Our patient is a 31 year-old woman with Peutz-Jeghers Syndrome, a history of GI bleeding and multiple abdominal surgeries who had a video capsule endoscopy for surveillance of her small bowel.
At two hours and 13 minutes into her study, video capsule endoscopy revealed a large pedunculated polyp, seen here in the distal small bowel; this was located most likely in the jejunum.
Because of the patient's risk factors and the large size of the polyp, jejunal polypectomy was attempted.
Attempts to reach the polyp with spiral enteroscopy and lower double balloon enteroscopy were unsuccessful, and the patient was scheduled for a laparoscopic assisted spiral enteroscopy.
After insufflation of the abdomen with carbon dioxide, the anterior abdominal wall adhesions which were seen were lysed with a combination of sharp dissection and electrocautery.
The small bowel was then run from the Ligament of Treitz towards the colon.
At 168 centimeters from the Ligament of Treitz, an area of intussusception is seen here, with a large palpable mass within it; this was marked with a suture.
Seen here, is the spiral device pleating the bowel on to itself, so that the enteroscope may be passed deeper into the small bowel.
Up close and in slow motion, each individual spiral can be seen here as the enteroscope is advanced towards the distal jejunum.
Using these techniques, the enteroscope is advanced to the area of intussesception.
The large polyp seen on video capsule endoscopy is seen here.
The polyp is then removed with a hot snare in one piece.
Retrieval with a Roth's net was successful; the polyp was withdrawn, and sent to pathology.
The abdomen was then inspected laparoscopically and all remaining ports were then removed.
Pathology revealed a polyp with broad bands of muscularis mucosa, smooth muscle fibers in the superficial mucosa, which were thicker centrally more than peripherally.
This Peutz-Jeughers polyp with focal misplaced glands did not have any features of cellular atypia.
This case demonstrates how a difficult clinical situation can be addressed with a multi-disciplinary team approach for a successful and positive patient outcome.
Bhavesh B. Shah, MD, University of Massachusetts College of Medicine
Jason Wong, MD, University of Massachusetts College of Medicine
Kanishka Bhattabcharya, MD, University of Massachusetts College of Medicine