Retrograde NaviAid Enteroscopy-Assisted Resection of Distal Ileal Hamartomatous Polyps

Abstract

Introduction: Hamartomatous polyps are rare GI polyps, often associated with Peutz-Jegher syndrome and Cowden's disease. With the advent of capsule endoscopy diagnostic evaluation of the small bowel has improved significantly. Yet, therapeutic interventions remain limited to push enteroscopy or device-assisted enteroscopy with balloon or spiral-overtube which are time consuming and require specialized training and equipment, making surgical intervention necessary far too often. NaviAid is a novel balloon assisted enteroscopy device using through-the-scope balloon on a standard endoscope allowing for deep intubation of the small intestine with rapid procedure times. We present two cases of NaviAid assisted retrograde enteroscopy used for resection of small bowel hamartomas thus preventing the need for surgical resection. Case 1: A 30-year-old female presented with anemia, melena, dizziness and fatigue with prior unrevealing colonoscopy and endoscopy. Her past medical history was noncontributory and family history was negative for cancer. She underwent a capsule endoscopy which showed a 25 mm ulcerated polypoid lesion in the distal ileum approximately 10 cm upstream from the Ileocecal valve. The patient underwent NaviAid assisted retrograde enteroscopy in which the partially obstructing mass was seen in the distal ileum (fig 1), successfully resected en-bloc with endoscopic mucosal resection. Pathology confirmed a hamartomatous polyp with features of Peutz-Jegher Syndrome (fig 2). Case 2: A 46-year-old male with history of Peutz-Jegher syndrome, diagnosed at age 4 years status post bowel resection for repeated bowel obstructions underwent a surveillance capsule endoscopy showing a 20 mm semi-pedunculated polyp in the distal ileum. He underwent a NaviAid assisted retrograde enteroscopy for removal of his distal ileal polyp. En-bloc endoscopic mucosal resection was successfully performed and the polyp was confirmed to be a hamartomatous polyp consistent with his clinical diagnosis of Peutz-Jegher syndrome. Discussion:Hamartomatous polyps can present initially as a small bowel obstruction as seen in patient 2, or insidiously with anemia and bleeding as seen in patient 1. NaviAid assisted enteroscopy successfully allowed for resection of hamartomatous polyps preventing the need for surgical intervention in these patients and should be considered for endoscopic resection of these polyps via antegrade or retrograde enteroscopy.2151_A Figure 1. NaviAid enteroscopy showing large distal ileal hamartomatous polyp2151_B Figure 2. Path showing characteristic arborizing pattern of smooth muscle distribution in the hamartomatous polyp