Efficacy of double-balloon enteroscopy for small-bowel polypectomy: clinical and economic evaluation

Application of capsule endoscopy in patients with chronic and recurrent abdominal pain: Abbreviated running title: capsule endoscopy in abdominal pain

OBJECTIVE

The incidence of chronic and recurrent abdominal pain increases every year, while the diagnosis is still unsatisfactory even after a number of check-ups. This study aimed to evaluate the diagnosis value of capsule endoscopy in patients suffering from chronic and recurrent abdominal pain.

METHODS

A retrospective case study was performed in 80 chronic and recurrent abdominal pain patients at Xiangyang Central Hospital from January 2013 to November 2017. Meanwhile, diagnoses by capsule endoscopy were collected for analysis.

RESULTS

Abnormal findings were found in 54 of 80 (67.5%) patients. The findings in chronic and recurrent abdominal pain patients include small intestinal erosion and congestion, small intestinal ulcers, small intestinal parasites, small intestinal vascular malformations, small intestinal polyps, small intestinal diverticulum, and small intestinal lymphangiectasia. There were no immediate significant side effects without being reported up to 1 month after ingestion of the capsule. The capsule was evacuated by all patients.

CONCLUSIONS

Capsule endoscopy has a great value in the diagnosis of chronic and recurrent abdominal pain with satisfactory safety and less pain for patients. Inflammatory lesions and ulcers in the small intestine account for the majority of positive findings in these patients.

A systematic review of symptomatic hamartomas of the jejunum and ileum

INTRODUCTION

Gastrointestinal hamartomas are rarely encountered benign growths made of an abnormal mixture of tissues normally found in the body where the growth occurs. Most hamartomas are asymptomatic and diagnosed incidentally. Evidence regarding symptomatic hamartomas of the jejunum and ileum is limited and restricted to anecdotal case reports. We aim to provide a contemporary overview to clarify various aspects linked to symptomatic hamartomas, helping aide management and clinical decision-making.

METHODS

The search terms 'small bowel', 'small intestine', 'jejunum' and 'ileum' were combined with 'hamartoma'. Embase, Medline, PubMed searches and Google Scholar hand-searches were conducted. All English language papers from 1 January 2000 to 1 June 2020 were included.

RESULTS

In total 39 cases were reviewed: 29 adults and 10 paediatric (0-16 years). Presenting symptoms included abdominal pain (87%), vomiting (56%), gastrointestinal bleeding (20.5%) and weight loss (5%); 36 of 39 cases (92%) presented as emergencies. Diagnostic investigations included: abdominal x-ray (49%), endoscopy (38%), computed tomography (56%), magnetic resonance imaging (5%), contrast study (15%) and video capsule endoscopy (5%). Initial management strategy was either open (30) or laparoscopic (7) surgery or endoscopy (2). All cases required surgery for definitive management. Twenty-five cases recorded hamartoma size, and mean maximum diameter was 3.56cm (1.2-8cm) with stricturing in seven cases. Nine of the 39 cases were associated with hamartomatous syndromes. Two mortalities were recorded.

CONCLUSIONS

This is the first published review addressing symptomatic hamartomas of the jejunum and ileum. New data relating to demographic cohort, symptom profile, investigations, management strategies, and morbidity and mortality provide greater insight to those encountering this challenging clinical finding in the future.

Hereditary inflammatory fibroid polyps caused by germline pathogenic variants in PDGFRA: Refining PDGFRA-mutation syndrome

A 35-year-old Filipino woman presented with epigastric pain and was found to have two large jejunal and ileal inflammatory fibroid polyps (IFPs) and dozens of subcentimeter small bowel submucosal nodules. Targeted exon sequencing of PDGFRA on the resected jejunum IFP identified a variant c.1664A>G that was subsequently confirmed in the germline. Family history was striking for three relatives with confirmed IFPs, including one with small bowel intussusception on five occasions. All relatives with IFPs were confirmed to have the same PDGFRA germline likely pathogenic variant, all were female, and all had IFPs by age 50 years that necessitated surgery. Two obligate carriers were reported to have had a similar phenotype while at least one obligate male carrier had no reported history of IFPs. This is the sixth reported family with a germline PDGFRA pathogenic variant and history of IFPs or gastrointestinal stromal tumor (GIST). This is the second report of the c.1664A>G likely pathogenic variant in a family that is unrelated to, and of different ethnic origin than, the first family. This second family exhibited a striking history of multiple IFPs without any reported GISTs, suggesting a possible genotype/phenotype association for this variant, and a possible female gender penetrance bias.

The Biology of Anastomotic Healing-the Unknown Overwhelms the Known

BACKGROUND

Anastomotic complications are among the most devastating consequences of gastrointestinal surgery. Despite its high morbidity, the factors responsible for anastomotic regeneration following surgical construction remain poorly understood. The aim of this review is to provide an overview of the typical and atypical factors that have been implicated in anastomotic healing.

METHODS

A review and analysis of select literature on anastomotic healing was performed.

RESULTS

The healing of an anastomotic wound mirrors the phases of cutaneous wound healing- inflammation, proliferation, and remodeling. The evidence supporting much of the traditional dogma for optimal anastomotic healing (ischemia, tension, nutrition) is sparse. More recent research has implicated atypical factors that influence anastomotic healing, including the microbiome, the mesentery, and geometry. As technology evolves, endoscopic approaches may improve anastomotic healing and in some cases may eliminate the anastomosis altogether.

DISCUSSION

Much remains unknown regarding the mechanisms of anastomotic healing, and research should focus on elucidating the dynamics of healing at a molecular level. Doing so may help facilitate the transition from traditional surgical dogma to evidence-based medicine in the operating room.

Serum C-Reactive Protein and Max Polyp Diameter Are Useful Markers of Complications of Small-Intestinal Polypectomy

BACKGROUND This study aimed to identify the risk factors of complications after small-intestinal polypectomy by single-balloon enteroscopy (SBE), and to assess the value of serum C-reactive protein (CRP) and the max polyp diameter (Dmax) in predicting postoperative complications of small-intestinal polypectomy. MATERIAL AND METHODS Between April 2017 and April 2018, clinical data from 37 patients who underwent small-intestinal polypectomy were retrospectively analyzed. RESULTS Thirty-seven small-intestinal polypectomy procedures (18 oral and 19 anal) were carried out in 37 patients (M: F 20: 17; age 35.6±13.0 years). A total of 1081 small-intestine polyps were removed. Three patients (8.1%) had bleeding and 3 patients (8.1%) had perforation after small-intestinal polypectomy. Based on multivariate logistic analysis, CRP [1.104 (95% CI 1.022-1.191)] was the only risk factor for complications among the patients. According to the area under the receiver operating characteristic (AUROC) curve, CRP (27.5 mg/L), Dmax (3.5 cm), and the combination of CRP + Dmax appear to be predictive factors for complications after small-intestinal polypectomy. CONCLUSIONS SBE is an effective endoscopic tool for patients with small-intestinal polyps. CRP, Dmax, and the combination of CRP+Dmax may be potential predictors of complications from small-intestinal polypectomy.

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.

Effect of Double-Balloon Enteroscopy on Diagnosis and Treatment of Small-Bowel Diseases

Background:

The diagnosis and treatment of small-bowel diseases is clinically difficult. The purpose of this study was to evaluate the diagnostic and therapeutic value of double-balloon enteroscopy in small-bowel diseases.

Methods:

The history and outcomes of 2806 patients who underwent double-balloon enteroscopy from July 2004 to April 2017 were reviewed, which included 562 patients with obscure digestive tract bleeding, 457 patients with obscure diarrhea, 930 patients with obscure abdominal pain, 795 patients with obscure weight loss, and 62 patients with obscure intestinal obstruction. Examinations were performed through the mouth and/or anus according to the clinical symptoms and abdominal images. If a lesion was not detected through one direction, examination through the other direction was performed as necessary. Eighty-four patients with small-bowel polyps, 26 with intestinal obstruction caused by enterolith, and 18 with bleeding from Dieulafoy's lesions in the small intestine were treated endoscopically.

Results:

A total of 2806 patients underwent double-balloon enteroscopy, and no serious complications occurred. An endoscopic approach through both the mouth and anus was used in 212 patients. Lesions were detected in 1696 patients, with a detection rate of 60.4%; the rates for obscure digestive tract bleeding, diarrhea, abdominal pain, weight loss, and intestinal obstruction were 85.9% (483/562), 73.5% (336/457), 48.2% (448/930), 49.1% (390/795), and 62.9% (39/62), respectively. For patients with small-bowel polyps who underwent endoscopic therapy, no complications such as digestive tract bleeding and perforation occurred. Intestinal obstruction with enteroliths was relieved with endoscopic lithotripsy. Among the 18 patients with bleeding from small-bowel Dieulafoy's lesions, 14 patients were controlled with endoscopic hemostasis.

Conclusion:

Double-balloon enteroscopy is useful for diagnosing and treating some small-bowel disease.