Advancements in endoscopic management of small-bowel polyps in Peutz-Jeghers syndrome and familial adenomatous polyposis

Abstract

Before the development of double-balloon enteroscopy (DBE), the standard management of small-bowel polyposis was surgical resection. This is an invasive procedure that could lead to short bowel syndrome. In the 21st century, several new enteroscopy techniques were distributed worldwide, including DBE, single-balloon enteroscopy, spiral enteroscopy, and motorized spiral enteroscopy. These devices enable the diagnoses and endoscopic interventions in the entire small bowel, even in patients with a history of laparotomy. In patients with Peutz-Jeghers syndrome (PJS), endoscopic ischemic polypectomy with clips or a detachable snare is the preferred method for managing pedunculated polyps because it is less likely to cause adverse events than conventional polypectomy. Although polyps in patients with PJS always recur, repeat endoscopic resection can reduce the total number and mean size of polyps in the long-term clinical course. Endoscopic reduction of small-bowel intussusception caused by PJS polyps can be successfully performed using DBE without surgery. A transparent hood is useful for securing a visual field during the treatment of small-bowel polyps, and minimal water exchange method is recommended to facilitate deep insertion. Familial adenomatous polyposis (FAP) is a genetic disorder that increases the risk of developing colorectal cancer. Because jejunal and ileal polyps in patients with FAP have the potential to develop into cancer via the adenoma-carcinoma sequence, periodical surveillance, and endoscopic resection are needed for them, not only polyps in the duodenum. In cases of multiple small-bowel polyps in patients with FAP, cold snare polypectomy without retrieval is an acceptable treatment option for polyps that are 10 mm or smaller in size. Additional good pieces of evidence are necessary to confirm these findings because this narrative review mostly includes retrospective observational studies from single center, case reports, and expert reviews.

Keywords: Peutz–Jeghers syndrome; endoscopic ischemic polypectomy; enteroscopy; familial adenomatous polyposis; intussusception.

Figure 1.

A hamartomatous polyp in a patient with Peutz–Jeghers syndrome.

Figure 2.

Contrast-enhanced computed tomography showing an intussusception caused by a large polyp in a patient with Peutz–Jeghers syndrome: (a) coronal and (b) axial sections. The head of the polyp is indicated by the arrow.

Figure 3.

Endoscopic ischemic polypectomy using a clip for a hamartomatous polyp in a patient with Peutz–Jeghers syndrome.

Figure 4.

Endoscopic ischemic polypectomy using a detachable snare: (a) an open detachable snare catches the head of polyp in sight; (b) the detachable snare is moved to the stalk while closing; (c) complete closure of the detachable snare; (d) release of the detachable snare and the polyp becomes purple.

Figure 5.

Crossed-clip strangulation method. (a) The first clip application to the stalk of the pedunculated polyp; (b) the transparent hood rotates the clip by 90°; (c) the second clip is being applied; (d) the completed crossed-clip strangulation makes the polyp purple.

Figure 6.

Endoscopic reduction of intussusception. Antegrade DBE strategy: (a) the tip of the endoscope is inserted beyond the polyp and then the balloon is inflated; (b) the endoscope is carefully withdrawn while feeling subtle resistance. Retrograde DBE strategy: (c) the endoscope is advanced to just the anal side of the intussusception area, and then water injection is performed to increase the intraluminal pressure. The backflow is prevented by inflating the balloon at the tip of the endoscope; (d) endoscopic reduction is accomplished. DBE, double-balloon enteroscopy.

Figure 7.

Endoscopic image of familial adenomatous polyposis of the small bowel observed by double-balloon enteroscopy-assisted chromoendoscopy using indigo carmine.

Figure 8.

Follow-up strategy for familial adenomatous polyposis. Factors used to determine the interval to the next double-balloon enteroscopy session. Source: Cited from Sekiya et al. with a permission.

Figure 9.

Cold snare polypectomy for a polyp of the small bowel in a patient with familial adenomatous polyposis: (a) snaring the polyp without submucosal injection or electrocauterization; (b) mucosal defect after the polypectomy.