Performance of double-balloon enteroscopy for the management of small bowel polyps in hamartomatous polyposis syndromes

Risk for Surgery in Patients with Polyposis Syndrome after Therapy by Device-Assisted Enteroscopy (DAE): Long-Term Follow Up

Background and aim of the study: Polyposis syndromes such as Peutz–Jeghers (PJ) and familial adenomatous polyposis (FAP) are associated with the growth of small bowel polyps; the risk is approximately 60–90% for PJ and 40–70% for FAP. The primary aim of this study was to evaluate the efficacy of device-assisted enteroscopy (DAE) in the detection and treatment of small bowel polyps to reduce the risk of surgery. The secondary objective was to study complications and mortality. Methods: We conducted a retrospective cohort study by analyzing a structured database. Between September 2006 and October 2019, we observed and followed 42 consecutive patients with polyposis syndromes; they underwent device-assisted enteroscopy and three were excluded from elective surgery after the exam. The endoscopic exams were performed for diagnostic and therapeutic purposes. Results: Thirty-nine patients were evaluated with a mean follow up of 6.7 years (±SD 2.7), 79.5% were female with a mean age of 43.8 years (±SD 15.02), and 68 enteroscopies were performed with the removal of 64 polypoid lesions. One bleeding episode occurred after operative enteroscopy, and the need for subsequent surgery occurred in six patients with PJ and in five patients with FAP. The surgical indications in PJ patients were the presence of large polyps (three patients) and three cases of intussusception, one of which was a patient with a polyp in the proximal ileum, not reachable with the scope. One patient with PJ died from pancreatic cancer during follow up. The surgical indications in patients with FAP were the presence of four large polyps with high-grade dysplasia and one ampullary neoplasia recurrence. Conclusions: In PJ patients, the endoscopic treatment of small bowel polyps was safe. During the follow-up period, the patients with successful endoscopic treatment did not need surgery. In FAP patients treated with DAE, none developed cancer.

Safety and efficacy of an enteroscopy-based approach in reducing the polyp burden in patients with Peutz-Jeghers syndrome: experience from a tertiary referral center

Background:

Patients with Peutz–Jeghers syndrome develop hamartomatous polyps in the small bowel, possibly causing anemia, intussusception, and obstruction. We aimed to evaluate the impact of an enteroscopy-based approach, including both device-assisted and intraoperative enteroscopy, on the reduction of the polyp burden in a cohort of adult Peutz–Jeghers syndrome patients.

Materials and methods:

A retrospective study was conducted at Azienda Ospedaliero-Universitaria Città della Salute e della Scienza in Turin, Italy. Consecutive Peutz–Jeghers syndrome patients eligible for device-assisted or intraoperative enteroscopy, between January 2003 and November 2019, were included. Enteroscopy technical issues and complications were recorded. At the time of index enteroscopy, the patients’ clinical records were retrospectively reviewed, and clinical data were recorded until November 2019.

Results:

Overall, 24 patients were included. Before inclusion, 16/24 patients (66.7%) underwent small bowel surgery for polyp-related complications, 13 of which (81.2%) in an emergent setting. Two patients had a history of small bowel neoplasms. During the timeframe, 47 device-assisted enteroscopies and 9 intraoperative enteroscopies were performed, and 247 small bowel polyps were endoscopically removed. The overall complication rate was 12.8% (8.5% for device-assisted enteroscopy, 22.2% for intraoperative enteroscopy). The median observation time was 108 months: in this timeframe, two patients developed small bowel polyp-related complications requiring emergent surgery. No patients developed small bowel cancer, but nine extra-gastrointestinal neoplasms were recorded.

Conclusion:

An enteroscopy-based approach appears to be well tolerated and effective in decreasing polyp-related complications in Peutz–Jeghers syndrome patients, thus reducing the need for emergent surgery. Although the prevention of small bowel polyp-related complications remains the main goal in these patients, the high incidence of extra-gastrointestinal neoplasms appears to be a rising issue.

Surgical Management of Jejunal Tumors: Experience from Tertiary Care Centre

INTRODUCTION

Small bowel is an uncommon site for primary neoplasm in the gastrointestinal tract. Traditionally, duodenum has been combined with jejunum and ileum in analysing the presentation and management of these tumors. Given the different presentation pattern, diagnostic difficulties and anatomical considerations, jejunal tumors may differ from duodenal tumors.

METHODOLOGY

Retrospective analysis of a prospectively maintained database of patients with histology proven jejunal tumors was done. Clinico-radiological characters, histological findings, surgical procedures and the outcomes in these patients were studied.

RESULTS

Sixteen patients were included in the study. Median age at presentation was 42 years (26-76 years) and majority were males (n = 11, 68.8%). Seven (43.7%) patients presented with emergencies. Endoscopic tissue diagnosis could be obtained in 5 (31.3%) patients. Histology of tumors were adenocarcinoma, gastrointestinal stromal tumor and lymphoma in 6 (37.5%), 5 (31.3%) and 3 (18.8%) respectively. Sarcoma (myxofibroma) and metastasis (urothelial origin) were present in one patient each. Two patients with adenocarcinoma had neoadjuvant chemotherapy. Curative resection was feasible in 14 patients. Resection of tumor-bearing segment with anastomosis was performed in 9 patients. Among these, 5 had duodenojejunostomy. One patient had resection and double-barrel jejunostomy. One patient with jejunal GIST had sleeve resection. Multi-visceral resection was performed in 3 patients. There were no mortality and median postoperative hospital stay was 11 days (range 7-33 days).

CONCLUSION

Histology spectrum of jejunal tumors are distinct. Difficulty in obtaining preoperative tissue diagnosis of these lesions need to be addressed by improved endoscopic and image-directed biopsy techniques.

Small bowel polyp resection using device-assisted enteroscopy in Peutz-Jeghers Syndrome: Results of a specialised tertiary care centre

INTRODUCTION

Enteroscopy resection of small bowel polyps in Peutz-Jeghers syndrome has only been described in small case series. Herein, we aimed to assess the efficacy of enteroscopy resection of small bowel polyps within a specialised tertiary care centre and the impact on intraoperative enteroscopy.

METHODS

This was an observational single-centre study. All adult Peutz-Jeghers syndrome patients followed in the Predisposition Digestive Ile-de-France network who underwent an endoscopic resection of at least one small bowel polyp ≥ 1 cm by enteroscopy between 2002-2015 were included. Small bowel polyps were detected under a dedicated screening programme by previous capsule endoscopy and/or magnetic resonance enterography, performed every 2-3 years. Complete treatment was defined as the absence of polyps ≥ 1 cm after conventional endoscopic resection. Intraoperative enteroscopy or surgical resection were indicated in incomplete treatments. The overall complete treatment rate including conventional enteroscopy and intraoperative enteroscopy was also considered.

RESULTS

Endoscopic resection of 216 small bowel polyps (median: 8.6 per patient, size: 6-60 mm) was performed by 50 enteroscopies in 25 patients (mean age: 36 years, range: 18-71, 56% male) with small bowel polyp ≥ 1 cm. Twenty-three patients (92%) underwent 42 screening capsule endoscopies and 14 (57%) had 23 magnetic resonance enterographies during a median follow-up of 60 months. Complete treatment was achieved in 76%. Intraoperative enteroscopy and surgical resection were performed in four (16%) and two (8%) patients. Intraoperative enteroscopy improved by 16% the complete treatment rate and the overall rate was 92%. The complication rate was 6%.

CONCLUSION

This long-term study confirmed the efficacy and safety of endoscopic resection of small bowel polyps in Peutz-Jeghers syndrome. Intraoperative enteroscopy can be a complementary approach in selected cases.

Update on small bowel surveillance in hereditary colorectal cancer syndromes

Despite its rarity in the general population, small bowel adenocarcinoma risk is increased in individuals with hereditary colorectal cancer syndromes (HCCS). In the last decade, the advent of capsule endoscopy and device-assisted balloon enteroscopy procedures in patients with HCCS have allowed to investigate the whole small bowel, increasing the diagnostic yield of small bowel tumor. Nonetheless, there is a significant variability in the international guideline recommendations. The aim of this review is to provide an update on surveillance of small bowel in HCCS and to identify the key points for the clinical management of these patients.

Double-Balloon Enteroscopy

Since the introduction of double-balloon enteroscopy 15 years ago, flexible enteroscopy has become an established method in the diagnostic and therapeutic work-up of small bowel disorders. With appropriate patient selection, diagnostic and therapeutic yields of 70% to 85% can be expected. The complication rates with diagnostic and therapeutic DBE are estimated at approximately 1% and 3% to 4%, respectively. Appropriate patient selection and device selection, as well as skill, are the key issues for successful enteroscopy. However, technical developments and improvements mean that carrying out enteroscopy is likely to become easier.

Deep enteroscopy - indications, diagnostic yield and complications

Since its introduction in 2001 capsule endoscopy opened up the small bowel for diagnostic approaches followed by double balloon enteroscopy which enabled the endoscopic community to perform therapeutic interventions in the whole small intestine. In this review the scientific developments related to indications, diagnostic yield and complications of the last years between the competing devices double ballon enteroscopy, single balloon enteroscopy and spiral enteroscopy are illustrated.