Literature Review

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

1

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

2

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.

3

1.

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

2.

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

3.

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

.

3

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.

4

•

“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.

5

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

6

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

7

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

Materials and Methods

• • •

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

8

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).

9

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

10

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

CE Showing Ileal Ulceration

11

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)

12

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%)

13

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

14

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.

3.

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

15

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?

2.

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.

16