Recent Advances in Minimal Access Surgery-2 Subhash Khanna
INDEX
Page numbers followed by f refer to figure, and t refer to table.
A
Abdominoperineal resection 10, 12
Acetaminophen 22, 23, 26
Adenocarcinoma 6, 213
Adjuvant therapy 124
use of 12
Adult respiratory distress syndrome 145
Airway 212
Altemeir's procedure 85, 86, 93
Ambulation, early 27
American Cancer Statistics 66
American College of Gastroenterology 112
American College of Obstetricians and Gynecologists 29
American Joint Committee on Cancer 43, 210
American Society for Enhanced Recovery 29
American Society for Metabolic and Bariatric Surgery 22, 164
American Society of Anesthesiologists Guidelines 21
American Society of Clinical Oncology 112
American Society of Colon and Rectal Surgeons 114, 116
rectal prolapse of 88
Amine precursor 48
Anal encirclement operation 84
Analgesia
multimodal 22, 24
opiate-sparing 26, 27, 116
paravertebral 136
thoracic epidural 136
Analgesics
dosage of 23
nonnarcotic 22
use of postoperative 188
Anesthesia
bariatric 177
general 174
Anesthetics, intraoperative 23
Angioectasia 4
Antibiotics, intravenous 221
Antiemetic prophylaxis 23, 26, 27
Anti-glycan antibodies 3
Antineutrophil cytoplasmic antibodies 3
Anti-reflux valve 169
Anti-saccharomyces cerevisiae antibodies 3
Anxiety 190
Aorta 212
Appetite loss 190
Arterial counterparts 157
Arteriovenous malformation 4
Artery
hepatic 40f
ileocolic 157, 157f
right colic 157
supermesenteric 159
Association of Laparoscopic Surgeons of Great Britain and Ireland 235
Atelectrauma 135
Azygos vein 212
B
Bacteremia 137
Bacterial translocation 91
Balloon enteroscopy 7
Bariatric enhanced recovery 28
Bariatric instruments 176
Bariatric procedure 170
Bariatric surgery 19, 167, 177, 219
options 175
Barotrauma 135
Barrett's esophagus 137, 169
Basement membrane 212
Bikini laparoscopic cholecystectomy 231
Bile duct
carcinomas 43
resection 40
Bile reflux 168
risk of 169
Biliary branches, secondary 36
Biliary cancer
comprises gallbladder cancer 35
laparoscopy for 35
staging laparoscopy in 35
Biliary gastritis 169
Biliary malignancies 43
Biliary reflux 175
Biliary system, core section of 43
Biliary tumors 43
Biliopancreatic diversion 103, 106, 166, 176
Biliopancreatic limb 167, 169
lengthening of 175
longer 166
Biopsy, gastroscopic 168
Bismuth carcinomas 44
Bladder cancer 29
Bleeding 4, 111
intra-abdominal 168
intraluminal 168
Blind-ending cystic sac 6
Blood
count, complete 220, 224
loss, reduced 180
Body mass index 70, 166
Bougie, size of 223
Bowel 177
disease
habits 111
obstruction 111
preparation 22, 116
Breast, reconstructive 28
Breath test biomarkers 4
C
Cancer
colorectal 69, 70, 110, 154
esophagus 131
Capnomediastinum 136
Capsule endoscopy 1, 50
Carbohydrate
drink 26
loading 21
Carbon dioxide
extraperitoneal 135
insufflation 138
Carcinoid 131
syndrome 50t, 51
tumors 50t
Carcinoma 131
gallbladder, early 38
hepatocellular 42
in situ 210
of esophagus, pathologic TNM staging of 211
Catabolism 24
Catheter, placement of 24
Caudate lobe resection 44
Cavity, abdominal 193
Celiac disease diagnosis of 4
Cell membrane 48
Central lymph nodes 153
Central vascular ligation 153, 156
Cervical
anastomosis 147
dissection, omission of 147
esophagus 141
Chemoprophylaxis 24
Chemoradiotherapy
long course 113
neoadjuvant 9, 146
Chemotherapy 113
neoadjuvant 113, 214
Chest wall 143
Cholangiocarcinoma
intrahepatic 42
laparoscopy for 42
perihilar 44
treatment of 42
Cholecystectomy 41
laparoscopic 231
mini-laparoscopic 233
postlaparoscopic 37
radical 41
robotic single port 233
two-port laparoscopic 232
Cholelithiasis 231
Chronic obstructive pulmonary disease 133
Cineloop defecography rectal prolapse 83f
Circumferential resection margin 9, 68, 119
Closed suction drains 24
Coagulopathy 137
Coloanal anastomosis 12
Colon cancer
basis of 154
left-sided 156
right-sided 154
surgical resection of 152
technique for 152
descending 156
Colonic nets 60
Colonoscopy 111
Combined modality therapy 112
Complete capsule endoscopy setup 2f
Complete mesocolic excision 155, 156, 159
review of 152
technique of 156
Computed tomography 208
contrast-enhanced 112
Connective tissue disorders 81
Constipation, risk of 22
C-reactive protein 182, 190, 193, 220
Crohn's disease 35, 7
endoscopic index of severity 5
Cystectomy 29
D
D’Hoore ventral rectopexy 89
da Vinci surgical system 12
Decubitus position, lateral 142
Deep venous thrombosis 22, 173
Dehydration, risk of 22
Delorme's procedure 85, 86f
Denonvilliers’ fascia 72, 152
Diabetes 219, 223
mellitus 98
type 2 165, 173
Diaphragm 212
Dieulafoy's lesion 4
Digital rectal examination 111
Discomfort, abdominal 22
Disease-free survival 113
Distal ascending colon 158
Distal coning 121
Distal margin 119
Distant metastasis 211, 212
Double-balloon enteroscopy 50
Drain along staple line, use of 223
Duodenal carcinoids 56
Duodenal switch 103, 106, 166, 176
Duodenojejunal bypass 176
Duodenum containing carcinoid tumor by laparoscopic stapler, laparoscopic resection of 58f
Dyslipidemia 98
Dysphagia 101
Dysplasia, high-grade 212
E
Electrolyte abnormalities 22
Embolism, pulmonary 24, 168
Endoscope-assisted laparoscopic
intragastric and transgastric resection technique 54f
wedge resection 53f
Endoscopic cooperative surgery 193
Endoscopic mucosal resection 51, 60
Endoscopic staple 53f
Endoscopic submucosal
dissection 53f
injection around tumor 55f
Endoscopic techniques 103, 104
Endoscopic ultrasound 209, 210
Endoscopy 1, 5, 50, 53f, 56
conventional 1
device assisted 3
imaging in 1
intraoperative 191
Endotherapy 221, 226
End-to-end anastomosis 143
stapler 144, 144f
Enhanced recovery after bariatric surgery 22
protocol 25
Enhanced recovery after surgery
components 20
goals of 19
Erosion 101
Esophageal cancer 148, 208, 215
surgery of 131
Esophageal carcinoma 131
Esophageal dilatation 101
Esophageal hiatus, visualization of 142
Esophageal mucosa 169
Esophagectomy 136
open 132, 146
transhiatal 62, 132
Esophagitis 169
Esophagogastric anastomosis, thoracoscopic creation of 144f
Esophagogastroduodenoscopy 138
Esophagus 62, 168
cancer of 131, 211
neoplasm of 131
proximal 144
European Organization for Research and Treatment of Cancer 147
European Society for Medical Oncology 112
Exclusion technique 222
Extensive extramural venous invasion 112
Extrahepatic bile duct 37
resections 42
Extralevator abdominoperineal excision 117
Extramesorectal nodes 112
Extramural vascular invasion 112
F
Fascia
mesocolic 156
mesorectal 112
parietal 152
visceral 152
Fast-track surgery, concept of 189
Fatigue, postoperative 190
Fecal incontinence 82
Feeding, early 27
Fibrin sealants 223
Fine needle aspiration 112
Fistula, management of 103
Flagellins, subtypes of 3
Fluid management 116
Foveolar hyperplasia 168
G
Gabapentin 23, 26
Gallbladder 231
benign disease 38
cancer 36, 37
carcinoma 37, 38
incidental 38
laparoscopy for 37
perforation, absence of 37
Gallstones 58
Gastrectomy
open distal 180
robotic 192
trials 190
Gastric
adenocarcinoma 188
artery, left 188
band
addition of 106f
complications 101f
over enlarged pouch after gastric bypass 103f
bypass 219, 225f
proximal 166
cancer 180, 182, 189, 190, 208210
early 189, 194
management of 180
pathologic TNM staging of 210
primary 182
staging 216
carcinoma 188
conduit 144
mobilization 139f
mucosa 169
nets 51
neuroendocrine tumors, types of 52t
outlet obstruction 100, 139
perforation, risk of 158
pouch 102, 169, 224
tube
longer 165
narrower 165
tubularization 140, 141f
wall, posterior 54f
Gastrocolic trunk 157f
Gastroenteritis, eosinophilic 7
Gastroepiploic vein 157
Gastroesophageal junction 211, 216
tumor 141, 208
Gastroesophageal reflux disease 99, 101, 166
Gastro-gastric fistula 100, 102
after Roux-en-Y gastric bypass 103f
Gastrointestinal
leak 219
after bariatric surgery 227
neoplasms 6
surgery 29
swallow, upper 24
tract 48
Gastrojejunal anastomosis 166
Gastrojejunostomy 102, 104, 224
Gastroparesis 168
Gastrostomy
closure of 144f
resection of 144f
Gene Xpert, role of 6
Genitourinary function 16
Glucagon-like peptide-1 167
Glucose intolerance 98
Glycemic control 166
Goal-directed therapy 136
H
Harvested lymph nodes 188
Heald's holy plane 67f
Health economic benefits 25
Heart disease, ischemic 133
Heartburn, symptoms of 169
Hemorrhage 177
Hemorrhoids, internal 82f
Heparin, unfractionated 24
Hepatic artery, common 39
Hepatic flexure 158
Hepatic functions tests 174
Hepatic resection 45
Hernia
hiatal 99
incisional 123
port site 168
Hilar cholangiocarcinoma 36, 43, 44
Holy plane 120, 122
Hybrid esophagectomy 146
Hyperglycemia
high risk of 21
uncontrolled 26
Hypertension 98, 219, 223
Hypoalbuminemia 223
Hypoglycemia 99
Hypoproteinemia 219
Hypovolemia 137
I
Ileum, terminal 5
Improper stapling technique 219, 224
Indocyanine green
intraoperative 123
simultaneous 191
Infection 101, 102, 137
risk of 21
Inferior mesenteric artery 156
Inflammation, chronic 173
Infra-red illuminated stents 123
Injury, iatrogenic 177
Insulin 21
releasing substances 167
resistance 21, 24
Interleukin-6 189
International Federation for Surgery of Obesity and Metabolic Disorders 164
Intersphincteric resection 117
Intestinal tuberculosis diagnosis of 5
Intestine 169
Intracranial pressure 137
Intra-gastric balloon insertion 174
Intramesocolic propria 154
Intraoperative leak test 223, 227
Intrathoracic esophagus, thoracoscopic mobilization of 147
Intussusception, rectorectal 83f
Invasion, depth of 112
Irritable bowel syndrome 5
Ivor Lewis esophagectomy 62, 137
J
Japanese Laparoscopic Surgery Study Group 181
Japanese Society for Cancer of Colon and Rectum 112, 154
Jaundice 111
Jejunal and ileal NETs 57
Jejunojejunal anastomosis 224
Jejunojejunostomy 224
Joint pains 98
K
Kaplan-Meier univariate analysis 146
Karnofsky score 133
Klatskin tumor 43
Korean Laparoscopic Gastrointestinal Surgery Study Group 181
L
Laparoscopic
abdominoperineal resection, port position for 63f
adjustable gastric band 101, 176
addition of 105
assisted
distal gastrectomy 188
endoscopic resection 53f
gastrectomy 180, 191
resection 75
surgery 69
total gastrectomy 189
colorectal train trainers course 235, 236
cooperative surgery 193
distal gastrectomy 56
endoscopic combined surgery 54f
gastrectomy 182, 188, 189, 192, 193
port position for 56f
gastric tube creation 147
intraoperative ultrasound 35
liver resection 35
low anterior resection, port position for 62f
procedures 100
radical
cholecystectomy 39
distal gastrectomy 188
gastrectomy 190
resection 58, 61
rectopexy 88
right colectomy 160
segmental duodenectomy 58f
sentinel node 213
seromuscular dissection around tumor 55f
sleeve gastrectomy 99, 104, 166, 219
spleen-preserving splenic hilar lymphadenectomy 193
stomach-preserving surgery 191
surgery 16, 41
use of 188
thoracoscopic
esophagectomy 137
McKeown approach 147
total gastrectomy 182
transhiatal
esophagectomy 137
mobilization 147
ventral mesh rectopexy 91, 92f
whole-layer cholecystectomy 41
Laparoscopy 53f, 56
diagnostic 36, 208
long-term follow-up of 189
minimally invasive surgical techniques of 215
role of 216
Laparotomy nontherapeutic 36
Large redundant sigmoid colon 81
Leak
after sleeve gastrectomy, common site for 220t
gastrojejunal 225
incidence of 224t
location of 224t
presentation, timing of 220
risk factors for 219
site of 220f, 224
Leaking part, suturing of 221
Left hemicolectomy, port position for 61f
Leiomyosarcomas 131
Lesser omentum 139
Lesser pain 180
Leukocyte count 189
Levator ani
joins rectum 119f
muscle 92
Levatorplasty 86
Ligament of Treitz 165
Limb, alimentary 167
Linitis plastica carcinoma 210
Liver 177
cancer, primary 42
cirrhosis 133
parenchyma, major 43
resection
extent of 39
open 43
tumors, primary 42
Lloyd-Davies position, modified 138
Loco regional recurrences 66
Loop gastric bypass 164
Low rectal cancers, management of 10
Low-molecular weight heparin 174
Low-pressure system 166
Luminal gastrointestinal neuroendocrine tumors 48
Luminal neuroendocrine tumors, surgical management of 48
Lung
injury 135
acute 135
ventilation 134
Lymph node 154, 155, 210, 213, 214
gastroepiploic 159
mesocolic 154
metastasis 188
nonlocoregional 36
number of 9, 191, 192
perigastric 188
prepyloric extramesocolic 158
Lymphadenectomy 40f, 43, 153, 188, 193
extent of 39
laparoscopic 41, 43
mesenteric 5
Lymphocyte count 189
Lymphoma 6, 131
Lymphovascular drainage 153
Lymphovascular invasion 68
M
Magnetic resonance imaging 66, 73, 209
high resolution 73
Malaise 111
Malignancy, risk of 169
Malignant cells 212
Malnutrition 99, 100
Mason's loop gastric bypass 165, 169
Mechanical bowel preparation 22, 116
role of 22
Meckel diverticulum 6
Melanomas 131
Mesh rectopexy 89
Mesocolic anatomy, appreciation of 152
Mesocolic defects 153f
Mesocolic vasculature 156
Mesorectal excision 68, 122f
in minimally invasive rectal cancer surgery, evidence-based management of 66
Mesorectal nodes 112
Mesorectum 66, 68, 121
irregularities on 121
Metabolic and bariatric
surgery accreditation and quality improvement program 20
surgical clinical reviewer 28
Metabolic procedure 98, 170
chronic complications of 99
Metabolic surgery, reoperative 98
Metabolic syndrome 98
resolution of 165
Metastasis 188, 211
port site 40
Metastatic deposits 49f
Metastatic disease 209
presence of 210
Metastatic neuroendocrine tumor 49f
Mid rectal cancers, management of 10
Midthoracic esophageal tumor 137
Mini-gastric bypass 164
one-anastomosis gastric bypass, current status of 164, 169
Minimal access
methods 52
surgery 48
Minimally invasive
approach, evidences in support of 132
esophagectomy 133135, 138, 145
laparoscopic port placement of 138f
technique 145
thoracoscopic port placement for 142f
tissue edema 136
method 118
surgery 16, 133, 145148, 180
Minimum nutritional effects 167
Mobilization, rectal 87
Mucus discharge 82
Multidisciplinary team approach 111
Multimodal accelerated recovery trajectory 29
Multiple randomized controlled trials 69
Muscle strength, loss of 24
Muscularis
mucosa 210, 212
propria, visualization of 122f
submucosa 212
N
Nasogastric tube 23
National Comprehensive Cancer Network 112
National Institute for Health and Clinical Excellence 134
Natural orifice transluminal endoscopic surgery 231, 233
Nausea
management of 24
postoperative 23, 30, 116
Needlescopic procedures 231
Neoadjuvant therapy 113, 114
indication of 113t
Neoadjuvant treatment 112
Nerve
autonomic 16
blocks, regional 23
compression 177
sparing 122
Neuroendocrine system 48
Neuroendocrine tumor 6, 48, 62
laparoscopic duodenal excision of 57f
Neuropeptides 48
Neurotransmitters 48
Non-exposed endoscopic wall-inversion surgery 55f
Nonsteroidal anti-inflammatory drugs 7, 23
enteropathy 7
Nutrition 225
early postoperative 24
preoperative 21
Nutritional
complications 175
deficiency rate 167
optimization 115
risk screening 134
status 190
O
Obesity 98
prevalence of 173
Obstructed defecation syndrome 86
Obstruction, intestinal 6
Obstructive sleep apnea 98
high risk of 173
Omentum 177
One-anastomosis gastric bypass 164, 175
Open spleen-preserving splenic hilar lymphadenectomy 193
Osteoarthritis, severe 173
Ostomy 123
Oxygen dependency 223
P
Pain
abdominal 111
back 111
chronic 25
management plan 25
postoperative 100, 180
Pancreas 159
posterior superior 39
Pancreaticoduodenal vein, anterior 157
Pancreaticoduodenectomy 56
Parenchymal liver deposits 36
Parenteral nutrition, total 221
Peak insulin secretion, early 166
Pelvic
floor 112
disorders 81
magnetic resonance imaging, high resolution 112
pain 111
Perforation 111
Pericardium 143, 212
Perineal procedures 84
Perineal stapled prolapse resection 87
Perineural invasion 68
Perioperative fluid management 116, 136
Peritoneal reflection 112
Peritoneum 212
visceral 153, 211
Petersen's defect 165
Peutz-Jeghers syndrome 6
Plasma chromogranin 50
Pneumonia 145
Pneumoperitoneum 138, 232
Pneumothorax 143
Polycystic ovarian disease 98
Polypectomy 60
Positron emission tomography scans 210
Post sleeve gastrectomy leak 219
Posterior mesh rectopexy 90
Postgastric bypass leak 223
Postweight loss surgery enteral leaks evidence-based management 219
Potassium chloride 7
Pouch dilatation 101
Pouch of Douglas 81, 92
Preoperative radiation therapy options 113
PRISMA diagram 12
Proctosigmoidectomy, perineal 86
Prophylactic ureteral stenting 122
Protein malnutrition higher risk of 167
Pyloroplasty 140
laparoscopic 140f
Q
Quality of life, health-related 145, 146
Quirke's grading protocol 121t
R
Radial resection margin 119
Radical abdominoperineal resection 110
Radiological imaging, advances in 3
Rectal adenocarcinoma
resection of 9, 10
surgical management of 9
Rectal cancer 69, 75, 111, 123
laparoscopic resection for 61
management of 152
signs of 111t
surgery
pathologist's role in 68
perioperative optimization of 110
symptoms of 111t
treatment of 16, 66, 67
upper 120f
Rectal carcinoma 9, 16, 17
robotic-assisted surgery for 15
treatment of 10
Rectal mucosal prolapse 81f
Rectal NETs 60
Rectal prolapse 80, 82f, 93
complete 80f, 81f
procedures 92
recurrent 93
surgical procedures for 84
Rectal surgery, holy plane of 110
Rectal tumor
obstructed 123
regression, MRI grading of 114t
Rectopexy
resection 88f
robotic 92
transabdominal
resection 88
sutured 87
Rectosigmoidectomy, perineal 86
Reflux disease 166
Regional lymph node 211, 212
dissection 121
involvement of 210
metastasis 211, 212
Regurgitation, symptoms of 169
Rehabilitation, accelerate postoperative 190
Renal functions tests 174
Resection, robotic-assisted 12
Restrictive procedure 102
Right colectomy group 160
Right colon complete mesocolic excision 157f
Right hemicolectomy 59
port position for 61f
Ripstein procedure 89, 89f
Ripstein repair 89
Robotic surgery 9, 10, 16, 17, 75
development of 16
Robotic Train Trainer Course 235, 237
Roux limb, distalization of 103
Roux-en-O configuration 224
Roux-en-Y gastric bypass 23, 99, 102, 105, 105f, 164, 175
revision of failed 104
S
Sacrocolpopexy, abdominal 93
Sarcoma 6, 131
Scopolamine patch 26
Self-expending-metallic-stent 222
Sentinel basin dissection 191
Sentinel lymph node
guided surgery 191
mapping 191
navigation surgery 191
Sepsis 137
Sequential compression devices 24
Serological tests 3
Shackelford's surgery 60
Shear wave elastography 3
Shock 137
Short course preoperative radiotherapy 113
Single anastomosis duodeno-ileal switch 176
Single incision laparoscopic
cholecystectomy 231, 233
surgery 73
Single lung ventilation 135
Single port laparoscopic distal gastrectomy 192
Skeletal muscle 21
Sleep apnea 219
presence of 223
Sleeve gastrectomy 19, 24, 175, 176, 220f
Sling rectopexy, anterior 89
Small bowel
diseases 1
disorders 4
diverticula 6
mass lesions 6
mucosal damage 4
neoplasias 7
Small cell carcinomas 131
Small intestinal cancer 6
Small intestine neuroendocrine tumors 6
Society Manual of Enhanced Recovery Programs 29
Specimen extraction techniques 193
Spectral attenuated inversion recovery 73
Sphincter
complex 112
saving procedures 117
sparing resection 117
Spine 28
Spleen 177
Spoiled gradient echo 209
Squamous cell carcinoma 212
Staging laparoscopy 35, 208, 213, 214
post neoadjuvant chemotherapy, role of 214
technique of 213
Staple line reinforcement and fibrin sealant 223
Stapled transanal rectal resection 86
Stapler hemorrhoidectomy, technique of 86
Stent, deployment of 222
Stereolithography 73
Stoma closure 124
Stomach 224
Stress, surgical 189
Super obesity 173
large left liver lobe in 178f
Superior mesenteric vein 156, 157, 157f
Surgery 131, 180, 221, 226
choice of 117
colorectal 116
metabolic 106
open 41, 133, 223
plane of 121
revisional 223
robot-assisted 45
timing of 114
Surgical resection, optimal principles of 118
Surgical site infection 168
System leak 101, 102
T
TEO platform 71f
Thiersch procedure 84, 85f
Thoracic aorta, descending 143
Thoracoscopy, minimally invasive surgical techniques of 215
Three-dimensional structures 73
Thrombocytopenia 137
Thromboembolism, risk for 24
Thromboprophylaxis 19, 24, 116
Thrombosis, cancer-associated 116
Toldt's fascia 156
Torsion, anastomotic 168
Total laparoscopic distal gastrectomy 193
Total laparoscopic-thoracoscopic Ivor Lewis esophagectomy 147, 148
Total mesorectal excision 9, 10, 66, 67, 110, 120, 152
specimen 121
Transabdominal approach 120
Transabdominal transanal operations 70
Transabdominal transanal procedure development of 110
Transanal endoscopic microsurgery 66, 71, 75f
devices 62f
Transanal endoscopic surgery 118
Transanal minimally invasive surgery 62f, 66, 118, 118f
Transanal total mesorectal excision 67, 70, 110, 121
procedure 71
Transpulmonary pressure, excessive 135
Transversus abdominis plane 23
block 23, 26
Trouble shooting scenarios 237
Tube disconnection 101
Tumor 212
cell dissemination, risk of 37
distal edge of 112
gastrointestinal 208
invades
adjacent structures 211, 212
adventitia 212
lamina propria 210, 212
muscularis propria 211, 212
other adjacent structures 212
pleura 212
serosa 211
submucosa 210, 212
invasion, depth of 210
left-sided 159
localization of 54f
pancreatic neuroendocrine 6
penetrates subserosal connective tissue 211
primary 51, 112, 210, 212
retraction of 55f
submucosal 192
tissue 48
Two-dimensional images 73
U
Ulcer, marginal 99, 100
Ultrasound, contrast-enhanced 3
United Kingdom Medical Research Council 69
Urinary
catheters 24
symptoms 111
V
Vaginal prolapse procedures 92
Vein
ileocolic 157f
right colic 157
Vertebral body 212
Very low-calorie liquid diet 174
Visual analogue scale pain score 147
Volutrauma 135
Vomiting, postoperative 30, 116
W
Watch-and-wait approach 124
Weight loss 100, 111, 165
excess 98
Wells posterior mesh rectopexy 90f
Wells procedure 90
White light endoscopy capsule 2f
Wound dehiscence, lower risk of 182
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Chapter Notes

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Novel Diagnostics for Small Bowel DiseaseCHAPTER 1

Subhash Khanna,
Dipak Kumar Sarma
 
INTRODUCTION
Small bowel diseases are difficult to diagnose at times. Evaluation of many small bowel diseases are now becoming easier because of advent of some novel diagnostics. With the introduction of video capsule endoscopy the visualization of whole small bowel is now becoming possible. It has revolutionized the diagnostic of bowel pathology. Other developments in serological test and breath test biomarkers are also creating newer insights in evaluation of many small bowel diseases.
 
ADVANCES IN IMAGING IN ENDOSCOPY
Endoscopy is an important tool in evaluation of many small bowel disorders. In last few years there has been tremendous development in the imaging system of the endoscopes. Visual diagnoses are becoming more sensitive and accurate. From the conventional endoscopy, endoscopists have shifted to many improvised endoscopic techniques like high definition endoscopy, dye based and digital chromoendoscopy, endosonography and capsule endoscopy. Moreover advanced technologies like full-spectrum endoscopy, endocytoscopy, autofluorescence, laser endoscopy, and endomicroscopy, including molecular imaging have changed the scenario in endoscopy.1
 
Capsule Endoscopy (CE)
Capsule endoscopy, also known as wireless video endoscopy or video capsule endoscopy (VCE) is a very powerful tool for diagnosis of small bowel diseases2 (Figs. 1 and 2). It was first introduced in 2001.2 Capsule endoscopy offers a perfect view of small bowel.3 Like conventional endoscopy CE does not need typical maneuvers like probing and sampling of tissues. But, it needs knowledge of normal anatomy, its variations and the anatomical changes that are occurring because of the disease.3 Recognition of anatomical landmarks is essential. The reader should be aware of artifact, unfamiliar normal anatomy in interpreting any pathology of the bowel. Image seen in small bowel CE is more magnified than conventional endoscopy. One must be very careful not to interpret a normal finding seen as huge in CE. Training and experience is essential for competency.3
In CE mucosa of small bowel can be inspected and diagnosis relies on visible findings.2 Initial CE system had primarily white light imaging (WLI) 2incorporated to it.2 Till now it is used. WLI may not detect subtle mucosal microlesion. Submucosal and/or transmural pathology may not be clearly detected. There are now some new developments in CE system where modalities like microultrasonography and infrared light are incorporated.2 They enhanced detection of pathologies and limitations of WLE are minimized. There is improved differentiation between and benign lesion.2 There are some studies on clinical efficacy of these new capsules. But study population is small. Further studies are required to know about their clinical efficacy.2
zoom view
Fig. 1: The white light endoscopy capsule.
zoom view
Fig. 2: The complete Capsule endoscopy setup.
Improved computer aided diagnosis will be a possibility from the newer diagnostic capsules.2 People will also get benefit from virtual biopsy and capsule localization from the newer capsules.2 Research is going on to 3incorporate sensors to capsules to measure physiological parameters or find out new biomarkers. It will increase sensitivity, specificity and clinical utility of the capsule.2
Device assisted endoscopy (DAE) is another development in history of small bowel endoscopy. It is used for both diagnostic and therapeutic purpose. DAE can help at times to overcome the limitations in CE.3
 
Advances in Radiological Imaging
Conventional barium studies have limited role in diagnosis of bowel diseases. Often additional CT studies are required to characterize small bowel lesions.4 Ultrasound is useful for assessing small gut specially in combination with oral or intravenous contrast agent.5 Contrast-enhanced ultrasound (CEUS) can detect bowel wall inflammation.6 Ultrasound Shear Wave Elastography (SWE) are found to be safe and effective.6 Point-of-care ultrasound (POCUS) is new modality used by the clinicians in an emergency set up for evaluation of acute abdomen. POCUS is an extension of the clinical examination when used by acute care clinicians in evaluating an acute abdomen.7 A trained physician can use POCUS findings for detection of specific intestinal pathologies.7 Conventional CT with intravenous (IV) and oral contrast is used as investigation for small bowel disease. Inflammatory and neoplastic diseases are usually detected.4
CT enteroclysis and CT enterography are used for many small bowel diseases like tumor, inflammatory diseae, celiac disease, malabsorption, low-grade small bowel obstruction and gastrointestinal (GI) bleed.4,5
Though CT is a good modality MR has some advantages over CT. Soft tissue contrast resolution, multiplane imaging and free from ionizing radiations are its advantages.4 MR is the preferred imaging modality in inflammatory bowel diseases (IBD) because of its capacity for multiparametric approach and evaluation of bowel motility. There is no radiation exposure for MRI.5 MRI is now considered important for evaluation of small bowel disease.8
Other than MR enterography novel MRI techniques such as DWI, motility studies, PET-MRI and molecular imaging are increasingly used for diagnosis of bowel disease.8 PET-CT is emerging as a new investigative tool for IBD patients.4 PET-CT with FDG increases the capacity of spatial localization in comparison with PET-FDG without CT.4,8 PET/CT can show functional and morphological picture of GIT with extraintestinal involvements.8 There is reduced uptake in fibrous areas of intestine in PET-CT.8 As PET-CT has better detection of colonic inflammation in comparison to CT or MRE it is more advantageous in evaluation of IBD.8
 
Serological Tests
For evaluation of Crohn's disease and ulcerative colitis newer serological markers named as antineutrophil cytoplasmic antibodies (pANCA) and anti-Saccharomyces cerevisiae antibodies (ASCA) are added to previously available markers like antibodies against the outer membrane porin C (OmpC) of E. coli, antibodies against subtypes of flagellins (CBir1) and various anti-glycan antibodies.9 They act as predictors before the diagnosis.4
 
Breath Test Biomarkers
Breath tests are used for diagnosis of small intestinal bacterial overgrowth (SIBO) in IBD.10,11 Breath H2S is a new addition to breath test biomarker for assessment of SIBO.11
 
NOVEL DIAGNOSTICS IN SOME SPECIFIC SMALL BOWEL DISORDERS
Bleeding: Use of capsule endoscopy has improved detection rate of source in GI bleed and obscure gastrointestinal bleeding (OGIB).10,12 American Gastroenterological Association has defined OGIB as persistent or recurring bleeding condition of unknown origin after negative upper and lower endoscopies.4 The source of bleed in OGIB has is in small bowel in 5–10% of these patients. It is found to be up to 27% of patients I some studies.4 A large systematic review showed the diagnostic yield of video capsule endoscopy as 59.4% in OGIB. Out of these > 50% had angiodysplasias.13 Another study shows its sensitivity in OGIB 42–80%.4,48 Common causes of OGIB are angioectasia (AE), Dieulafoy's lesion (DL), arteriovenous malformation (AVM).12 Subsequent to VCE deep enteroscopy is done for diagnosis of small bowel Ads and also to control active bleed or to improve anemia.12 The indications for DE and VCE are same. But, VCE can visualize almost 90% of the bowel.12 Real time viewing or increased battery capacity can increase more visualization.12 Diagnostic yield of VCE is highest when it is done at the time of bleeding.12 Many GI societies recommend VCE as first line investigation for evaluation of small bowel bleed.12
Celiac disease: Diagnosis of celiac disease is usually done by demonstrating histological small-bowel mucosal damage induced by gluten. New noninvasive serological tools are available now.14 Breath tests and other biomarkers are also used for diagnosis of the disease.10 Endoscopic biopsy is essential for a definitive diagnosis. MR studies may be done for diagnosis in patients with atypical symptoms.4 MR enterography is helpful for complications in known patients with celiac disease.4 VCE was also evaluated as an alternative to invasive endoscopic biopsies.10
Inflammatory bowel disase: In last few years many diagnostic modalities are developed for diagnosis of IBD and for its follow up in the course of the disease. MRI has been increasingly used. Advanced development of MRI like diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) MR perfusion and MR motility is enhancing diagnostic accuracy in assessment of the disease.15 Use of spectroscopy, PET-MRI and molecular imaging are currently under investigation to improve the diagnosis, follow-up and management of the disease.8 MR enterography has become a part of standard diagnostic modality in Crohn's disease (CD).8 DWI for detecting and assessing ileal inflammation in CD.8 Fibrosis in bowel wall can be seen directly magnetization transfer imaging technique.15
Horsthuis K et al found that CTE and MRE have similar capacity to diagnose CD. CT5 PET and PET-CT are now increasingly used for assessment of CD.15 Hybrid imaging (PET/MRI) has also shown its potentiality.155
Ultrasound findings are non-specific in IBD. But it can be used as initial guide for further investigations.8
Recent use of EUS in assessing perianal fistulas in CD and chromoendoscopy for dysplasia surveillance has widened the role of USG.16 In a recent study by Cathy Lu et al CEUS (Contrast-enhanced ultrasound) and SWE (Ultrasound Shear Wave Elastography) are found to be safe and effective. CEUS can detect bowel wall inflammation. Measurement of bowel wall thickness can be measured by SWE. They can act as noninvasive objective biomarkers in management of strictures in Crohn's disease.6
Early detection of SIBO in Irritable Bowels Syndrome (IBS) is a strategy in management of IBS. Current method based on hydrogen breath test (HBT) has limitations and drawbacks. Most of the times it fails to detect SIBO caused by ‘non-hydrogen-producing’ bacteria of colon. Breath H2S is a novel biomarker for assessment of SIBO. It can detect SIBO in cases where often HBT fails to detect it. It is non-invasive and rapid.11 Study showed it useful for accurately identifying SIBO either at onset or after eradication of disorder.11
Endoscopy is an important tool in diagnosis of inflammatory bowel disease. Endoscopists are getting advantages from newer advances in endoscopic techniques like dye-based and digital chromoendoscopy, high-definition endoscopy, capsule endoscopy, and endosonography. Advanced experimental technologies like full-spectrum endoscopy, endocytoscopy, auto fluorescence, laser endoscopy, and endomicroscopy, including molecular imaging are used for evaluation of inflammatory bowel disease.1
CE has high sensitivity and high specificity for Crohn's disease.2 It is useful for monitoring activity of the disease and its response to therapy.2,10
Crohn's Disease Endoscopic Index of Severity (CDEIS) is used for measuring mucosal disease in Crohn's disease.17 For Capsule Endoscopy a newer index is developed. It is known as Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score). A comprehensive view of small intestine is possible with capsule endoscopy in CD patients.2,17
With the advent of the second generation of the CE of the colon (PillCam 2 or “IBD” capsule), a new score (CECDAIic) is developed as this generation of CE has ability to visualize both small bowel and colonic inflammation.17
Genetic and serological tests are tried for diagnosis of inflammatory bowel disease. But, ECCO-ESGAR Guideline (2018) does not recommend Genetic or serological testing for routine diagnosis of CD or UC.18
 
INTESTINAL TUBERCULOSIS
The diagnosis of intestinal tuberculosis is a challenge to the physician. Use of ultrasound, CT and MRI has been tried with varied success. Ultrasound guided aspiration followed by diagnostic laparoscopy is an option.19 Diagnostic laparotomy is the last resort.19 CE and Enteroscopy are not in diagnostic algorithm because of limited data from the use of these investigations.19 There is also a possibility of capsule causing complete obstruction in tuberculous small bowel stricture.19
MR images may be helpful by showing circumferential wall thickening of cecum and terminal ileum, mesenteric lymphadenopathy, wall ulcerations and peritoneal involvement.46
Role of gene Xpert is studied for diagnostic efficacy. In one study diagnostic sensitivity is found to be very poor (8.1%), but specificity was found very high (100%).20
 
Small Intestinal Cancer
Three to six percent of all gastrointestinal neoplasms are found in small bowel.5 The types of neoplasm are adenocarcinoma (30–45%), neuroendocrine tumor (20–40%), lymphoma (10–20%), and sarcoma (10–15%).5 Molecular tools are new development in diagnostics for some neoplasm of small bowel.
Monoanalyte biomarkers(CgA or other monolyte peptides/hormones) are found to be ineffective as diagnostic marker in gastroenteropancreatic neuroendocrine tumors.21 Elevated NETest, a multianalyte molecular signature is found to be effective in diagnosing PNETs (pancreatic neuroendocrine tumors) and SINETs (Small Intestine Neuroendocrine tumors). NETest was 92% concordant with anatomical imaging, 94% with Ga-SSA-PET/CT and 96% dual modality (CT/MRI and Ga-SSA-PET/CT).21 To observe accurate progression of the disease NETest can be used.21
CE was found to be superior to MRE for FAP and Peutz–Jeghers syndrome in a prospective study of 20 patients in identifying smaller polyps (<5 mm diameter).2 British Society of Gastroenterology recommended that CE should be done at interval of 1-3 years for surveillance of hereditary polyposis syndrome.2 Surveillance can also be done for small bowel cancer10 and other mucosal disorders. Differentiation between small bowel tumors and benign bulges has been improved after using a novel endoscopic algorithm.10 It is difficult to identify pathology and tumor type based on endoscopic appearance of lesions gained from CE. Missed rate of detection by CE for neoplastic disease can reach upto18,9%.4 Pennazio et al. described 51 patients showing polypoid lesions in CE without confirmation by further examinations (false positive capsule endoscopy).4 A positive CE requires further invasive examinations like endoscopic or surgical interventions.4
Capsule retention is seen in approximately 10–25% of cases of bowel neoplasms. So some favors MR enteroclysis for small bowel neoplasm.4
Newer cross-sectional radiologic techniques, such as CTE and MRE are favored for the detection of small bowel mass lesions (SBMLs) having predominant extraluminal component.4
 
Small Bowel Diverticula
MR and CT enteroclysis can detect small bowel diverticula. Because distension of the small bowel prevents collapse of diverticular segments of the intestine. It can also detect extraluminal abnormalities with inflammation.4
 
Intestinal Obstruction
Meckel diverticulum may present with gastrointestinal bleeding and obstruction. CT and ultrasound have a poor sensitivity for diagnosis of Meckel's diverticulum; MR can detect blind-ending cystic sac and blood products inside it.47
 
NSAIDs Enteropathy
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause mucosal injury of small intestine. As a result ulcers and subsequently circumferential strictures can develop. The gold standard for detecting NSAID enteropathy is capsule endoscopy and balloon enteroscopy.5 Differential diagnoses at imaging are radiation strictures, CD strictures, potassium chloride tablets and eosinophilic gastroenteritis.5 These strictures are difficult to detect at CTE, MRE and barium examinations. These are weblike short segment strictures unlike longitudinal strictures of Crohn's disease.5
 
CONCLUSION
Diagnosing lesions of small bowel has traditionally been based on various traditional radiological investigations and at times on clinical judgment. In the recent past various novel diagnostic modalities have been proposed ranging from MRI to various methods of enteroscopy, capsule endoscopy, image enhancement and also various types of biomarkers. It is assumed that many of such novel diagnostic methods are likely to be the routine methods of investigation in suspected cases of inflammatory bowel disease, occult lesions causing melaena and various small bowel neoplasias in near future.
REFERENCES
  1. Hundorfean G, Pereira SP, Karstensen JG, Vilmann P, Saftoiu A. Modern endoscopic imaging in diagnosis and surveillance of inflammatory bowel disease patients. Gastroenterology research and Practice. Volume 2018 |Article ID 5738068 | 10 pages | https://doi.org/10.1155/2018/5738068
  1. Cummins G, Cox BF, Ciuti G, Anbarasan T, Desmulliez MPY, Cochran S, et al. Gastrointestinal diagnosis using non-white light imaging capsule endoscopy. Nature Reviews Gastroenterology & Hepatology. 2019;16:429–47.
  1. Pennazio M, Rondonotti E, Koulaouzidis A. Small bowel capsule endoscopy normal findings and normal variants of the small bowel. Gastrointest Endoscopy Clin N Am. 2017;29–50.
  1. Masselli G. Small Bowel Imaging: Clinical Applications of the Different Imaging Modalities—A Comprehensive Review. Volume 2013 |ArticleID 419542 | 13 pages | https://doi.org/10.1155/2013/419542
  1. Laghi A, Hara AK. Small Bowel Disease. Diseases of the Abdomen and Pelvis 2018-2021. pp 117–22.
  1. Lu C, Gui X, Chen W, Fung T. Ultrasound shear wave elastography and contrast enhancement: effective biomarkers in Crohn's disease strictures. Inflammatory Bowel Diseases, 2017;23(3):421–30.
  1. Abu-Zidan FM, Cevik AA. Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced. World J Emerg Surg. 13, 47 (2018) doi:10.1186/s13017-018-0209-y
  1. Elfaal MW. Updates on the role of imaging in the assessment of Crohn's disease. Hamdan Med J. 2019;12:47–51.
  1. Fiona DM van Schaik, Bas Oldenburg, Andrew R Hart, Peter D Siersema, Stefan Lindgren, Olof Grip, et al. Serological markers predict inflammatory bowe disease years before the diagnosis. Gut 2013;62:683–88. doi:10.1136/gutjnl-2012-302717.
  1. Kopylov U, Seidman EG. Diagnostic modalities for the evaluation of small bowel disorders. Curr Opin Gastroenterol. 2015;31(2):111–7. doi: 10.1097/MOG.000000 0000000159.8
  1. Gourab Dutta Banik, De A, Som S, Jana S, Daschakraborty SB. Hydrogen sulphide in exhaled breath: A potential biomarker for small intestinal bacterial overgrowth in IBS. J. Breath Res. 10(2016)026010. Doi:10.1088/1752-7155/10/2/026010
  1. Sakai E, Ohata K, Nakajima A, Matsuhashi N. Diagnosis and therapeutic strategies for small bowel vascular lesions. World J Gastroenterol. 2019; 25(22): 2720–33.
  1. Liao Z, Gao R, Xu C, Li ZS. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: A systematic review. Gastrointest Endosc. 2010; 71(2):280–6
  1. Kurppa K, Taavela J, Saavalainen P, Kaukinen K, Lindfors. Novel diagnostic techniques for celiac disease. Expert Review of Gastroenterology & Hepatology. DOI:10.1586/17474124.2016.1148599.
  1. Li Y, Hauenstein K. New imaging technique in the diagnosis of inflammatory bowel disease. Viszerrrraimedizin 2015;31:227–34. www.karger.com/vim
  1. Bharadwaj S, Narula N, Tandon P, Yaghoobi M. Role of endoscopy in inflammatory bowel disease Gastroenterology Report, 2018;6(2):75–82.
  1. Niv Y, Gal E, Gabovitz V, Hershkovitz, Lichtenstein L, Avni I. Capsule endoscopy Crohn's Disease Activity Index (CECDAIic or Niv Score) for the Small Bowel and colon. J Clin Gastroenterol. 2018;52(1):45–49.
  1. Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, et al. ECCO-ESGAR guideline for diagnostic assessment in inflammatory bowel disease. Journal of Crohn's and Colitis. August 2018 DOI: 10.1093/ecco-jcc/jjy113.
  1. Abu-Zidan FM, Sheek-Hussein M. Diagnosis of abdominal tuberculosis: lessons learned over 30 years: pectoral assay. World Journal of Emergency Surgery. 2019; volume 14 Article number: 33.
  1. Kedia S, Das P, Madhusudan KS, Dattagupta S, Sharma R, Sahni P, et al. Differentiating Crohn's disease from intestinal tuberculosis. World J Gastroenterol. 2019; 25(4):418–32.
  1. Malczewska A, Witkowska M, Makulik K, Bocian A, Walter A, Pilch-Kowalczyk J, et al. NETest liquid biopsy is diagnostic of small intestine and pancreatic neuroendocrine tumors and correlates with imaging. Endocrine Connections. 2019;8:442–53.