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Xiao P, Zhang T, Wang Y, Xiao Y, Li X, Wang R, Li Y, Song T. Successful treatment of juvenile polyposis of infancy with sirolimus: a case report. BMC Pediatr 2024; 24:544. [PMID: 39180038 PMCID: PMC11342571 DOI: 10.1186/s12887-024-04994-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 08/06/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Infantile Juvenile polyposis of infantile (JPI) is a rare and aggressive form of juvenile polyposis syndrome (JPS) typically diagnosed in the first year of life. It often carries a poor prognosis due to chronic gastrointestinal bleeding, protein-losing enteropathy, malnutrition and immune deficiency. CASE PRESENTATION We report a case of a girl initially presented with pallor at 7 months of age, which progressed to gastrointestinal bleeding and protein-losing enteropathy. Endoscopic examination, which included both upper gastrointestinal endoscopy and enteroscopy, showed diffuse polyposis. Histopathology results indicated the presence of juvenile polyps with no dysplasia in all removed polyps. Genetic testing identified a 2.1 Mb deletion on chromosome 10q23.2q23.31 involving the phosphatase and tensin homolog (PTEN) and bone morphogenetic protein receptor type IA (BMPR1A) genes. Treatment with sirolimus initiated at 10 months of age led to a reduction in the need for blood and albumin infusions, improved patient growth, and quality of life. While the frequency of endoscopic evaluations decreased with sirolimus, regular endoscopic polypectomy every 5 months remained necessary. However, discontinuation of sirolimus resulted in polyp recurrence after 2 months due to pneumonia. CONCLUSION This case highlights sirolimus treatment can alleviate many complications of JPI, it does not eliminate the need for aggressive polypectomy.
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Affiliation(s)
- Pei Xiao
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China
| | - Ting Zhang
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China
| | - Yizhong Wang
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China
| | - Yongmei Xiao
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China
| | - Xiaolu Li
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China
| | - Ruixue Wang
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China
| | - Youran Li
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China
| | - Ting Song
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, 355 Luding Road, Shanghai, 200062, China.
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Rapamycin inhibition of polyposis and progression to dysplasia in a mouse model. PLoS One 2014; 9:e96023. [PMID: 24763434 PMCID: PMC3999114 DOI: 10.1371/journal.pone.0096023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 04/02/2014] [Indexed: 01/09/2023] Open
Abstract
Familial adenomatous polyposis (FAP) is often due to adenomatous polyposis coli (APC) gene germline mutations. Somatic APC defects are found in about 80% of colorectal cancers (CRCs) and adenomas. Rapamycin inhibits mammalian target of rapamycin (mTOR) protein, which is often expressed in human adenomas and CRCs. We sought to assess the effects of rapamycin in a mouse polyposis model in which both Apc alleles were conditionally inactivated in colon epithelium. Two days after inactivating Apc, mice were given rapamycin or vehicle in cycles of two weeks on and two weeks off. Polyps were scored endoscopically. Mice were euthanized at time points or when moribund, and tissue analyses were performed. In other studies, mice with demonstrable Apc-defective colon polyps were given rapamycin, followed by analysis of their colon tissues. The median survival of mice receiving rapamycin treatment cycles was 21.5 versus 6.5 weeks in control mice (p = 0.03), and rapamycin-treated mice had a significantly lower percentage of their colon covered with polyps (4.3+/− 2 vs 56.5+/− 10.8 percent, p = 0.001). Mice with Apc-deficient colon tissues that developed high grade dysplasia treated with rapamycin underwent treatment for significantly longer than mice treated with vehicle (15.8 vs 5.1 weeks, p = 0.003). In Apc-defective colon tissues, rapamycin treatment was linked to decreased levels of β-catenin and Sox9 at 7 weeks. Other effects of rapamycin in Apc-defectivecolon tissues included decreased proliferation and increased numbers of differentiated goblet cells at 7 weeks. Rapamycin did not affect β-catenin-regulated gene expression in cultured intestinal epithelial cells. Rapamycin has potent inhibitory effects in a mouse colon polyposis model, and mTOR inhibition is linked to decreased proliferation and increased expression of differentiation markers in Apc-mutant colon epithelium and delays development of dysplasia. Our findings highlight the possibility that mTOR inhibitors may have relevance for polyposis inhibition approaches in FAP patients.
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Bridoux V, Schwarz L, Suaud L, Dazza M, Michot F, Tuech JJ. Transanal minimal invasive surgery with the Endorec(TM) trocar: a low cost but effective technique. Int J Colorectal Dis 2014; 29:177-81. [PMID: 24196874 DOI: 10.1007/s00384-013-1789-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) is a well-established surgical approach for local excision of benign adenomas and early-stage rectal cancer. This technique is expensive and associated with a long learning curve. To avoid these obstacles, we have developed an alternative approach using the Endorec(TM) trocar (Aspide, France), which combines the advantages of local transanal excision and single-port access. The aim of this study was to evaluate the feasibility of this technique. PATIENTS AND METHODS Fourteen consecutive patients underwent transanal resection using Endorec trocar and standard laparoscopic instruments. A retrospective evaluation of the outcome of this technique was performed. RESULTS Fourteen patients were successfully operated. Rectal lesions included adenoma in ten patients, T1 adenocarcinoma in three and one T2 adenocarcinoma not amenable for abdominal surgery. The average distal margin from the anal verge was 10 cm (range 5-17 cm), and the mean diameter was 3.5 cm (range 1-5 cm). Negative margins were obtained in 13 patients (92,8 %). Median operating time was 60 min (range 20-100). The excisional area was sutured in nine patients. Median postoperative stay was 4 days (range 1-13). Postoperative complications (21 %) included postoperative fever in one patient and two patients were readmitted with rectal blood loss 6 and 15 days postoperatively and were treated with conservative measures. CONCLUSIONS Our current data show that transanal surgery using Endorec trocar is feasible and safe. Although long-term outcomes and definite indications should be yet evaluated, we believe that this new technique offers a promising alternative to TEM.
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Affiliation(s)
- Valérie Bridoux
- Department of Digestive Surgery, Rouen University Hospital, 1 rue Germont, 76031, Rouen, Cedex, France
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Sallinen V, Santti H, Liukkonen T, Hellström P, Mäkelä J, Puolakka VM, Paajanen H. Safety and long-term results of endoscopic transanal resection in treating rectal adenomas: 15 years' experience. Surg Endosc 2013; 27:3431-6. [PMID: 23494510 DOI: 10.1007/s00464-013-2885-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 02/15/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic transanal resection (ETAR) is a scarcely used technique to treat large or sessile rectal adenomas not amenable to polypectomy. The purpose of this study was to evaluate safety and long-term results of ETAR in treating rectal adenomas in three hospitals over 15 years. METHODS Patients who underwent ETAR during 1996-2010 were retrospectively analyzed with respect to patient, adenoma, and operative characteristics, earlier operations, complications, follow-up time, recurrence rates, recurrence treatment, and cancer incidence. RESULTS Ninety-two patients underwent a total 111 ETARs to treat rectal adenoma. The mean age of patients was 71 years, and the median ASA class 3. Twenty-eight patients previously had received other treatments for rectal adenoma. Incidental carcinoma was found in eight patients. Sixty-seven adenomas were treated with only one ETAR and 17 with two or three ETARs. Sixty-seven patients did not have a recurrence, whereas 14 patients had an adenoma recurrence and 3 patients developed invasive carcinoma during a mean follow-up of 30 months. Complications occurred in 14 patients; all were minor, except for one explorative laparotomy without findings. No mortalities or conversions to open surgery occurred. CONCLUSIONS ETAR is a minimally invasive and safe technique with inexpensive instrumentation to treat rectal adenomas that are not amenable to polypectomy. Adenoma recurrence rate was 15% and cancer incidence 3% in follow-up.
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Affiliation(s)
- Ville Sallinen
- Department of Surgery, South Karelia Central Hospital, Valto Käkelän Katu 1, 53130 Lappeenranta, Finland.
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Modarai B, Forshaw MJ, Sankararajah D, Murali K, Stewart M. Endoscopic transanal resection of rectal adenomas using the urological resectoscope. Colorectal Dis 2009; 11:859-65. [PMID: 18727717 DOI: 10.1111/j.1463-1318.2008.01677.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital. METHOD Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed. RESULTS Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10-65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2-162 months), local recurrences occurred in 13% (n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections. CONCLUSION ETAR is simple and safe for managing rectal adenomas.
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Affiliation(s)
- B Modarai
- Department of Surgery, Darent Valley Hospital, Dartford, Kent, UK
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Abstract
Transanal excision (TE), endoscopic transanal resection (ETAR) and transanal endoscopic microsurgery (TEM) can be used to remove adenomatous polyps. However, their use is limited by the size or location of the tumor. TE is limited to the lower rectum, TEM offers better access to lesions in the middle and upper rectum, and ETAR is used less frequently than it deserves for resection of rectal lesions.
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A novel use for the rigid cystoscope: the removal of sacral tacks after a coloanal anastamosis dehiscence. Adv Urol 2009:978038. [PMID: 19197375 PMCID: PMC2633451 DOI: 10.1155/2009/978038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 12/14/2008] [Indexed: 11/17/2022] Open
Abstract
A 69-year-old female presented as an emergency with atrial fibrillation, which was treated with warfarin. She subsequently developed fresh rectal bleeding and after further investigations a Dukes B adenocarcinoma of the rectum was found. She subsequently underwent a low anterior resection, coloanal anastamosis and a defunctioning ileostomy. Three sterile surgical metallic tacks (pins) were inserted into the sacrum to stop brisk bleeding from the presacral venous plexus. Following discharge, she was readmitted with septic shock and a CT scan revealed a presacral fluid collection in the area surrounding the sacral tacks (pins) and an anastamotic dehiscence. The patient was not fit for further pelvic surgery to remove the tacks, so an alternative minimally invasive cystoscopic procedure was performed. The sacral tacks (pins) were removed by the urologist using a rigid cystoscope and cold cup biopsy forceps. To our knowledge, this is the first reported case in the literature.
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The multidisciplinary management of gastrointestinal cancer. Multimodal treatment of rectal cancer. Best Pract Res Clin Gastroenterol 2007; 21:1049-70. [PMID: 18070703 DOI: 10.1016/j.bpg.2007.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Greater understanding of the natural history of rectal cancer, and the knowledge that a histologically involved circumferential margin due to inadequate lateral dissection confers a high risk of local recurrence have driven technical advances in surgical technique with meticulous surgical dissection along embryological planes. Significant improvements in local control and overall survival have been seen for patients with resectable rectal cancer. However, even high-quality surgery cannot always achieve a curative resection for locally advanced cancers that extend below the levators, having transgressed the mesorectal fascia. Magnetic resonance imaging is now accepted as a practical method of clinical staging, and can accurately predict pre-operatively the likelihood of achieving a clear circumferential margin. Technological advances in radiation planning and new effective cytotoxic drugs also give scope for dealing with unresectable rectal cancer, and the potential for controlling distant micrometastases. Hence, modern multimodal treatment of rectal cancer attempts to integrate surgery, radiotherapy and chemotherapy, and address the two distinct problems of local recurrence and metastatic disease. Multidisciplinary teams achieve the best results. This paper discusses the surgical management of rectal cancer, the pathology, the principles of imaging, and the lessons learnt from randomized trials of radiotherapy and chemoradiation.
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