in addition , tumor marking using injection of ink for the exact location during dbe has been helpful for subsequent operations , especially for laparoscopic resection . by utilizing dbe , we were able to locate the multiple ileal tumors and to perform laparoscopic surgery without intraoperative endoscopy in the patient reported here . dbe is a safe procedure , with low complication rates even when therapeutic maneuvers are performed . as only dbe allows direct , controlled visualization of small intestine tumors and their histological confirmation preoperatively , it may be considered the gold standard for the diagnosis of such tumors . dbe is extremely useful to detect and diagnose asymptomatic small lesions in the small intestine . based on the case presented here , we recommend total digestive tract observation using dbe before performing laparoscopic operation for multiple tumors of the small intestine .
summarybackgroundmultiple carcinoid tumors of the small intestine are rare and are very difficult to detect preoperatively.case reporta 75-year - old woman in whom the bleeding focus could not be found by upper and lower endoscopy and abdominal ct was admitted for evaluation of anemia . 
 we examined the patient with total double - balloon endoscopy ( dbe ) and located multiple submucosal tumors . 
 the multiple carcinoid tumors were resected successfully under laparoscopy.conclusionswe report a case of a successful laparoscopic operation for multiple carcinoid tumors in the small intestine without intraoperative endoscopy . 
 total digestive tract observation using dbe is very useful for laparoscopic operation for multiple tumors in the small intestine .