Literature Review

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Transcript Literature Review

Literature Review

Peter R. McNally, DO, FACP, FACG University Colorado School of Medicine Center for Human Simulation Aurora, Colorado 80045

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Beltran PV, Nos P, Bastida G, Beltran, B, Arguello L, Aguas M, Rubin A, Pertejo V, Sala T. Evaluation of postsurgical recurrence in Crohn’s disease: a new indication for capsule endoscopy? Gastrointest Endoscopy. 2007;66:533-40

Valencia, Spain

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Introduction

• • •

Postoperative relapse of Crohn’s disease is common. 1

Neoileum relapse is 73 & 85% and symptomatic relapse is 20 & 34% at 1 and 3 yr Post Op. 1 Prophylactic post operative immunosuppressant therapy is recommended for the High Risk to Relapse Group. 2

Fistulizing Disease

Ileocolonic location

Smoker Post Operative endoscopic surveillance at 6-12 mo is recommended for the Average Risk to Relapse Group.

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1.

Rutgeert P, et al. Gastroenterol. 1990;99:956-63.

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Rutgeert P. Gut. 2002;51:152-3.

3.

D’Haens G, et al. Inflamm Bowel Dis. 1999;5:295-303

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Introduction

Wireless capsule endoscopy (CE) has recently been shown to be more accurate than Ileocolonoscopy in detecting small bowel activity among patients with Crohn’s.

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“Gold Standard” for the monitoring Post Op Crohn’s Disease for relapse has been Ileocolonoscopy.

This study examined safety and utility of CE to monitor for post operative relapse when compared to the “Gold Standard.”

4 .Triester S, Leighton JA, Leontiadis GI, et al. Am J Gastroenterol 2006;101:954-64 4

Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Aim

To test the safety and accuracy of CE to detect post operative relapse of Crohn’s in the neoileum.

Compare the safety, patient tolerance, accuracy of CE to Ileocolonoscopy to detect relapse among clinically asymptomatic post operative Crohn’s patients.

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Study Design:

• • •

Prospectively enrolled Crohn’s patients after ileocolonic anastomosis between Oct 2003 and Oct 2005.

Demographics

N=24 (13 ♀ and 11 ♂)

All Asymptomatic

None on prophylactic treatment to prevent relapse Exclusion Criteria:

– – –

History Dysphagia Pregnancy Lactation

– –

Life-threatening conditions Nonsteroidal anti-inflammatory drug intake

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Study Evaluations

• • • • • • •

Study Evaluations (all within 2 wk):

M2A Patency Capsule (Given Imaging Ltd, Yoqneam,Isreal),

Ileocolonoscopy (CF-VL, Olympus, Tokyo, Japan)

CE (M2A Given Imaging Ltd, Yoqneam,Isreal).

Rutgeerts’ Index 1 > 2 used to defined recurrence 0: no changes 1: < 5 aphathous lesions 2: > 5 aphathous lesions, with nl “skip” mucosa 3: diffuse aphathous ileitis 4: diffuse inflammation: ulcers, nodules &/or narrowing

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Materials and Methods

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Evaluations: M2A Patency Capsule Capsule passage: Patient confirmation or X-ray location in colon or patency scanner Transit “normal” < 40hrs Patency Capsule Patency Capsule Scanner

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Materials and Methods

Examination Neoileum

Ileocolonoscopy (CF VL, Olympus, Tokyo, Japan)

CE (M2A Given Imaging Ltd, Yoqneam,Isreal).

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Evaluations: Ileocolonoscopy

Fosfosoda (Casen Fleet) bowel prep 45 ml X2

Conscious Sedation: medazolam (2-3 mg) or Fentanyl (50 microgram)

– –

Neoileum examined as far as possible (10-30 cm) Findings Graded by Rutgeerts’ Index 1

Evaluations: Patient Comfort Survey

Completed after CE and Ileocolonoscopy

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

CE Showing Ileal Ulceration

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40 Patient Characteristics: Gender: 11/13 (M/F) Age: 38 (18-71 yr) Clinical Characteristics Smokers ∆ time from surgery Perianal Disease 50% 254 days 88% Surgery Ileo-Ascending anastamosis Ileo-Transverse anastamosis Length resection (cm) 67% 33% 34 (13-60) Disease Activity Markers Erythrocyte sedimentation 19 (7-24) C-reactive protein (0-8mg/L) 1.2 (0-6) Crohn’s Disease Activity Index 56 (23-168)

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Results: CE vs.. Ileocolonoscopy

N =24 Patency M2A 22/24 CE 21/22 Ileocolon oscopy 24/24 Procedure Failure 2/24 ( 8.3%) Non passage Crohn's (+) 1/22 ( 4.5%) Fail to transmit 3/24 (12%) Fail to intubate 15/22 (62%) 13 proximal 6/21 (25%)

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Results: Patient Comfort

• • • •

All patients preferred CE to endoscopy Bowel prep for endoscopy disrupted daily activity more than liquid diet for CE (83% vs. 20%) 50% of the pts considered the endoscopy uncomfortable 8/24 (33%) pts required additional conscious sedation during the neoileal exploration

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Reviewer Comments

Beltran, et al, have clearly shown the following: 1.

2/24 (8.3%) non passage of patency capsule suggests the need to evaluate luminal patency before CE in asymptomatic post op Crohn’s 2.

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CE is superior to endoscopy (62% vs. 25%) in the detection of active post operative Crohn’s disease.

CE is preferred by pts over endoscopy for evaluation of post operative Crohn’s

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Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

Reviewer Comments

Beltran, et al, do not answer the question: 1.

Does detection of post operative Crohn’s disease by either method (endoscopy or CE) make a difference in managing this disease?

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However, the authors will certainly have an answer in the future. Those patients in this study with Rutgeerts’ score > 2 were offered therapeutic modification with 2.5 mg/kg/day azathioprine.

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