Transcript Literature Review
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