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Silverman AL, Bouchiba H, Aelvoet A, MacDonald J, Dekker E, Zayadi A, Le J, Feagan B, Jairath V, Ma C, Samadder J. Endoscopic scoring indices for assessing disease severity in familial adenomatous polyposis: Systematic review. Endosc Int Open 2024; 12:E799-E809. [PMID: 38904059 PMCID: PMC11188755 DOI: 10.1055/a-2330-8037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/03/2024] [Indexed: 06/22/2024] Open
Abstract
Background and study aims There is limited consensus on the optimal method for measuring disease severity in familial adenomatous polyposis (FAP). We aimed to systematically review the operating properties of existing endoscopic severity indices for FAP. Methods We searched MEDLINE, EMBASE, and the Cochrane Library from inception to February 2023 to identify randomized controlled trials (RCTs) that utilized endoscopic outcomes or studies that evaluated the operating properties of endoscopic disease severity indices in FAP. Results A total of 134 studies were included. We evaluated scoring indices and component items of scoring indices, such as polyp count, polyp size, and histology. Partial validation was observed for polyp count and size. The most commonly reported scoring index was the Spigelman classification system, which was used for assessing the severity of duodenal involvement. A single study reported almost perfect interobserver and intra-observer agreement for this system. The InSIGHT polyposis staging system, which was used for assessing colorectal polyp burden, has been partially validated. It showed substantial interobserver reliability; however, the intra-observer reliability was not assessed. Novel criteria for high-risk gastric polyps have been developed and assessed for interobserver reliability. However, these criteria showed a poor level of agreement. Other scoring indices assessing the anal transition zone, duodenal, and colorectal polyps have not undergone validation. Conclusions There are no fully validated endoscopic disease severity indices for FAP. Development and validation of a reliable and responsive endoscopic disease severity instrument will be informative for clinical care and RCTs of pharmacological therapies for FAP.
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Affiliation(s)
| | - Hicham Bouchiba
- Department of Gastroenterology and Hepatology, Cancer Center, University of Amsterdam, Amsterdam, Netherlands
| | - Arthur Aelvoet
- Department of Gastroenterology and Hepatology, Cancer Center, University of Amsterdam, Amsterdam, Netherlands
| | | | - Evelien Dekker
- Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | | | - Jessica Le
- Alimentiv, Alimentiv Inc, London, Canada
| | - Brian Feagan
- Alimentiv, Alimentiv Inc, London, Canada
- Division of Gastroenterology and Department of Epidemiology and Biostatistics, Western University, London, Canada
| | - Vipul Jairath
- Alimentiv, Alimentiv Inc, London, Canada
- Division of Gastroenterology and Department of Epidemiology and Biostatistics, Western University, London, Canada
| | - Christopher Ma
- Alimentiv, Alimentiv Inc, London, Canada
- Division of Gastroenterology & Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Jewel Samadder
- Gastroenterology and Hepatology, Mayo Clinic Scottsdale, Scottsdale, United States
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Lauricella S, Rausa E, Pellegrini I, Ricci MT, Signoroni S, Palassini E, Cavalcoli F, Pasanisi P, Colombo C, Vitellaro M. Current management of familial adenomatous polyposis. Expert Rev Anticancer Ther 2024; 24:363-377. [PMID: 38785081 DOI: 10.1080/14737140.2024.2344649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION APC-associated polyposis is a rare hereditary disorder characterized by the development of multiple adenomas in the digestive tract. Individuals with APC-associated polyposis need to be managed by specialized multidisciplinary teams in dedicated centers. AREAS COVERED The study aimed to review the literature on Familial adenomatous polyposis (FAP) to provide an update on diagnostic and surgical management while focusing on strategies to minimize the risk of desmoid-type fibromatosis, cancer in anorectal remnant, and postoperative complications. FAP individuals require a comprehensive approach that includes diagnosis, surveillance, preventive surgery, and addressing specific extracolonic concerns such as duodenal and desmoid tumors. Management should be personalized considering all factors: genotype, phenotype, and personal needs. Total colectomy and ileo-rectal anastomosis have been shown to yield superior QoL results when compared to Restorative Procto colectomy and ileopouch-anal anastomosis with acceptable oncological risk of developing cancer in the rectal stump if patients rigorously adhere to lifelong endoscopic surveillance. Additionally, a low-inflammatory diet may prevent adenomas and cancer by modulating systemic and tissue inflammatory indices. EXPERT OPINION FAP management requires a multidisciplinary and personalized approach. Integrating genetic advances, innovative surveillance techniques, and emerging therapeutic modalities will contribute to improving outcomes and quality of life for FAP individuals.
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Affiliation(s)
- Sara Lauricella
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Rausa
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ilaria Pellegrini
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Teresa Ricci
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Signoroni
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena Palassini
- Medical Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Cavalcoli
- Gastroenterology and Digestive Endoscopy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Patrizia Pasanisi
- Nutrition Research and Metabolomics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Chiara Colombo
- Sarcoma Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marco Vitellaro
- Hereditary Digestive Tract Tumors Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Aelvoet AS, Martin I, Cockburn J, Cabalit C, Cuthill V, Spalding D, Busch O, Bastiaansen BA, Clark SK, Dekker E, Latchford A. Outcomes following duodenectomy in patients with familial adenomatous polyposis. Endosc Int Open 2024; 12:E659-E665. [PMID: 38707599 PMCID: PMC11068438 DOI: 10.1055/a-2298-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/27/2024] [Indexed: 05/07/2024] Open
Abstract
Background and study aims Some patients with familial adenomatous polyposis (FAP) and extensive duodenal polyposis or cancer require total duodenectomy. Regular postoperative endoscopic surveillance of the remaining jejunum and stomach is recommended, but little is known about the outcomes after this surgery. Patients and methods Patients with FAP who underwent either pancreatoduodenectomy (PD) or pancreas-preserving total duodenectomy (PPTD) were identified at two expert centers. Data about postoperative endoscopic surveillance outcomes were collected, as well as survival outcomes. Results Overall, 119 patients (50% female) underwent duodenectomy (86 PD and 33 PPTD); 100 for benign duodenal polyposis and 19 for duodenal or ampullary cancer. Details of postoperative endoscopic surveillance were available for 88 patients (74%). During a median follow-up of 106 months, 36 patients (41%) were diagnosed with jejunal adenomas after duodenectomy, with a significantly higher proportion in patients who underwent PPTD compared with patients who underwent PD (log-rank, P < 0.01). Two patients developed jejunal cancer (2%). Twenty-six patients (30%) were diagnosed with a total of 66 gastric adenomas, of which 61% were located in the fundus/body and 39% in the antrum. Five patients (6%) developed gastric cancer after a median of 15 years (range 6-23 years), all but one within carpeting fundic gland polyposis. Patients who underwent surgery for cancer had worse survival than patients with benign disease and all but one patient with postoperative gastric/jejunal cancer died. Conclusions After duodenectomy in FAP, a considerable risk of developing adenomas and cancer in the stomach and jejunum exists with poor cancer prognosis, highlighting the need for close postoperative endoscopic surveillance.
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Affiliation(s)
- Arthur S. Aelvoet
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Isabel Martin
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
| | - James Cockburn
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
| | - Cherryl Cabalit
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
| | | | - Duncan Spalding
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
| | - Olivier Busch
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC location, Amsterdam, the Netherlands
| | - Barbara A.J. Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Susan K. Clark
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Andrew Latchford
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
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Losurdo G, Di Leo M, Rizzi S, Lacavalla I, Celiberto F, Iannone A, Rendina M, Ierardi E, Iabichino G, De Luca L, Di Leo A. Familial intestinal polyposis and device assisted enteroscopy: where do we stand? Expert Rev Gastroenterol Hepatol 2023; 17:811-816. [PMID: 37515779 DOI: 10.1080/17474124.2023.2242240] [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: 04/02/2023] [Accepted: 07/25/2023] [Indexed: 07/31/2023]
Abstract
INTRODUCTION Hereditary polyposis syndromes are a group of inherited disorders associated with a high risk of developing colorectal cancer. The best known ones are familial adenomatous polyposis (FAP), Peutz-Jeghers (PJS), juvenile polyposis and Cowden syndromes, as well as conditions predisposing to cancer, such as Lynch syndrome. Some of them are characterized by an increased risk of small bowel polyps occurrence. AREAS COVERED Literature search in PubMed was performed in November 2022 and a narrative review was carried out. Since performing small bowel polypectomy is important in such patients, device assisted enteroscopy (DAE) is the key for this procedure. A screening strategy for small bowel polyps is recommended only for PJS. Guidelines endorse either magnetic resonance imaging (MRI) or videocapsule endoscopy (VCE) every 1-3 years, according to the phenotype of the disease. Enteroscopy should be considered for therapeutic purpose in patients with a positive VCE or MRI. DAE has a central role in the resection of polyps larger than mm or causing symptoms of subocclusion or intussusception. Both single (SBE) and double balloon enteroscopy (DBE) are indicated and able to resect polyps up to 6-10 cm. American guidelines have restricted the indications to small bowel enteroscopy only to FAP patients with grade IV Spiegelman. EXPERT OPINION Only some groups of patients (PJS, FAP with demonstrated small bowel polyp burden) may benefit from DAE.
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Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, ASST Santi Paolo E Carlo, Milano, Italy
| | - Salvatore Rizzi
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Ilaria Lacavalla
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Francesca Celiberto
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Maria Rendina
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
| | | | - Luca De Luca
- Digestive Endoscopy Unit, ASST Santi Paolo E Carlo, Milano, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Bari, Italy
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Shah RS, Mehta N, Burke CA, Mankaney G, Stevens T, Augustin T, Walsh MR, Bhatt A. Efficacy of endoscopic retrograde cholangiopancreatography in familial adenomatous polyposis patients after duodenectomy. DEN OPEN 2022; 2:e85. [PMID: 35310730 PMCID: PMC8828246 DOI: 10.1002/deo2.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/17/2021] [Accepted: 11/27/2021] [Indexed: 12/02/2022]
Abstract
Objectives Familial adenomatous polyposis (FAP) patients with Spigelman stage IV polyposis should be considered for prophylactic duodenectomy. Post‐surgical pancreaticobiliary complications occur and may require management via endoscopic retrograde cholangiopancreatography (ERCP). We aimed to assess the success and adverse events of ERCP in FAP patients after pancreas‐sparing duodenectomy (PSD) and pancreaticoduodenectomy (PD). Methods A retrospective review of FAP patients who underwent ERCP after PSD or PD from 1992 to 2020 at a quaternary referral center was completed. The technical success of ERCP was defined as the ability to identify the anastomosis and cannulate the duct. Post‐procedural adverse events were defined by bleeding, perforation, pancreatitis, or cholangitis. Clinical outcomes included the need for surgical intervention and recurrent pancreatitis after ERCP were assessed. Results Of 84 FAP patients with duodenectomy, 12 patients with PSD and two patients with PD underwent 17 ERCPs for pancreatic indications and five for biliary indications. The technical success of ERCP in patients with PSD and a single neoampullary complex for pancreatic (n = 6) and biliary (n = 5) indications was 100% but for those with PD (n = 2) or PSD reconstruction with pancreatic divisum or separate anastomoses (n = 3), it was 0%. Surgical intervention was required in 50% of patients with technically failed ERCP after PSD (2/4) and PD (1/2). There were no adverse events. Conclusions ERCP is expected to be therapeutically successful for biliary complications following PSD. Assessment and potential therapy for pancreatitis post‐PSD are best in the setting of a single neo‐ampullary complex rather than in PD or PSD with pancreatic divisum.
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Affiliation(s)
- Ravi S. Shah
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Neal Mehta
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Carol A. Burke
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Gautam Mankaney
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Tyler Stevens
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
| | - Toms Augustin
- Department of Hepatobiliary Surgery Cleveland Clinic Cleveland USA
| | - Matthew R. Walsh
- Department of Hepatobiliary Surgery Cleveland Clinic Cleveland USA
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology, and Nutrition Cleveland Clinic Cleveland USA
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Naples R, Simon R, Moslim M, Augustin T, Church J, Burke CA, Bhatt A, Kalady M, Walsh RM. Long-Term Outcomes of Pancreas-Sparing Duodenectomy for Duodenal Polyposis in Familial Adenomatous Polyposis Syndrome. J Gastrointest Surg 2021; 25:1233-1240. [PMID: 32410179 DOI: 10.1007/s11605-020-04621-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreas-sparing duodenectomy (PSD) offers definitive therapy for duodenal polyposis associated with familial adenomatous polyposis (FAP). We reviewed the long-term complications of PSD and evaluated the incidence of high-grade dysplasia (HGD) and cancer in the remaining upper gastrointestinal tract. METHODS Forty-seven FAP patients with duodenal polyposis undergoing PSD from 1992 to 2019 were reviewed. Long-term was defined as > 30 days from PSD. RESULTS All patients were treated with an open technique, and 43 (91.5%) had Spigelman stage III or IV duodenal polyposis. Median follow-up was 107 months (IQR, 26-147). There was no 90-day mortality. Seven patients died at a median of 10.5 years (IQR, 5.4-13.3) after PSD, with one attributed to gastric cancer. Pancreatitis occurred in 10 patients (21.3%), and two required surgical intervention. Seven patients (14.9%) developed an incisional hernia, and all underwent definitive repair. Forty-one patients (87.2%) had postoperative surveillance endoscopy over a median follow-up of 111 months (IQR, 42-138). Three patients (6.4%) developed adenocarcinoma (two gastric, one jejunal), and four (8.5%) had adenomas with HGD (two gastric, two jejunal) with a median of 15 years (IQR, 9-16) from PSD. One patient with gastric adenocarcinoma and all patients with HGD or adenocarcinoma of the jejunum required surgical intervention. CONCLUSION PSD can be performed with a low but definable risk of long-term morbidity. Risk of gastric and jejunal carcinoma rarely occurs and was diagnosed decades after PSD. This demonstrates the need for lifelong endoscopic surveillance and educates us on the risk of carcinoma in the remaining gastrointestinal tract.
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Affiliation(s)
- Robert Naples
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA.
| | - Maitham Moslim
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA
| | - Toms Augustin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA
| | - James Church
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA.,Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - Carol A Burke
- Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA.,Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Bhatt
- Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA.,Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Kalady
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA.,Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, Cleveland, OH, 44195, USA.,Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia, Cleveland Clinic, Cleveland, OH, USA
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Reply to: Letter to the Editor: "Long-Term Outcomes of Pancreas-Sparing Duodenectomy for Duodenal Polyposis in Familial Adenomatous Polyposis Syndrome". J Gastrointest Surg 2020; 24:2435-2436. [PMID: 32779085 DOI: 10.1007/s11605-020-04769-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/30/2020] [Indexed: 01/31/2023]
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