Laparoscopic Assisted Pan Enteroscopy for Resection of Large Polyps in Small Bowel in a Patient with Peutz-Jeghers Syndrome

Abstract

Purpose: A 72-year-old male presented with complaints of fatigue and 20 lbs. weight loss for six months. Patient was noted to have iron deficiency anemia with Hgb of 6.2 g/dl, serum Iron <10 ug/dl and ferritin 4 ng/ml. Patient had history of Peutz-Jeghers syndrome and had undergone small bowel segmental resection 45 years ago for intussusception. An upper endoscopy showed multiple sessile polyps in the duodenum that were tubular adenomas on histopathology. Small bowel evaluation by CT enterography showed multiple intraluminal lesions nodules throughout the small bowel suggestive of large polyps. Considering the extensive involvement of the whole small bowel and large size of the polyps, decision was made to perform laparoscopy assisted panenteroscopy (LAPE). The two main objectives to perform LAPE were 1) exclusion of obvious small bowel malignancy in view of marked weight loss, and 2) reduce the tumor burden to minimize source of chronic blood loss and reducing the risk of malignancy by removal of the larger polyps. During LAPE, a colonoscope (Olympus CF-H180 AL) was inserted per orally towards distal duodenum. Then the endoscope was maneuvered past the ligament of Treitz with laparoscopic assistance. The small bowel loops were straightened and gently pleated onto the endoscope. After reaching within one foot of IC valve, careful withdrawal of the endoscope was performed removing 25 large polyps up to 3 cm in size by snare resection. Around 15 clips were used for prophylaxis on the resected stalks of very large polyps. A distal ileal enterotomy occurred at the site of a laparoscopically placed enteral clamp. This was immediately recognized and repaired by under running with intra corporeal suturing. Immediate post-operative course was uneventful and patient was discharged after 3 days. Our case reaffirms the role of LAPE in endoscopic management of lesions deep in the small bowel. In view of the number, size and location of the polyps, operative approach alone would have required multiple enterotomies. Removing several large polyps in a single endoscopic session is not a common practice due to higher risks of complications such as bleeding and perforation. Combining the two methods of enteroscopy and laparoscopy provided a safe and successful approach for removing multiple large polyps in the small bowel in a single session.Figure: [893]