Adenocarcinoma of the small bowel: a surgical dilemma

Indications and Limitations Associated with the Patency Capsule Prior to Capsule Endoscopy

The retention of the capsule used during small bowel capsule endoscopy (SBCE) is a serious complication that can occur in patients with known or suspected small bowel stenosis, and a prior evaluation of the patency of the gastrointestinal (GI) tract is therefore essential. Patency capsule (PC) is a non-diagnostic capsule the same size as the diagnostic SBCE. To date, there are no clear guidelines regarding the contraindications for undergoing a PC evaluation prior to SBCE. Each small bowel disorder has specific occasions to inhibit the progress of PC and SBCE, even though they do not have any stenotic symptoms or abnormalities on imaging. In this review, we summarize the indications and limitations of PC prior to SBCE, especially the contraindications, and discuss clinical scenarios in which even PC should be avoided, and therefore such areas of stenosis should be evaluated by alternative modalities. We thus propose this new algorithm to evaluate the patency of the GI tract for patients with suspected and known small bowel stenosis in order that they may undergo SBCE safely.

Obscure gastrointestinal bleeding with negative abdominal computed tomography study: The importance of enteroscopy for early diagnosis of small bowel malignancy

Small bowel tumors are rare among all gastrointestinal (GI) cancers. The most common histological subtype is adenocarcinoma. Adenocarcinoma of the small bowel is difficult to diagnose, often presents at a late stage, and has a poor prognosis. We describe a case of a patient with adenocarcinoma of the small intestine who presented to the hospital with nonspecific GI symptoms and obscure GI bleeding. An initial examination using abdominal computed tomography revealed negative findings. The patient underwent subsequent enteroscopy with capsule endoscopy and double‐balloon endoscopy, and an early‐stage jejunal adenocarcinoma was finally diagnosed.

Assessment of the external validity of the AJCC 8th staging system for small intestinal adenocarcinoma: a time to reconsider the role of tumor location?

Background

The current study evaluates the validity and performance of the 8^th edition of the American Joint Committee on Cancer (AJCC) staging system for small intestinal adenocarcinoma patients.

Methods

Surveillance, Epidemiology and End Results (SEER) database [2004-2015] was explored and AJCC 6^th, 7^th, and 8^th versions were assigned for each patient. Through Kaplan-Meier estimates, overall survival analyses were conducted. Cox regression analysis (adjusted for age, race, gender, sub-site, grade and surgical treatment) was conducted for cancer-specific survival and additionally, pairwise hazard ratio comparisons were performed.

Results

A total of 2,997 small intestinal adenocarcinoma patients were eligible and included in the analysis. Overall survival was compared according to the three AJCC staging systems. For the three versions, the P value for the trend in overall survival was significant (P<0.0001). Cancer-specific Cox regression hazard was calculated for the three staging systems. Pairwise hazard ratio comparisons between different AJCC 6^th stages were conducted and all P values for comparisons were significant (P<0.0001). Pairwise hazard ratio comparisons between different AJCC 7^th and 8^th stages were also performed, and all comparisons were significant (P<0.05) except for stage IIB vs. IIIA. C-statistic (using death from small intestinal adenocarcinoma as the dependent variable) for AJCC 6^th staging system was: 0.645 [standard error (SE): 0.011; 95% CI: 0.623-0.668]; for c-statistic for AJCC 7^th staging system was 0.658 (SE: 0.011; 95% CI: 0.637-0.680); while c-statistic for AJCC 8^th staging system was 0.660 (SE: 0.011; 95% CI: 0.638-0.682). Multivariate analysis of factors affecting cancer-specific survival suggested that older age (P=0.005), higher lymph node ratio (P<0.0001) and duodenal localization of the primary are associated with worse outcomes (P=0.008).

Conclusions

There is no evidence that AJCC 8^th system provided better prognostic characterization compared to previous AJCC staging systems for small intestinal adenocarcinoma. Subsite-specific staging paradigms should be explored in future editions of the staging system.

Small bowel malignancy in patients undergoing capsule endoscopy at a tertiary care academic center: Case series and review of the literature

BACKGROUND AND STUDY AIMS

Small bowel cancer is rare, accounting for < 5 % of all gastrointestinal neoplasms. Capsule endoscopy has become the procedure of choice for non-invasive diagnosis of small bowel diseases. Data on capsule endoscopy diagnosis of small bowel cancer are limited. The objective of the study was to determine the frequency, indications and diagnostic work-up of patients with small bowel malignancy found by capsule endoscopy at a Scottish tertiary center.

PATIENTS AND METHODS

In this retrospective study, records all patients who underwent small bowel capsule endoscopy at our center over a 10-year period were reviewed for possible malignancy. Further data were gathered on preceding and subsequent investigations, management and outcome of these patients.

RESULTS

From 1949 studies, small bowel malignancies were diagnosed in only 7 patients (0.36 %; 2F/5M; median age 50, range 34 - 67). The main indication was iron-deficiency anemia (n = 5). Prior to capsule endoscopy, 6 of 7 patients had bidirectional endoscopies and one had gastroscopy. All prior investigations were normal or nondiagnostic. Two of 7 experienced capsule retention. Five of 7 underwent surgery. Four patients died, giving a 5-year survival rate of 42.9 %.

CONCLUSION

 Small bowel malignancies diagnosed by capsule endoscopy are rare, and the median age of 50 indicates they are more common in relatively younger patients. Capsule endoscopy is effective at diagnosing a rare malignancy when other imaging modalities have failed.

Jejunal adenocarcinoma-a case report with review

Primary Small bowel tumours are rare accounting for only 3-6% of GI neoplasm; 1-2% of these are malignant. Their presentation is usually with nonspecific symptoms that causes delay in diagnosis and consequently a worse outcome for the patient. We report a case of Jejunal adenocarcinoma where early diagnosis and treatment lead to good outcome.