First case of isolated small bowel transplantation at the university of cologne: rejection-free course under quadruple immunosuppression and endoluminal monitoring with video-capsule

Initial Experience of Video Capsule Endoscopy After Intestinal Transplantation

BACKGROUND

Intestinal transplantation is a procedure which inflicts immunological and infectious complications that affect the transplanted graft, posing both diagnostic and therapeutic challenges. Video capsule endoscopy (VCE) offers easy access to the entire small intestine and presents itself as an interesting option. However, at present, no studies evaluating the usefulness of video capsule endoscopies in this setting have been published. Our aim was to evaluate the usefulness of VCE in detecting complications that arise after intestinal transplantation.

METHODS

We included 7 adult patients with either isolated intestine (n = 1) or multivisceral grafts (n = 6). These patients underwent 12 VCE between 2004 and 2015 at the Sahlgrenska University Hospital. The median age was 42 (21-67) years (4 women/3 men). VCE was used in clinical situations where the conventional diagnostic methods failed to provide answers to the clinical question.

RESULTS

Indications for the procedure were: suspicion of rejection (n = 4 examinations), gastrointestinal dysmotility (n = 4 examinations), high stomal output (n = 2 examinations), suspicion of lymphoproliferative disease in the transplanted graft (n = 1 examination), and clinical surveillance (n = 1 examination). The median time after transplantation for performing an examination was 740 (26-3059) days. VCE was useful in 83% of the examinations and the results influenced the planned management. The overall agreement between VCE findings and biopsies was moderate (κ = 0.54, P = 0.05) but increased when comparing the presence of inflammation/rejection (κ = 0.79, P < 0.001).

CONCLUSIONS

VCE is a promising diagnostic method after intestinal transplantation. However, larger studies are needed to evaluate its potential risks and gains.

Small bowel video capsule endoscopy in Crohn’s disease: What have we learned in the last ten years?

Since its introduction in 2001, capsule endoscopy (CE) has become the most important advance in the study of small bowel disease, including Crohn’s disease (CD). This technique has been demonstrated to be superior to all other current forms of radiological investigation in detecting mucosal abnormalities of small bowel nonstricturing CD. CE has proven to be extremely useful in diagnosing CD in patients with inconclusive findings from ileocolonoscopy and x-ray-based studies. Almost half of all patients with CD involving the ileum also present lesions in proximal intestinal segments, with the small bowel being exclusively involved in up to 30% of all CD cases. Despite the widespread use of CE, several questions concerning the utility of this technique remain unanswered. The lack of commonly agreed diagnostic criteria for defining CD lesions with the aid of CE may have had an influence on the variation in diagnostic results for CE reported in the literature. The utility of CE in monitoring CD and in guiding therapy has also been proposed. Furthermore, CE could be a useful second-line technique for patients with an established diagnosis of CD and unexplained symptoms. Finally, as no threshold for CD diagnosis has been agreed upon, a severity scale of mucosal disease activity has not been universally followed. None of the available activity indexes based on CE findings has been independently validated. This article discusses several cutting-edge aspects of the usefulness of CE in CD 10 years after its introduction as a sensible method to study the small intestine.

Current status of transplantation of the small intestine

The evolution of small bowel transplantation has been significant over the past 20 years to the point at which it can now be considered a viable and often successful option in the treatment of many forms of short bowel syndrome. A refinement of surgical techniques, improved immunosuppression, enhanced understanding of gut immunology, and better treatment and prevention of complications have contributed to a marked improvement in graft and patient survival. Whereas this transplant population is still beset with many potential complications after isolated bowel or multivisceral transplantation and long-term graft survival (like with other solid organ transplants) remains a challenge, the future holds promise for a continuation of the current positive trend of improvement in several areas.

Diagnosis of small-bowel diseases in the era of capsule endoscopy

Capsule endoscopy is a major breakthrough in gastrointestinal endoscopy and is a first-line tool to detect abnormalities of the small bowel, in up to 50% of patients, intestinal disorders are not associated with any physical findings or positive tests. Indications, yield and impact on patient management of this method of diagnosing small-bowel diseases are analyzed critically in light of current scientific knowledge.

Capsule endoscopy: practical applications

Few advances in the history of gastroenterology have made as dramatic an impact on the diagnosis of gastrointestinal disease as the development and rapid clinical implementation of wireless capsule endoscopy. Less than 4 years after the landmark publication, capsule endoscopy is widely considered an essential component of the diagnostic workup of obscure gastrointestinal bleeding, and its role is expanding in the diagnosis of small bowel diseases such as Crohn's disease. This review appraises the available literature and highlights practical aspects of capsule endoscopy of interest to the clinician. We discuss safety concerns, optimal preparation for the procedure, diagnostic utility as compared to conventional methods, indications for capsule endoscopy, and outcomes.