Current Health Sciences Journal Vol. 38, No.

2, 2012 April June

Original Paper
The Contribution of the Video Capsule
Endoscopy in Establishing the Indication of
Surgical Treatment in the Tumoral Pathology of
the Small Bowel. Running head: Videocapsule
Endoscopy and Small Bowel Tumors
VERE C.C., STREBA C.T., ROGOVEANU I., GEORGESCU M.,
PIRVU D., IORDACHE SEVASTITA, GHEONEA D.I, SAFTOIU A.,
CIUREA T.
Department of Internal Medicine, University of Medicine and Pharmacy of Craiova
ABSTRACT Background and aims: Capsule endoscopy (CE) represents a novel method which allows safe, non-
invasive and rapid exploration of the small bowel. Our aim was to determine the feasibility CE has in assessing
tumoral pathology of the small bowel and aiding surgical teams in determining appropriate treatment. Material and
Method Our study was conducted on 11 patients who presented tumoral pathology of the small bowel, from a total of
50 patients investigated by VCE. Malignancy was determined on the surgical resection piece, by histological exam.
Statistic analysis of the data was conducted using Fishers Exact Test. Results Tumoral pathology was represented
by: 3 intestinal polyps, 2 benign stromal tumors, 2 malign stromal tumors, 2 adenocarcinomas, one neuroendocrine
malign tumor and one duodenal papilla carcinoma. We followed the presence of malign tumors in regards to age. All
malign tumors (n=6) were recorded in patients over 60 years old, while benign tumors were recorded in most cases
(80%, n=4) in people under 60 years old. One case of benign tumor (intestinal polyp) was observed above 60 years
old. Conclusion Capsule endoscopy represents a real help for the surgeon, as it allows identification of small bowel
pathology, giving information regarding the approximate localization of lesions, their size and orienting on their
nature. Tumoral pathology is encountered mainly with the old age population and can be presented under a multitude
of forms. We believe that an efficient method for incipient detection and a protocol to establish malignity is necessary
KEY WORDS Adenocarcinoma, Capsule endoscopy, Small Bowel, Tumor
Introduction
The present technological progress has made
possible the introduction of new techniques of
non-invasive exploration of the digestive tract.
The video capsule endoscopy (VCE) allows a
non-invasive evaluation of each segment of the
digestive tract, from the esophagus to the colon,
presently being used mainly for the exploration of
the small bowel, where it can identify lesions
which cant be detected by conventional means.
[1]
The number of applications for this method is
steadily rising. VCE can be successfully used in
diagnosticating obscure gastrointestinal bleeding
[2-5], Crohns disease [6, 7] celiac disease and its
complications (8, 9) intestinal vascular lesions
[10] or tumor pathology [11, 12]
The introduction of the exploration of the small
bowel by means of VCE represents a real help for
the surgeon, because it allows the identification of
the pathology affecting the small bowel and
supply information regarding the approximative
location of lesions, their dimensions and an
orientation on their etiology.
Materials and Method
Patient characteristics
All VCE patients underwent upper digestive
endoscopy or total colonoscopy with negative
results. Main symptoms were represented by:
signs of gastrointestinal bleeding (blood in stool or
hematochezia); feriprive anemia of unknown
origin; abdominal pain accompanied by diarrhea,
inapetence and weight loss otherwise
undiagnosed; suspicions of Crohns disease and
complications of non-steroidal anti-inflammatory
drug treatment.
From a total number of 50 patients investigated
by VCE in the J une 2008 - March 2010 period
within Internal Medicine and Gastroenterology
Clinic 1 of the County Clinic Emergency Hospital
of Craiova, 11 presented tumoral pathology of the
small bowel, establishing the indication of surgical
treatment.
All patients gave informed consent for all
medical procedures and sample collection, and the
study had the necessary approvals of the Ethics
Committee of the hospital.
Assoc. Prof. Vere C.C , MD, PhD, Department of Internal Medicine, University of Medicine and Pharmacy of Craiova 69
Vere C.C and colab: The Contribution of the Video Capsule Endoscopy in Establishing the Indication of Surgical Treatment in ...
Capsule endoscopy: technical details
The video capsule is an 11/26 mm device that
weighs 3.8 grams. It is capable of sending 2
images per second on a radio system (an average 8
hour recording containing over 50 000 images),
the visibility field being of 145 degrees, with a
zoom rate of 1:8 and depth of field of 1 to 30 mm.
It allows the visualization of lesions with
dimensions of a minimum of 0.1 mm. Its main
components are an optic dome and a lens system,
6 LEDs (light emitting diodes) for illumination,
the CCD (Charge Coupled Device) camera
module, internal circuits designed to process video
data and adjust lightning and an antenna that helps
transmitting images to the electrodes attached to
the body. A portable storage device permits data
recording as well as real-time viewing. [15]
Capsule endoscopy: procedure
Each patient was administered the video
capsule after a preliminary preparation. Standard
preparation consisted of alimentary restrictions for
1216 hours before the exploration, associated
with intestinal lavage with a solution of
polietylenglycol (PEG) (two liters) administered
the day before exploration 1014 hours before
starting the recording. We did not usually use the
preparation of the small bowel with prokinetics
because recent information has shown that such
techniques are not always necessary [13]. Patients
were able to consume clear liquids two hours after
ingesting the capsule and a light lunch four hours
after ingesting the capsule [13, 14]. Patients were
monitored for eight hours. Collected data were
analyzed by an experienced gastroenterologist
who pointed the diagnostic and recommended
surgical intervention where necessary.
Surgical treatment
Surgical intervention was performed in each of
the 11 cases with suspected small bowel tumors,
practising a segmentary enterectomy in 10 cases
(91%) and cephalic duodeno-pancreatomy in one
case. The surgically collected samples were sent
to the Pathology Department of the Clinic
Emergency Hospital of Craiova, where they were
histopathologically prepared and processed. The
malignancy diagnosis was given by the
histopathological exam.
Statistics
Statistical processing of results and description
of groups were made using the methods of
descriptive statistics and the Fishers Exact Test
(test for verifying the statistical significance which
is used on small size groups) [16].
Results
A total number of 50 patients were investigated
by VCE. The main indication for VCE was
obscure gastrointestinal bleeding (70%, n=35), 15
of these also presenting anemia. The other patients
presented symptoms specific to Crohns disease
(8%, n=4), celiac disease (6%, n=3) and other
non-specific symptoms, otherwise not explained
(16%, n=8). After investigation, we obtained
negative VCE results in 9 (18%) patients.
The study group contained 11 patients
suffering from small bowel tumoral pathology,
investigated by VCE and surgically intervened on.
All these patients underwent VCE for either sings
of obscure gastrointestinal bleeding or abdominal
pain and diarrhea. The structure of the group was:
54.54% men (n=6) and 45.45% women (n=5),
ages between 54 and 79 years of age, average
being 63.72 years; standard deviation 7.11,
confidence interval (CI) 95% 4.77. The group was
divided according to sex, age and pathology for
statistical analysis.
Tumoral pathology of patients included in the
study consisted of: 3 intestinal polyps (Fig. 1), 1
benign stromal tumor, 3 malignant stromal tumors
(Fig. 2), 2 adenocarcinoma, 1 neuroendocrine
malignant tumor, 1 duodenal papilla carcinoma.
(Table I)

Fig 1. a, b, c. Videocapsule Endoscopy images of intestinal polyps
70
Current Health Sciences Journal Vol. 38, No. 2, 2012 April June

Fig 2.a. Intestinal malignant lymphoma, operatory piece; b. Intestinal malignant polyp: Videocapsule
endoscopy aspect.
Table I. Repartition by Sex of Tumor Pathology
Men Women
Polyps 2 1
Benign Stromal Tumor 0 1
Malignant Stromal Tumor 3 0
Neuro-endocrine Tumor 0 1
Adenocarcinoma 1 1
Duodenal Papilla Carcinoma 0 1
Total 6 5
Benign tumors represented 45.45% of the total
(polyps 27.27%; benign stromal tumors 18.18%),
while malignant tumor pathology was represented
thus: 18.18% malignant stromal tumors, 18.18%
adenocarcinoma, 9.09% neuroendocrine tumors,
and 9.09% duodenal papilla carcinoma. Of the six
men included, 33.3 % (n=2) presented benign
tumors (intestinal polyps), the others being
diagnosed with malignant tumors (3 stromal
malignant tumors and 1 case of adenocarcinoma).
Of the five women included, 40 % (n=2)
presented benign tumors (one intestinal polyps,
one benign stromal tumor), the others being
diagnosed with malignant tumors (one neuro-
endocrine tumor, one adenocarcinoma and one
duodenal papilla carcinoma).
We tracked the repartition of malignant and
benign tumors by age, starting from the hypothesis
that malignant pathology appears predominantly
over 60 years of age, while benign tumors appear
predominantly before this age. The age of 60
years was taken as a reference point in dividing
the group, since it is close to the average age of
the group. For the application of Fishers Exact
Test, the group was subdivided in two subgroups,
over and under 60 years. All the malignant tumors
(n=6) were observed on patients over 60 years,
while the majority of benign tumors (80%, n=4)
were observed under 60 years. (Tables II and III)
A single case of a benign tumor (intestinal polyp)
was recorded in a patient aged above 60 years. By
applying Fishers Exact Test a p value of 0.01515
2-Tail (CI 95% threshold value 0.05) was
obtained, a statistically significant result which
verifies the initial hypothesis.
Table II. Tumor Pathology of the Small Bowel
Table of Incidence
<60 years >60 years Total
Malignant Tumors 0 7 (54.54%) 7 (54.54%)
Benign Tumors 3 (27.27%) 1 (11.11%) 4 (45.45%)
Total 3 (27.27%) 8 (72.72%) 11 (100%)
Table III. Tumor Pathology Repartition by Etiology and Age Groups
Benign Tumors (45.45%) Malignant Tumors (54,54%) Total
Polyps
Stromal
Tumors
Neuroendocrine
Tumors
Adenocarcino
ma
Stromal
Tumors
Duodenal papilla
carcinoma

<60
years
2 (18.18%) 2 (18.18%) 0 0 0 0 3 (27.27%)
>60
years
1 (9.09%) 0 1 (9.09%) 2 (18.18%) 2 (18.18%) 1 (9.09%) 8 (72.72%)
Total 3 (27.27%) 2 (18.18%) 1 (9.09%) 2 (18.18%) 2 (18.18%) 1 (9.09%) 11 (100%)
71
Vere C.C and colab: The Contribution of the Video Capsule Endoscopy in Establishing the Indication of Surgical Treatment in ...
Discussions
Although the small bowel represents 75 % of
the length and 90 % of the absorption surface of
the intestinal tract, malignant tumors present at its
level represent less than 5 % of the total of
gastrointestinal cancers. [17, 18] They also
represent less than 0.3 % of the total of neoplasms
and are often poorly diagnosed or discovered in
very late stages [18, 19]. Recent studies have
shown an increase in incidence of small bowel
tumors all over the globe. [18, 20-24]. Hurst RD
analyzed the annual diagnostics in the United
States concluding that approximately 140 000
cases of colorectal cancer, 22 000 new cases of
gastric cancers are diagnosed, compared to only
4.500 5000 cases of small bowel cancer [25].
In a recent retrospective study, Karl Y.
Bilimoriaet al [26] described the characteristics of
a group of 65.843 patients included in the 1985-
2005 period in the National Cancer Data Base
(NCDB) and in the Epidemiology and End
Results program (SEER, 1973-2004). Of these,
25.339 (37.4%) were diagnosed with carcinoid
tumors, 25.053 (36.9%) with adenocarcinoma,
11.711 (17.3%) with lymphoma and 5.740 (8.4%)
with stromal tumors. Repartition by sex showed a
slight predominance of men (54% vs. 46%), while
the average age was 67 years (ages between 56
and 76 years). An increase in incidence from 11.8
cases per million in 1973 to 22.7 cases per million
in 2004 was noticed. It is worthy of note that the
study did not include cases diagnosed by autopsy.
Total incidence in 2005 was of 8.4/100 000
people, of which 85%-90% were discovered by
chance when autopsied. [27]
Due to the large number of cases recorded
post-mortem, it is sufficiently clear that an
efficient method of early discovery of this tumor
pathology is necessary. Classic diagnosis methods
for tumors of the small bowel include upper
digestive endoscopy (for lesions of the duodenum
and proximal jejunum), radiographic methods
(computerized tomography or seriography).
Lesions located beyond the ligament of Treitz are
very difficult to diagnose because of the length of
the small bowel. [28]
Thus, it becomes a necessity to find new means
of diagnostic that are effective, well tolerated, and
with a high diagnostic yield. The video capsule
endoscopy system fulfills all the necessary
conditions for such an investigation: ease of use,
combined with good tolerability, a minimum
number of side effects and a high diagnosis rate all
recommending it as a high value diagnostic
method for early identification of small bowel
pathology. [29, 30]
Histopathology examination gave the final
diagnosis. The protocols used have shown
histological characteristics specific to the types of
benign or malignant tumors, supplying sufficient
information to establish a precision diagnosis
regarding malignity.
Immunohistochemistry is a relatively new
method, which allows the localization of specific
proteins by utilizing the antigen-antibody reaction.
[31] It is successfully used in accurate diagnosis
of malignant lesions, by identifying tumor markers
that are specific to each type of malignant
neoplasm.
Tumoral pathology of the small bowel is
under-evaluated by comparison with the other
segments of the digestive tract, detection rate
during life being much lower than in other cases.
It is predominantly occurring in third age persons
and it presents under a multitude of forms. It is
therefore necessary to find an efficient method of
early identification of lesions and a protocol which
would establish malignancy.
The video capsule endoscopy is, without doubt,
a modern effective means of identifying tumoral
lesions. It can prove to be of precious help to the
surgeon in all steps of the diagnosis. Being a non-
invasive technique and having a high degree of
acceptability from patients, it can be successfully
used in screening the multiple pathologies of the
small bowel. When combined with the patency
capsule and modern enteroscopic methods (SBE),
it widens its diagnosis accuracy and eases the
work of the surgeon, simultaneously helping the
patient by reducing the extent of the surgical
intervention.
By using histology and immunohistochemistry
techniques it leads to a precise malignancy
diagnosis for all tumors of the small bowel,
directing therapeutic efforts and correctly
evaluating the pathology.
Acknowledgements
This work was partially supported by CNMP,
Ministry of Education and Research, PC 4
competition, project ID 41073.
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Correspondence Adress: Costin Teodor Streba, University of Medicine and Pharmacy Craiova, St. Petru
Rares Nr. 4, Craiova, 200349, Dolj. Romania E-mail: [email protected]