Capsule endoscopy in small-bowel surveillance of patients with hereditary polyposis syndromes

Purpose  

Familial adenomatous polyposis (FAP) and Peutz–Jeghers syndrome (PJS) are hereditary polyposis syndromes with a high risk for benign small-bowel polyps and cancer. The aim of this study was to assess the prevalence of small-bowel polyps beyond the duodenum in patients with FAP and PJS and to examine the clinical value and the optimal interval of capsule endoscopy (CE) for the surveillance of small-bowel polyps in patients with FAP.     

Initial experience of real-time capsule endoscopy in monitoring progress of the videocapsule through the upper GI tract

BACKGROUND: Wireless capsule endoscopy (WCE) is one of the most important investigations for small bowel examination. Although newer-generation WCE is equipped with a real-time viewer, the role of this advancement in daily practice remains unknown. OBJECTIVE: Our purpose was to determine the role of the real-time viewer for monitoring of the videoendoscope passage through the upper GI tract. DESIGN: Case-control comparison. SETTING: Single tertiary referral center. PATIENTS: Forty-five consecutive patients who underwent capsule endoscopy in a 12-month period were studied. Twenty-seven patients received conventional WCE, whereas 18 patients were examined by real-time WCE. Passage into the small bowel was monitored with the real-time viewer in the second group of patients. Gastric transit time and the rate of complete small bowel examination were compared. INTERVENTIONS: On-demand polyethylene glycol and erythromycin were prescribed according to the progress as viewed by the real-time monitor. MAIN OUTCOME MEASUREMENTS: Small bowel examination completion rate and gastric transit time. RESULTS: Small bowel examination was completed in 19 (70.4%) and 17 (94.4%) patients undergoing conventional and real-time WCE, respectively (P = .048). With the real-time monitoring and on-demand preparations, gastric passage time was significantly reduced (100 vs 59 minutes, P = .02). LIMITATIONS: Nonrandomized study. CONCLUSIONS: The use of the real-time viewer may help to secure the passage of the capsule endoscope into the small bowel and hence result in a higher rate of complete small bowel examination.     

A prospective trial comparing wireless capsule endoscopy and barium contrast series for small-bowel surveillance in hereditary GI polyposis syndromes

BACKGROUND: Capsule endoscopy has demonstrated its clinical utility in the evaluation of the small bowel, and, accordingly, it has been suggested that it could be useful for the identification of small-intestinal polyps in patients with polyposis syndromes. The objective was to establish the effectiveness of wireless capsule endoscopy for detecting small-bowel polyps in patients with hereditary GI polyposis syndromes in comparison with barium contrast series. METHODS: Consecutive patients with GI polyposis syndromes were included. Small-bowel follow-through series and capsule endoscopy were performed within 1 week, in a blind fashion. The number and the location of polyps were analyzed. RESULTS: Twenty-four patients with familial adenomatous polyposis (n = 20) or Peutz-Jeghers syndrome (n = 4) were included. Capsule endoscopy detected small-bowel polyps in 7 of 24 patients (29%), whereas a barium contrast study identified small-intestinal polyps in only 3 of these 7 patients. In the 4 remaining patients, all of them with familial adenomatous polyposis, polyps detected by the capsule but missed in radiographic series were located at either ileum (2 patients), jejunum (1), or duodenum (1). No procedure-related complication was observed in any patient. CONCLUSIONS: Wireless capsule endoscopy is a highly accurate technique for the detection of small-bowel polyps in patients with hereditary GI polyposis syndromes, and it represents a valuable alternative to barium contrast series in the surveillance of patients with Peutz-Jeghers syndrome.     

Capsule endoscopy is useful and safe for small-bowel surveillance in familial adenomatous polyposis

BACKGROUND: Duodenal cancer and ampullary cancer are major causes of death after a prophylactic colectomy in patients with familial adenomatous polyposis (FAP). Forward-viewing endoscopy and side-viewing endoscopy are recommended in patients with FAP for surveillance of periampullary and duodenal polyposis. The study of polyps distal to the duodenum in FAP is limited. A capsule endoscopy (CE) allows visualization of the mucosa of the entire small bowel. OBJECTIVE: The objective was to detect whether CE has clinical value or any utility for the surveillance of small-bowel polyps in patients with FAP and to evaluate whether there are genotypic factors that predict which patients are at a lower risk of small-bowel polyps. SETTING: Two Italian tertiary-referral centers. PATIENTS: Twenty-three patients with FAP who presented for a CE. MAIN OUTCOME MEASUREMENTS: Patients with FAP were examined by CE to assess the location, size, and number of small-bowel polyps. Patient age at CE, sex, years of observation after surgery, type of surgery, duodenal adenomas, and colorectal cancer at surgery were analyzed. All patients were selected for mutation analysis, and the germline adenomatous polyposis coli (APC) gene mutation was detected. RESULTS: Eleven of 23 patients with FAP had duodenal polyps. During CE, jejunal-ileal polyps were detected in 7 of 23 FAPs, with a total number of 15 polyps in the ileum. The presence of duodenal adenomas was the only clinical feature predictive of small-bowel polyps. Identification of the ampulla of Vater was not achieved with CE; duodenal polyps were only seen in 4 of 11 patients identified endoscopically, with an underestimation of polyp numbers. APC mutations between codons 499 and 805 were associated with the absence of small-bowel polyps. CONCLUSIONS: CE is useful and safe for the surveillance of jejunal-ileal polyps in selected patients with FAP. CE is not useful in the surveillance of the duodenum where the majority of small-bowel cancers occur.     

Initial experience with taTME in patients undergoing laparoscopic restorative proctocolectomy for familial adenomatous polyposis

Background

Transanal total mesorectal excision (taTME) is a minimally invasive technique which was developed to overcome the difficulties associated with the “top-down” pelvic dissection by enabling a “bottom-up” dissection in patients with mid- and low rectal cancer. While this technique was primarily designed to manage tumors in the mid- and lower rectum, its spectrum of indications has been broadened to include benign colorectal pathologies. The aim of the present study was to assess our initial experience with taTME in patients undergoing restorative proctocolectomy for familial adenomatous polyposis (FAP).

Methods

All consecutive patients (undergoing prophylactic restorative proctocolectomy with IPAA for FAP using taTME between April and October 2016 at our institution) were included in the study.

Results

There were 8 patients (6 females and 2 males). The median age was 19.5 years (range 16–31 years). In all cases, surgery was successfully completed using with taTME. No perioperative complications were recorded. A median of 5 bowel movements (range 4–6 bowel movements) with intermittent anti-diarrheal medication was recorded in all cases.

Conclusions

Our initial experience with 8 consecutive cases suggests taTME is safe and effective in patients undergoing prophylactic restorative proctocolectomy with IPAA for FAP.

     

Video capsule endoscopy compared with standard endoscopy for the evaluation of small-bowel polyps in persons with familial adenomatous polyposis (with video)

BACKGROUND: Video capsule endoscopy (VCE) may be useful for surveillance of small-bowel polyps in patients with familial adenomatous polyposis (FAP). OBJECTIVE: To compare VCE to standard endoscopy for diagnosing small-bowel polyps in a defined segment of small bowel (proximal to a tattoo) and the entire examined small bowel. DESIGN: Prospective. SETTING: Single tertiary referral center. PATIENTS: Participants with FAP (n = 32). The majority were selected for their high number of proximal small-bowel polyps and prior endoscopic tattoo placement in the proximal small bowel. INTERVENTIONS: VCE (interpreted by 2 readers), push enteroscopy (PE), and lower endoscopy (LE) to count and measure small-bowel polyps. RESULTS: In the defined segment, VCE detected a median of 10.0 (interquartile range [IQR], 5.0-19.0) and 9.0 (IQR, 6.0-16.0) polyps for each reader compared with a median of 41.0 (IQR, 19.0-64.0) polyps on PE (P = .002). Agreement between the 2 methods was fair (kappa = 0.34, 0.36). Agreement between VCE and PE was poor to fair (kappa = 0.10, 0.22) for estimating the size of the largest polyp and poor (kappa = -0.20, -0.27) for detecting large polyps (> or =1 cm). In the entire examined small bowel, VCE diagnosed a median of 38.0 (IQR, 10.5-71.5) and 54.0 (IQR, 13.0-100.0) polyps for each reader compared with a median of 123.0 (IQR, 38.5-183.0) for combination endoscopy (PE and LE) (P < .001). Agreement between the 2 methods was fair to moderate (kappa = 0.21, 0.56). LIMITATIONS: Participants selected for high polyp burden, and results may not be applicable to all patients with FAP. CONCLUSIONS: VCE underestimates the number of small-bowel polyps in persons with FAP and does not reliably detect large polyps.     

Role of videocapsule endoscopy for gastrointestinal bleeding

Obscure gastrointestinal bleeding （OGIB） is defi ned as bleeding of an unknown origin that persists or recurs after negative initial upper and lower endoscopies. Several techniques, such as endoscopy, arteriography, scintigraphy and barium radiology are helpful for recognizing the bleeding source; nevertheless, in about 5%-10% of cases the bleeding lesion cannot be determined. The development of videocapsule endoscopy （VCE） has permitted a direct visualization of the small intestine mucosa. We will analyze those techniques in more detail. The diagnostic yield of CE for OGIB varies from 38% to 93%, being in the higher range in those cases with obscure-overt bleeding.