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Literature Review

Literature Review. Peter R. McNally, DO, FACP, FACG University Colorado School of Medicine Center for Human Simulation Aurora, Colorado 80045. Beltran PV, Nos P, Bastida G, Beltran, B, Arguello L, Aguas M, Rubin A, Pertejo V, Sala T. .

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Literature Review

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

  2. 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

  3. 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.

  4. 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

  5. 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.

  6. 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

  7. 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’ Index1> 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

  8. 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

  9. 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).

  10. 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’ Index1 Evaluations: Patient Comfort Survey Completed after CE and Ileocolonoscopy Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40

  11. Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40 CE Showing Ileal Ulceration

  12. Clinical Characteristics Smokers 50% ∆ time from surgery 254 days Perianal Disease 88% Surgery Ileo-Ascending anastamosis 67% Ileo-Transverse anastamosis 33% Length resection (cm) 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) Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40 Patient Characteristics: Gender: 11/13 (M/F)Age: 38 (18-71 yr)

  13. Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40 Results: CE vs.. Ileocolonoscopy

  14. 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

  15. Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40 Reviewer Comments Beltran, et al, have clearly shown the following: • 2/24 (8.3%) non passage of patency capsule suggests the need to evaluate luminal patency before CE in asymptomatic post op Crohn’s • 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

  16. Beltran VP, et al. Gastrointest Endoscopy. 2007;66:533-40 Reviewer Comments Beltran, et al, do not answer the question: • Does detection of post operative Crohn’s disease by either method (endoscopy or CE) make a difference in managing this disease? • 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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