Minimally invasive colonoscopic treatment of terminal ileal inflammatory myoma polyps

Current treatment of IFP in the literature

We searched PubMed for relevant studies using the terms ‘inflammatory fibroid polyp’ and ‘Vanek tumor’ and retrieved a total of 496 articles. There were 378 articles on IFP treatment and 165 articles on IFP endoscopic treatment. Endoscopic treatment included 84 articles for gastric lesions, 36 articles for colonic lesions, and 1 article for enterostomy of the distal ileum.6Because terminal ileal IFP is rare and the symptoms and signs of small bowel disease are generally obscure due to its central location in the gastrointestinal tract, diagnosis is often missed in clinical practice. Fistula and capsule endoscopy are ideal examination methods7However, they are not commonly used in hospitals. Instead, small bowel disease is often diagnosed using barium small bowel follow-through in the primary hospital. With advances in colonoscopy technology, terminal ileal examination using colonoscopy facilitates early detection and treatment of IFP.Studies have also shown that colonoscopy treatment of terminal ileal lesions is equally safe and effective8,9,10,11.

Origin of IFP and need for resection

To date, the etiology of IFP remains unknown, but many studies suggest that IFP may be associated with chemical, physical, and metabolic inducers.FiveIFP gene studies have shown an association between IFP and platelet-derived growth factor receptor alpha (PDGFRA) mutations.12, also found in KIT-negative gastrointestinal stromal tumors. Therefore, some researchers have proposed that IFP may be neoplastic rather than simple inflammatory lesions.13Most researchers believe that IFP is neither metastatic nor aggressive and that its onset is insidious. However, some lesions may grow over time and cause complications such as intussusception.14,stomach ache15,16,bleeding17,18and obstacles19,20Therefore, excision is recommended.

Importance of terminal ileal insertion rate in colonoscopy

All lesions in this study were small in size and were resected early in the disease course using colonoscopic resection. Lesions were predominantly early-onset and without complications. The rate of terminal ileal insertion by colonoscopy at our Gastroenterological Endoscopy Clinic is about 86.5% (4439/5132), and the detection rate of terminal ileal disease is 8.8% (392/4439). We retrospectively analyzed 12 cases of terminal ileal IFP treated at our institution from 2016 to 2020, accounting for 3.1% (12/392) of all terminal ileal lesions. Therefore, colonoscopy emphasizes the insertion rate of the terminal ileum, improves the detection rate of terminal ileal lesions, and contributes to the early diagnosis and treatment of terminal ileal diseases. There were some discrepancies between the clinical features of the current study and previous observations, possibly due to the small sample size.

Surgical challenges and procedural skills

Colonoscopy presents several technical challenges and corresponding procedures. (1) Because the lesion was close to the ileocecal valve, it was easy for colonoscopy to slip out of the ileocecal valve, and it was necessary to enter the ileocecal valve many times during surgery. colonoscopic surgery, and the operator must be proficient in controlling the colonoscope. In this case, the operator needs to form a fulcrum for the endoscope main body outside the examination bed so as to stabilize the endoscope main body. To ensure the accuracy of surgery, the operator should handle the endoscope body alone, and the assistant should not fix the endoscope body. (2) The terminal ileum has a thin bowel wall, weak submucosa, and poorly exposed submucosal infusion layer, which is likely to damage or perforate the muscularis propria or tumor. Therefore, carbon dioxide was used during the procedure. The injection point was chosen at a distance of 0.5 cm from the lesion, allowing the submucosal injection to gradually spread to the lesion. The mucosa was then dissected to establish the submucosal space. (3) Endoscopy is difficult to progress in the terminal ileum where colonoscopy is difficult to access or the transparent cap is difficult to function. This problem is usually related to failure to straighten the endoscope body or excessive inflation during manipulation. Therefore, to advance the endoscope along the lumen, reduce the infusion of CO2, unwind the formed loop in time, and ensure that the colonoscope reaches the ileocecal junction without forming a loop. To do so, the clear cap must be applied completely. Colonoscopy procedures at this site require advanced technical experience. Therefore, the director of the gastroenterological endoscopy department of our hospital performed 12 of his operations. He has completed over 6000 of his endoscopic mucosal dissections (ESD). No traction device was used in any of the 12 cases. However, for relatively inexperienced operators, proper traction techniques can more fully expose the lesion and facilitate establishment of the submucosal space, thereby making the procedure less difficult. (4) Colonoscopic closure of lesions at this site was difficult, but the operator was skilled and all wounds could be closed with hemoclips or nylon sutures. For inexperienced operators, the insufflation should be reduced to ensure visualization during the procedure and clear caps should be used more often to expose the surgical field. By reducing the insufflation, excessive stretching of the bowel can be avoided, thereby reducing the difficulty of suturing.

ESD at the terminal ileum should be performed by a highly experienced operator, and less experienced operators may attempt resection of less complex lesions based on the above skills.

Pathological features of IFP

The main histopathological feature of IFP is the location of the submucosal lesion. They exist as short spindle cells arranged in bundles or sheets against a background of intermediate cell density and abundant inflammatory cells.Varying amounts of eosinophils are also commonly found in the stromaFour.

White-light colonoscopy and endoscopic ultrasound findings of terminal ileal IFP should be differentiated from lipomas. The lipoma is soft on white-light colonoscopy with no ‘bubble’ appearance, whereas on ultrasound colonoscopy the lipoma is a uniform hyperechoic of submucosal origin bounded by the muscularis propria. Appears as clumps.twenty one.

In addition, IFP is histopathologically associated with some gastrointestinal tumors, non-neoplastic diseases, and spindle cell lesions, including inflammatory fibrosarcoma, spindle cell carcinoids, leiomyomas, gastrointestinal stromal tumors, and nerve sheath tumors. must be distinguished.4,5All lesions in this study were immunohistochemically examined after resectionFourImmunohistochemical results of all 12 lesions showed that CD34 and vimentin were highly expressed, whereas CD117 was not expressed. Therefore, the incidence of IFP at this site was thought to be significantly higher than that of other spindle cell tumors such as leiomyomas and stromal tumors.

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