Discussion
Our study showed that polyps larger than 10 mm in small bowel can be resected effectively. SBE is effective and safe for resection of small bowel polyps in patients with PJS. Treatment of small bowel polyps in PJS has evolved over the past decades. Before enteroscopy development, patients with PJS often underwent acute or elective operations for elective intestinal resection. Hinds et al reported that 68% of PJS patients underwent a laparotomy because of obstruction before the age of 18 years[22]. In our study, 80.4% of patients had undergone at least one laparotomy. In addition, the risks of gastrointestinal and non-gastrointestinal malignancies significantly increase in patients with PJS[8,9]. In our study, 18 (17.6%) patients were diagnosed with cancer (breast cancer in three, colorectal cancer in three, and ovarian cancer in two, lung cancer in two, thyroid cancer in two, Cervical cancer in two, duodenal malignancy in two, and gastric cancer in two). Therefore, except for surveillance of the small bowel, regular check-up on other organs of these patients may be important.
Success rates of total enteroscopy of DBE were reported to be 40% to 80%[23,24]. In our study, the success rate of total enteroscopy was 42.4%, probably because of high rate of previous laparotomies in these patients. Hence, we compared the intubation depth between patients with history of laparotomy and patients without history of laparotomy. We found that intubation depth via oral approach of patients with history of laparotomy was significantly shorter than that of the patients without history of laparotomy ([241.6±64.2] cm vs [280.9±40.2] cm, P = 0.008). Intraabdominal adhesions would influence the motion of small bowel within the abdominal cavity, impacting the intubation depth of SBE. Laparotomies should be avoided if at all possible. The complication rate (7.8%) of this study was slightly higher than that previously reported by Sakamoto et al (6.8%)[14] and Mensink et al (4.3%)[25]. The key point may be that most of SBE procedures involved polypectomies of multiple large polyps, which were technically challenging. After conservative therapy or surgical operations, these patients had favorable final outcomes. Regarding the complication of children, only one perforation occurred among the 8 patients. The complication rate was not increased for children as we reported in this study. However, the SBE procedures in children with PJS are difficult. The key reasons are as follows: One is narrow intestinal lumen, another is thinner intestinal wall, and the third is sharper angle of enteroscopy. The sample size of children was small, the safety of SBE in children should be interpreted with caution.
The major limitation of this study was its retrospective and single center design. However, due to its large number of patients and polypectomies, it allows us to draw some conclusions regarding efficacy and safety.