ORIGINAL ARTICLE: Clinical Endoscopy Evaluation of postsurgical recurrence in Crohn’s disease: a new indication for capsule endoscopy? Vicente Pons Beltra ´n, MD, PhD, Pilar Nos, MD, PhD, Guillermo Bastida, MD, Bele ´n Beltra ´n, MD, PhD, Lidia Argu ¨ello, MD, Mariam Aguas, MD, Angel Rubı ´n, MD, Virginia Pertejo, MD, PhD, Teresa Sala, MD, PhD Valencia, Spain Background: Recurrence after surgery to treat Crohn’s disease is frequent and unpredictable. The efficacy of postsurgery capsule endoscopy in detecting recurrence in patients with Crohn’s disease is yet to be confirmed. Objective: To assess the safety, accuracy, and therapeutic impact of capsule endoscopy in these patients. Design: Crohn’s disease recurrence at the neoileum (Rutgeers score) was assessed in the patients by colono- scopy and capsule endoscopy. The M2A Patency Capsule (Given Imaging, Yoqneam, Israel) was administered 1 week before capsule endoscopy. Capsule endoscopy was performed within 2 weeks of colonoscopy. Investi- gators were blinded to the results of each technique. Patient comfort during the procedures was recorded. Patients: Twenty-four patients with Crohn’s disease with ileocolonic anastomosis were prospectively included. All patients were asymptomatic and did not receive any prophylactic treatment. Main Outcome Measurements: Neoileum recurrence. Results: A colonoscopy was performed in all patients, although the neoileum could not be reached in 3 of them. M2A Patency Capsule excretion was delayed in 2 patients; thus capsule endoscopy was given only to 22 patients. Recurrence was visualized with colonoscopy in 6 patients and with capsule endoscopy in 5. Ten additional recurrences were visualized only with capsule endoscopy. Moreover, proximal involvement was detected in 13 patients. Therapeutic management was modified in 16 patients. All patients preferred capsule endoscopy. Conclusions: Capsule endoscopy is more effective in the evaluation of recurrence after surgery for Crohn’s dis- ease and is better tolerated than colonoscopy. This is of significant therapeutic relevance. (Gastrointest Endosc 2007;66:533-40.) Crohn’s disease (CD) is a chronic granulomatous disease that often requires bowel resection. After ileal or ileocolonic resection, most patients have a postsurgical CD recurrence in the neoileum. 1 This recurrence follows a sequence of endoscopic lesions in the anastomotic and preanastomotic regions, followed by the development of clinical symptoms. The presence of extensive lesions in the neoileum area, identified through ileocolonoscopy in the months after surgery, predicts a rapid evolution to recurrent symptoms and eventual complications. 2 There are patient- and disease-related risk factors for postoperative recurrence. Fistulizing disease, ileocolonic location, and a smoking habit increase the risk of recur- rence. Thus, these patients receive immunosuppressive therapy immediately after surgery. However, patients with a low risk of recurrence, such as nonsmokers and those with fibrostenotic disease, do not usually receive prophylactic treatment to prevent the development of new lesions. In such patients, clinical practice guidelines recommend that they undergo an ileocolonoscopy 6 to 12 months after resection, with the appropriate treatment when significant endoscopic lesions are detected. 3 The accuracy of ultrasonography 4 and tomographic 5 tech- niques in detecting morphologic recurrence has also been evaluated but has been shown to be inferior to that of conventional ileoscopy. Wireless capsule endoscopy (CE) currently constitutes the most effective available morphologic exploration for visualizing the small bowel. Recently, significant progress has been made in the diagnostic techniques used in Abbreviations: CD, Crohn’s disease; CE, capsule endoscopy. See CME section; p. 557. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.12.059 www.giejournal.org Volume 66, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 533
Transcript
ORIGINAL ARTICLE: Clinical Endoscopy
Evaluation of postsurgical recurrence in Crohn’s disease: a newindication for capsule endoscopy?
Background: Recurrence after surgery to treat Crohn’s disease is frequent and unpredictable. The efficacy ofpostsurgery capsule endoscopy in detecting recurrence in patients with Crohn’s disease is yet to be confirmed.
Objective: To assess the safety, accuracy, and therapeutic impact of capsule endoscopy in these patients.
Design: Crohn’s disease recurrence at the neoileum (Rutgeers score) was assessed in the patients by colono-scopy and capsule endoscopy. The M2A Patency Capsule (Given Imaging, Yoqneam, Israel) was administered1 week before capsule endoscopy. Capsule endoscopy was performed within 2 weeks of colonoscopy. Investi-gators were blinded to the results of each technique. Patient comfort during the procedures was recorded.
Patients: Twenty-four patients with Crohn’s disease with ileocolonic anastomosis were prospectively included.All patients were asymptomatic and did not receive any prophylactic treatment.
Main Outcome Measurements: Neoileum recurrence.
Results: A colonoscopy was performed in all patients, although the neoileum could not be reached in 3 ofthem. M2A Patency Capsule excretion was delayed in 2 patients; thus capsule endoscopy was given only to22 patients. Recurrence was visualized with colonoscopy in 6 patients and with capsule endoscopy in 5. Tenadditional recurrences were visualized only with capsule endoscopy. Moreover, proximal involvement wasdetected in 13 patients. Therapeutic management was modified in 16 patients. All patients preferred capsuleendoscopy.
Conclusions: Capsule endoscopy is more effective in the evaluation of recurrence after surgery for Crohn’s dis-ease and is better tolerated than colonoscopy. This is of significant therapeutic relevance. (Gastrointest Endosc2007;66:533-40.)
Crohn’s disease (CD) is a chronic granulomatousdisease that often requires bowel resection. After ileal orileocolonic resection, most patients have a postsurgicalCD recurrence in the neoileum.1 This recurrence followsa sequence of endoscopic lesions in the anastomoticand preanastomotic regions, followed by the developmentof clinical symptoms. The presence of extensive lesions inthe neoileum area, identified through ileocolonoscopy inthe months after surgery, predicts a rapid evolution torecurrent symptoms and eventual complications.2
There are patient- and disease-related risk factors forpostoperative recurrence. Fistulizing disease, ileocolonic
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy
0016-5107/$32.00
doi:10.1016/j.gie.2006.12.059
www.giejournal.org
location, and a smoking habit increase the risk of recur-rence. Thus, these patients receive immunosuppressivetherapy immediately after surgery. However, patientswith a low risk of recurrence, such as nonsmokers andthose with fibrostenotic disease, do not usually receiveprophylactic treatment to prevent the development ofnew lesions. In such patients, clinical practice guidelinesrecommend that they undergo an ileocolonoscopy 6 to12 months after resection, with the appropriate treatmentwhen significant endoscopic lesions are detected.3 Theaccuracy of ultrasonography4 and tomographic5 tech-niques in detecting morphologic recurrence has alsobeen evaluated but has been shown to be inferior tothat of conventional ileoscopy.
Wireless capsule endoscopy (CE) currently constitutesthe most effective available morphologic exploration forvisualizing the small bowel. Recently, significant progresshas been made in the diagnostic techniques used in
Capsule endoscopy in Crohn’s disease recurrence Pons Beltran et al
CD.6 Radiographic imaging techniques based on com-puted tomography7,8 and magnetic resonance9 arenoninvasive means of evaluating the small bowel inpatients with known or suspected CD. CE can also be aneffective tool for confirming diagnoses in patients withsuspected CD when other more conventional diagnosticmethods fail.10 Moreover, it allows physicians to estimatethe presence and extent of the disease.11,12 Recently, theGiven patency system has been shown to adequatelyassess the functional patency of the small bowel and couldbe useful in detecting strictures in CD.13
Only one study has evaluated the role of CE in theevaluation of the postsurgical recurrence of CD.14 Nostudies have evaluated the role of the patency system orpatient preference with respect to the diagnostictechnique used. The aim of this study was to prospectivelycompare the diagnostic yield of CE with that of conven-tional ileocolonoscopy in the detection of preanastomoticrecurrent mucosal lesions in CD and to evaluate its possi-ble therapeutic impact and patient preference regardingthese procedures.
PATIENTS AND METHODS
Study designTwenty-four patients with CD (13 female and 11 male;
median age 38 years, range 18-71 years) with ileocolonicanastomosis were seen between October 2003 andOctober 2005 at the Department of Gastroenterology,La Fe University Hospital, Valencia, Spain. All wereprospectively included in this study. Their demographiccharacteristics and clinical data are shown in Table 1.
All patients had undergone an ileocolonic resection withside-to-side anastomosis 6 to 12 months before their enroll-ment in the study. All were asymptomatic (Crohn’s diseaseActivity Index !200) and were not receiving prophylactictreatment for recurrence. Exclusion criteria were the follow-ing: under age, pregnancy or lactation, dysphagia preclud-ing safe capsule ingestion, life-threatening conditions, andnonsteroidal anti-inflammatory drug intake. Before inclu-sion, each patient was evaluated by a clinical specialist ininflammatory bowel disease (P.N.M., G.B.P.). A completeblood cell count, erythrocyte sedimentation rate, andC-reactive protein and fibrinogen levels were recorded foreach subject on enrollment. All eligible patients underwentM2A Patency Capsule (Given Imaging Ltd., Yoqneam, Israel),ileocolonoscopy, and CE within 2 weeks. The results ob-tained with each technique (ileocolonoscopy and CE)were evaluated by different researchers, each of whomwas unaware of the results of the other technique. Bothexaminations were assessed according to the Rutgeerts in-dex,2 grading the lesions observed in the neoterminal ileumfrom 0 to 4. Scores of R2 were classified as morphologicrecurrence. The lesions detected by CE in the proximalsmall bowel were also recorded.
d Most patients with Crohn’s disease experience recurrenceafter therapeutic resection.
d The presence of extensive lesions predicts a rapidevolution to recurrent symptoms and eventualcomplications.
What this study adds to our knowledge
d In 22 patients, capsule endoscopy was more effectivethan colonoscopy in the evaluation of recurrence aftersurgery for Crohn’s disease and led to changes in therapyfor 13 patients.
d Capsule endoscopy was preferred by all patients.
Ethical guidelinesThe study was approved by the human research ethics
committee of our institution and written informed con-sent was obtained from each patient.
Patency capsuleThe M2A Patency Capsule was administered to verify the
absence of strictures in the GI tract. This capsule is ingest-ible, dissolves with time when retained, is the same size asa normal M2A capsule, and contains a small transponderin the form of a passive radiofrequency identification tagand a soluble, radiopaque body. At one end of the capsulethere is a paraffin plug, which dissolves when in continu-ous contact with intestinal fluids. Patency is verified whenthe capsule is excreted intact. Excretion is tested with a pa-tency scanner before disintegration takes place. The exter-nal patency scanner transmits a radiofrequency signal thatactivates the microchip to respond with an identifying ra-diofrequency signal of its own, which is in turn detectedby the scanner. If the capsule is retained in the GI tract,it disintegrates into small, mostly soft fragments that caneasily pass through the strictures.
After overnight fasting, patients swallowed the patencycapsule with 100 to 200 mL of water. Afterward, they wereallowed to continue with their normal diets and activities.Patients were instructed to inspect their feces for thepresence of the capsule. Transit was considered normalwhen the capsule was excreted intact less than 40 hoursafter ingestion or when it was not excreted in said periodbut was detected intact in the colon by x-ray examination.A CE study was not performed if the patency capsule wasretained and not excreted.
Capsule endoscopyCE was performed with the M2A Capsule System. If no
stricture was identified with the patency system, patientsunderwent CE within the following 2 weeks. Subjectsconsumed a liquid diet the day preceding CE and fasted
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Pons Beltran et al Capsule endoscopy in Crohn’s disease recurrence
for 8 hours before the procedure. The CE capsule wastaken with 100 to 200 mL of water. Thereafter, patientswere free to return home and continue their regularactivities. Ingestion of clear fluids was permitted after2.5 hours, and a small amount of solids could be takenafter 4.5 hours. Patients returned 8.5 hours after ingestionof the capsule to have the data recorder removed.Subjects were told to look for the capsule in their feces.Those who did not detect the capsule over the next 10days underwent a plain abdominal radiography to confirmthat the capsule had been excreted.
An experienced gastroenterologist (V.P.B.) reviewed eachof the capsule examinations. A CE examination of the smallbowel was judged to be complete when the ileocolonicanastomosis was clearly identified. Evaluation of the CEexploration lasted approximately 1.5 hours per patient.
A standardized evaluation form was completed by theresearcher immediately after each study. The duodenum,jejunum/proximal ileum, and terminal/neoterminal ileumwere evaluated separately, and the presence or absenceof small lesions (aphthoid ulcerations or small ulcers)and large lesions (cobblestone pattern, deep/fissuralulcerations) were recorded and quantified. To excludenonspecific lesions, mucosal edema and erythema wereconsidered insufficient for the diagnosis of recurrence.
IleocolonoscopyAn ileocolonoscopy was performed with a colonoscope
(CF-VL, Olympus, Tokyo, Japan) by 2 experienced exam-iners (L.A.V., V.P.P.).
All patients underwent a bowel cleansing preparationwith 90 mL (2 doses of 45 mL) of aqueous sodiumphosphate (Fosfosoda, Casen Fleet, Utebo, Spain). Smalland large lesions were evaluated in the neoileum, ileo-colonic anastomosis, colon, and rectum. The neoileumwas examined as far as possible (10-30 cm). Patientswere sedated with midazolam (2-3 mg) or fentanyl (50mg) when necessary.
Patient comfortPatient preference regarding the 2 procedures was
recorded. After each study, the patients completed a sub-jective questionnaire designed to compare CE withileocolonoscopy. The questions are shown in Table 2.
Patient managementAfter both procedures, patients returned to their refer-
ring physicians for follow-up. Therapeutic managementchange was offered when morphologic recurrence wasdetected by ileocolonoscopy or CE. The patients wereaware that the evidence about the indication of treatmentbased on CE findings is not available and also that thetreatment could have potential therapeutic risks. Whenthe therapeutic modification was accepted by the patient,a 2.5 mg/kg/day azathioprine dose was started.
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Statistical analysisContinuous variables are expressed as median and range.
Categorical data are expressed as counts (percent). Thec2 test was used to compare the distribution of categoricalvariables among the groups, and proportions were com-pared by means of the Fisher exact test. The Student t testfor independent samples was used to assess differencesbetween continuous variables. A 2-sided P value of lessthan .05 was considered statistically significant.
RESULTS
Patency capsuleA patency capsule was administered to all the patients
included in the study (n Z 24), all of whom ingested it
TABLE 1. Demographic and clinical characteristics
of patients (n Z 24)
Age (y) 38 (18-71)
Sex (male/female) 11/13
Smokers (%) 12 (50%)
Period between surgery
and inclusion (d)
254 (118-439)
Disease behavior (S/P/I) 14 (58%)/9
(38%)/1 (4%)
Perianal disease (%) 21 (88%)
Indication for surgery
(ST/RM/SD/O)
15 (63%)/5
(21%)/0
(0%)/4 (16%)
Type of anastomosis (IA/IT) 16 (67%)/8 (33%)
Resected length (cm) 34 (13-60)
Extension of the lesion
(surgical piece) (cm)
17.5 (4-42)
Hemoglobin (g/dL) [12-16]* 13.7 (11-16)
Hematocrit (%) [37-47]* 41.7 (35-46)
Leukocyte count � 103/mL
[4.8-10.8]*
6.6 (5.3-10.8)
Platelet count � 103/mL
[125-400]*
249 (64-310)
Erythrocyte sedimentation
rate (mm/h)
19 (7-24)
C-reactive protein (mg/L) [0-8]* 1.2 (0-6)
Fibrinogen (mg/dL) [170-400]* 291 (240-406)
Crohn’s Disease Activity Index 56 (23-168)
Values are median (range) or percentage.
S, Stricturing; P, penetrating; I, inflammatory; ST, stenosis;
RM, resistance to medical treatment; SD, steroid dependence;
O, other; IA, ileoascendent colon; IT, ileotransverse colon.
Capsule endoscopy in Crohn’s disease recurrence Pons Beltran et al
without difficulty. A total of 22 patients (91.6%) passed thecapsule intact and without clinical repercussions. The me-dian time required to expel the intact capsule was 10.5(5-35) hours. Patency capsule excretion was delayed in 2patients: one excreted the capsule partially degraded 54hours after ingestion, whereas the other excreted it com-pletely degraded. These 2 patients complained of mild ab-dominal pain while the capsule was moving along the GItract. The patient who excreted the capsule completelydegraded was not offered CE because it was considereda contraindication. Although we felt that the patient whoexcreted the capsule partially degraded could take theCE, he declined to undergo a further exploration.
Video capsule endoscopyAfter exploration with the patency capsule, 22 of the
patients underwent CE. All swallowed the capsuleswithout major problems and the test was well tolerated,without adverse events. The capsule reached the colon
TABLE 2. Questionnaire for assessing patient
satisfaction
Preparation (colonoscopy and capsule endoscopy)
The day before the test, did you have to stop/change
some of your usual activities?
Yes, I could not go to work or carry out my usual
activities.
Yes, I was able to go to work and carry out my usual
activities but with a considerable amount of
discomfort.
I could carry out my usual activities with no
problems.
Please mark the level of discomfort caused by
preparation for the test
0 1 2 3 4 5
Technique (colonoscopy and capsule endoscopy)
During the day of the test
I carried out my usual daily activities without
problems.
I carried out my usual daily activities partially or with
some difficulties.
I was unable to carry out my usual daily activities.
(ie, the complete small bowel could be visualized) in 21patients (95%). Capsules were retrieved intact by allpatients (excretion time: median 11 hours, range 6-30hours). In the remaining patient the CE failed to explorethe whole of the small bowel because of an electronicsystem failure that occurred 2.5 hours after the initiationof the study. Gastric transit median time was 21 minutes(range 11-111 minutes), and intestinal transit mediantime was 247 minutes (range 125-460 minutes). Table 3summarizes the results of the CE explorations. Accordingto the criteria described above, neoileum CD recurrencewas observed in 15 patients and proximal involvementwas observed in 13 patients (Fig. 1).
IleocolonoscopyIleocolonoscopy was carried out in all the patients
included in the study. Despite several attempts, it wasnot possible to intubate the neoileum in 3 patients(12%) because of technical difficulties. Recurrence was de-tected in 6 (28%) of the 21 patients whose neoileum wasexplored. None had CD in the colon. The median of theneoileums explored was 15 cm (range 3-20 cm). Table 3shows the findings in all the patients.
No complications occurred in any patient duringileocolonoscopy. Eight required medication (sedation oranalgesia) during the procedure.
Comparison of CE versus ileocolonoscopyCE detected CD recurrence in 15 (62%) patients,
whereas ileocolonoscopy detected inflammatory lesionsin the neoterminal ileum in only 6 (25%) patients.Compared with ileocolonoscopy, CE did not show anyfalse-negative results; however, the ileocolonoscopy didnot detect recurrence in 8 patients in whom lesionswere detected by CE (ulcers in 7 patients and more than5 aphthous lesions in 1 patient). In addition, CE revealedlesions in the jejunum of 13 patients, one of whoseduodenum was also affected by CD.
CE was not possible in 3 patients: in 2 because of thedelayed excretion of the patency capsule and in 1 froma failure of the recording system. Equally, the ileoscopycould not be performed in 3 other patients because oftechnical difficulties.
Therapeutic impact of CE findingsAlthough the therapeutic strategies were re-evaluated
in 16 patients, 6 of them had been already detected bythe ileocolonoscopy. This information was sufficient foroffering a change of therapeutic management in these 6patients. On the basis of recurrence detected exclusivelyby CE, the therapeutic modification was offered toanother 10 patients. Three of these 10 patients rejectedthe suggested modification, whereas the others gavetheir consent to the initiation of immunosuppressive
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Pons Beltran et al Capsule endoscopy in Crohn’s disease recurrence
TABLE 3. Colonoscopic and CE findings in all patients and therapeutical changes
applied
CE
No. Colonoscopy Neoileum
Proximal
affection
Therapeutic
management
1 Failure (3) No recurrence (1) No No
modification
2 Recurrence (2) Yes (2) Modification (2)
3
4 No recurrence (15) No achievement (1)
5 Failure (1)
6 Recurrence (8) Yes (6) Modification (5)
7 Patients
rejected (3)
8
9
10
11
12 No (2)
13
14 No recurrence (5) Yes (3) No
modification
15
16
17 No (2)
18
19 Recurrence (6) No achievement (1) Modification (1)
20 Recurrence (5) Yes (2) Modification (4)
21 Patients
rejected (1)
22 No (3)
23
24
maintenance therapy with azathioprine. Therapeutic man-agement was not modified in those patients in whomproximal CD affection was detected by CE but who didnot present a recurrence.
Patient comfortAll patients preferred CE to ileocolonoscopy. Although
the differences are not statistically significant, it seemsthat the bowel preparation for ileocolonoscopy interferedwith the patient’s daily activity to a greater degree (83%)than did the preparation (liquid diet) for CE (20%). The
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impact on the patient’s daily routine of the 2 techniquesthemselves was not significantly different. Fifty percentof the patients considered the ileocolonoscopy uncom-fortable and 8 patients required sedation or analgesia dur-ing the course of the exploration. None of the patientsconsidered CE to be uncomfortable.
DISCUSSION
Our study is a prospective comparison of the efficacyof CE and ileocolonoscopy in detecting postsurgical
Capsule endoscopy in Crohn’s disease recurrence Pons Beltran et al
recurrence of CD. We administered the patency capsulebefore CE exploration to detect strictures in the smallbowel. The preferences of the patients regarding the 2techniques were also registered. The results havepreviously been presented as preliminary results.15 The
Figure 1. CE images of 3 different patients. A, Proximal (duodenal) af-
fectation in a patient with a recurrence in the neoileum. B, Ileocolonic
anastomosis with an ulceration and a surgical staple. C, Neoileal ulcera-
tion in a patient with negative ileocolonoscopy results.
principal finding of this study is the superior diagnosticyield of CE, compared with that of ileocolonoscopy, withrespect to recurrence of CD. A second significant aspectis the therapeutic impact of CE exploration, which isdirectly related to the capacity of the technique fordetecting more extensive and more proximal lesionsthan ileocolonoscopy. The third important observation isa marked preference for CE among the patients.
Our results show that neoterminal recurrence wasdetected by CE in 62% patients and by ileocolonoscopyin only 25%. The only other study to compare both tech-niques detected more CD recurrence through endoscopicevaluation than through CE.14 It is possible that this differ-ence is due to the length of the neoileum explored. Diffi-culty in reaching and passing through the anastomosisand the limited endoscopic visualization afforded by thefew distal centimeters it reveals could explain the underes-timation of recurrence by ileocolonoscopy. All our patientspresented a side-to-side reconstitution of the neoileum.Surgeons in our center believe this type of anastomosisclosely resembles the physiology of the terminal ileumand cecum. However, this anastomosis is more difficultto explore through ileocolonoscopy than through a end-to-end anastomosis, which suggests that this surgicaltechnique has limited our evaluation of the neoileum.
Rutgeerts et al2 defined an endoscopic score to assessand quantify lesions in the anastomotic and preanasto-motic regions. An accurate score requires the explorationof the last 30 cm of the neoterminal ileum. However, an ac-curate determination of the extent of ileal disease is notalways possible with ileocolonoscopy, and patients withlesions extending beyond the reach of the endoscopeneed to undergo barium meal follow-through studies toevaluate the extent to which the bowel is affected. In thestudy by Rugeerts et al, subsequent proximal preanasto-motic spread of the disease was observed during the bar-ium meal follow-through in 13.5% of patients. In ourstudy, we have evaluated the extend of the recurrencelesions with a CE, a technique that allows a better evalua-tion of the small-bowel mucosal breaks in CD than a bariummeal follow-through. We consider that this could be thereason our study shows a higher rate of recurrence with CE.
Location of disease, length of segment involvement,and small bowel transit information can be ascertainedfrom the capsule images. It is likely that the wirelesscapsule will play an increasingly important role in researchinto and the management of CD by gaining preferenceover radiologic (x-ray) evaluations.16 Thus, CE will be ofassistance in early diagnoses and in determining theextent and sites of small intestinal involvement. In thisregard, our study shows that small intestinal affectionoccurs in 59% of CD patients, which is a much higherrate than that previously suggested by radiologic data.Our results are similar to those of a recent report on CEthat reported small bowel involvement in approximately60% of the cases studied.14
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Pons Beltran et al Capsule endoscopy in Crohn’s disease recurrence
With respect to the therapeutic impact of our data, CEis shown to be a useful tool for detecting both CDrecurrence and previously undetected small bowelinvolvement. This is evidence enough to recommenda change in the plan of therapy in 42% of patients, incontrast to ileocolonoscopy that when considered alonewould recommend the therapeutic change only in 25%of them. Currently, the main reason for a change intherapy is the detection of more extensive recurrentlesions, but we believe that the clinical relevance ofproximal lesions needs to be further assessed. Our studypopulation consisted of patients who were not receivingany prophylactic treatment for recurrent CD at the timeof inclusion in the study. Currently, therapy is offered tothose patients in whom severe progressive lesions ina long segment of the neoterminal ileum are discoveredthrough ileocolonoscopy within a year after surgery. Wesuggest that these patients are best assessed with CEbecause it is a superior technique for the evaluation ofthe entire neoterminal area and also because it allowsproximal small bowel evaluation, therefore making it farmore effective than ileocolonoscopy.
Some clinical studies of the patency capsule haverecently been published17 and have shown it to be safeand reliable for detecting small bowel stenosis. In ourstudy, we decided not to perform a barium meal follow-through given that the patency capsule provides directevidence of the functional patency of the gut lumen,even in those patients whose stricture has not beendetected in a radiologic study of the small bowel (falsenegative). The patency capsule allowed us to detectboth postsurgical strictures and CD-related strictures inother locations.
Patient preferences regarding the 2 procedures were re-corded in a subjective questionnaire. This kind ofquestionnaire has been used to compare CE with alterna-tive diagnostic procedures18 but has not been validatedand was used in our study merely to provide informationof interest. All the aspects evaluated in our questionnairehighlight an obvious preference for CE, both in terms ofthe technique itself and bowel preparation. A liquid dietthe day before CE was the only indication for CE prepara-tion. This option was based on a previous multicenter Span-ish study19 that showed equal efficacy and higher toleranceof a liquid diet than that seen with aqueous sodium phos-phate or polyethylene glycol electrolyte solutions.
CE is well tolerated by patients, is less invasive thanconventional endoscopy, and can be performed withoutany sedation or anesthesia. In some circumstances, evi-dence indicates that CE is an adequate test for diagnosingCD and is more accurate than enteroclysis12 and CT20 inthe evaluation of small bowel involvement. Moreover,there are some studies suggesting that CD can be diag-nosed with CE in patients who have had negative resultsfrom colonoscopy, gastroscopy, and a small bowel bariumstudy.10,21-23
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Enhancement of the endoscopic visualization of theneoileum is mandatory in the detection of postsurgical re-currence. Given the correlation between the endoscopicappearance of lesions and the clinical course of the dis-ease, endoscopy is the gold standard for documentingsaid lesions. Nowadays, there is an increasing belief thatmucosal healing or mucosa without lesions can be a desir-able outcome in CD. Postsurgical morphologic lesions areeasily detected with this new diagnostic tool, which willundoubtedly improve the therapeutic management ofthe disease.
In conclusion, this prospective study shows CE to be aneffective, safe, and well-tolerated method for detectingpostsurgical recurrence of CD. The patency system helpedto avoid complications resulting from stenosis. Moreover,CE provided additional and valuable information aboutthe extension of recurrent disease and the existence ofupper GI tract lesions. In light of our findings, a CE explo-ration is of great use in the evaluation and treatment man-agement of recurrent CD.
DISCLOSURE
The authors attest that they have no commercialassociations that might be a conflict of interest inrelation to this article.
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