Carcinoids and Capsules: A Case Series Highlighting the Utility of Capsule Endoscopy in Patients with Small Bowel Carcinoids.

Introduction Neuroendocine tumors (NETs) or carcinoids arise at many different sites of the gastrointestinal tract. The small intestine is the second most common site for NETs after the lungs. Diagnosing small bowel carcinoids remains challenging given their nonspecific presentations and the overall low incidence of small bowel tumors. Video capsule endoscopy (VCE) has significanly improved our ability to detect small bowel malignancies. We explore the value of VCE in the initial work-up and management of a series of small bowel carcinoid patients. Methods We retrospectively analyzed adult patients undergoing surgical management for small bowel lesions from July 2005- September 2015 at a tertiary care center. Patient characteristics, presenting symptomatology, diagnostic work-up and surgical management were analyzed among patients with pathology confirmed small bowel carcinoid tumors. Results Our study identified sixteen patients treated surgically for small bowel carcinoids. The mean age of the study sample was 64 12.5 years, 44% were males, and 100% were Caucasian. The majority of patients (87.5%) presented with either occult gastrointestinal bleeding or anemia. Of all patients, 14 (87.5%) presented with chronic symptoms. Most patients (87.5%) were initially evaluated with various endoscopic and imaging modalities before ultimately undergoing surgery. Three-quarters (75%) of patients had a VCE, with 83.3% (10/12) having positive findings that correlated with intraoperative findings compared to 62.5% (5/8) with computed tomography scan, 21.4% (3/14) with colonoscopy, 44% (4/9) with deep enteroscopy, and 0% (0/9) with esophagogastroduodenoscopy. Upon surgical resection, 68.7% (11/16) of patients were found to have multiple lesions. Final histopathologic examination revealed lympathic, vascular, and neural involvement in 68.7% (11/16), 37.5% (6/16), 6.25% (1/16) of patients, respectively. There were no 30-day mortalities and only one 30-day readmission. Median follow-up time was 53.5 months with 68.7% (11/16) of patients being asymptomatic. At the time of our chart review, only 2 patients had died due to metastatic disease – notably, both patients initially presented with obstructive symptoms, received no endoscopic interventions, were found to have mutliple lesions upon surgical resection, and both were alive, although symptomatic (diarrhea/vomiting) at >80 months follow-up. The biology of carcinoids detected by capsule endoscopy appears to be different from those with a surgical presentation (pain and diarrhea). In general, even though small and metastatic to local nodes, none have recurred after surgical resection. Conclusion In patients without signs and symptoms of obstruction, VCE is an effective endoscopic modality in the diagnostic workup of small bowel carcinoids. Furthermore, positive VCE findings appear to highly correlate with surgical findings, thus suggesting a valuable role for VCE in the initial surgical assessment of patients with small bowel carcinoids.