Accuracy of capsule colonoscopy and computed tomographic colonography in individuals with positive results from the fecal occult blood test

Prospective study of diagnostic yields of flexible spectral imaging color enhancement installed in colon capsule endoscopy for colorectal polyps and tumors

BACKGROUND AND AIMS

We prospectively determined the efficacy of flexible spectral imaging color enhancement (FICE) used with second-generation colon capsule endoscopy (CCE) for colorectal polyps and tumors (CRTs).

METHODS

This study included optical colonoscopy within 4 months after CCE. Two colonoscopists independently reviewed CCE using white-light images (CCE-WL) and CCE using FICE images (CCE-FICE), respectively. Based on colonoscopic findings as the criterion standard, the diagnostic accuracy for CRTs was compared between CCE-WL and CCE-FICE.

RESULTS

Of 89 enrolled patients (65 men and 24 women; 75 with CRTs including 36 with serrated lesions, 63 with adenomas, and 9 with adenocarcinomas), the per-patient detectability of CCE-FICE for the representative CRTs was significantly higher than that of CCE-WL: overall CRTs (CCE-WL, 79%; CCE-FICE, 88%; P = .0001), 6- to 9-mm CRTs (CCE-WL, 63%; CCE-FICE, 94%; P = .0055), and ≥6-mm CRTs (CCE-WL, 78%; CCE-FICE, 93%; P = .0159). The per-lesion sensitivity of CCE-FICE was significantly higher than that of CCE-WL for CRTs: overall (CCE-WL, 61%; CCE-FICE, 79%; P < .0001), <6 mm (CCE-WL, 53%; CCE-FICE, 69%; P < .0001), 6- to 9-mm CRTs (CCE-WL, 65%; CCE-FICE, 93%; P = .0007), slightly elevated CRTs (CCE-WL, 53%; CCE-FICE, 75%; P < .0001), tubular adenomas (CCE-WL, 61%; CCE-FICE, 79%; P < .0001), and serrated polyps (CCE-WL, 57%; CCE-FICE, 74%; P = .0022). Both modes detected all adenocarcinomas. No significant differences were found between CCE-WL and CCE-FICE of the per-lesion sensitivity for ≥10-mm CRTs (CCE-WL, 81%; CCE-FICE, 94%; P = .1138) or protruding CRTs (CCE-WL, 77%; CCE-FICE, 86%; P = .0614). Kappa coefficients for overall CRTs for CCE-WL and CCE-FICE were .66 and .64, respectively, which indicated substantial agreement.

CONCLUSIONS

CCE-FICE improved the detection rates for all CRTs except adenocarcinomas, ≥10-mm polyps, and protruding polyps when compared with CCE-WL. (Clinical trial registration number: UMIN 000021125.).

AGA Clinical Practice Update on Risk Stratification for Colorectal Cancer Screening and Post-Polypectomy Surveillance: Expert Review

DESCRIPTION

Since the early 2000s, there has been a rapid decline in colorectal cancer (CRC) mortality, due in large part to screening and removal of precancerous polyps. Despite these improvements, CRC remains the second leading cause of cancer deaths in the United States, with approximately 53,000 deaths projected in 2023. The aim of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review was to describe how individuals should be risk-stratified for CRC screening and post-polypectomy surveillance and to highlight opportunities for future research to fill gaps in the existing literature.

METHODS

This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All individuals with a first-degree relative (defined as a parent, sibling, or child) who was diagnosed with CRC, particularly before the age of 50 years, should be considered at increased risk for CRC. BEST PRACTICE ADVICE 2: All individuals without a personal history of CRC, inflammatory bowel disease, hereditary CRC syndromes, other CRC predisposing conditions, or a family history of CRC should be considered at average risk for CRC. BEST PRACTICE ADVICE 3: Individuals at average risk for CRC should initiate screening at age 45 years and individuals at increased risk for CRC due to having a first-degree relative with CRC should initiate screening 10 years before the age at diagnosis of the youngest affected relative or age 40 years, whichever is earlier. BEST PRACTICE ADVICE 4: Risk stratification for initiation of CRC screening should be based on an individual's age, a known or suspected predisposing hereditary CRC syndrome, and/or a family history of CRC. BEST PRACTICE ADVICE 5: The decision to continue CRC screening in individuals older than 75 years should be individualized, based on an assessment of risks, benefits, screening history, and comorbidities. BEST PRACTICE ADVICE 6: Screening options for individuals at average risk for CRC should include colonoscopy, fecal immunochemical test, flexible sigmoidoscopy plus fecal immunochemical test, multitarget stool DNA fecal immunochemical test, and computed tomography colonography, based on availability and individual preference. BEST PRACTICE ADVICE 7: Colonoscopy should be the screening strategy used for individuals at increased CRC risk. BEST PRACTICE ADVICE 8: The decision to continue post-polypectomy surveillance for individuals older than 75 years should be individualized, based on an assessment of risks, benefits, and comorbidities. BEST PRACTICE ADVICE 9: Risk-stratification tools for CRC screening and post-polypectomy surveillance that emerge from research should be examined for real-world effectiveness and cost-effectiveness in diverse populations (eg, by race, ethnicity, sex, and other sociodemographic factors associated with disparities in CRC outcomes) before widespread implementation.

Colon Capsule Endoscopy - Shining the Light through the Colon

PURPOSE OF REVIEW

Colon capsule endoscopy (CCE) is a non-invasive, wireless capsule endoscope. In this article, we review its current applications, compare its performance with optical colonoscopy (OC) and alternative imaging modalities like CT colonography (CTC), and highlight developments that may increase potential future use.

RECENT FINDINGS

By comparison to OC both CCE and CTC have a good sensitivity and specificity in detecting colonic polyps. CCE is more sensitive in detecting sub centimetre polyps. CCE is capable of detecting colonic inflammation and anorectal pathologies, commonly missed by CTC. However, rates of complete CCE examinations are limited by inadequate bowel preparation or incomplete colonic transit, whereas CTC can be performed with less bowel purgatives. Patients tolerate CCE better than OC, however patient preference between CCE and CTC vary. CCE and CTC are both reasonable alternatives to OC. Strategies to improve completion rates and adequacy of bowel preparation will improve cost and clinical effectiveness of CCE.

Colon Capsule Endoscopy in the Diagnosis of Colon Polyps: Who Needs a Colonoscopy?

Colon screening programs have reduced colon cancer mortality. Population screening should be minimally invasive, safe, acceptably sensitive, cost-effective, and scalable. The range of screening modalities include guaiac or immunochemical fecal occult blood testing and CT colonography and colonoscopy. A number of carefully controlled studies concur that second-generation capsule endoscopy has excellent sensitivity for polyp detection and a high negative predictive value. Colon capsules fulfill the screening expectation of safety, high sensitivity for polyp detection, and patient acceptance, and appear to straddle the divide between occult blood testing and colonoscopy. While meeting these criteria, there remains the challenges of scaling, capsule practitioner training, resource allocation, and implementing change of practice. Like CT colonography, capsule screening presents the clinician with a decision on the threshold for colonoscopy referral. Overall, colon capsules are an invaluable tool in polyp detection and colon screening and offer a filter that determines “who needs a colonoscopy?”.

Systematic review and meta-analysis of colon capsule endoscopy accuracy for colorectal cancer screening. An alternative during the Covid-19 pandemic?

Aim

To determine the diagnostic accuracy of colon capsule endoscopy for colorectal cancer screening.

Methods

Studies that compared the diagnostic performance of colonoscopy and second-generation colon capsule endoscopy (CCE-2) for screening of asymptomatic patients aged 50–75 years were included. The primary outcomes were sensitivity, specificity, and positive and negative likelihood ratios for polyps and adenomas measuring at least 6 mm or 10 mm.

Results

Eight full-text studies that evaluated 1602 patients were included for systematic review. Of these, 840 (52.43%) patients participated in an opportunistic screening program. The pooled outcomes of CCE-2 for polyps at least 6 mm / 10 mm were (CI = confidence interval): sensitivity: 88% (95% CI: 0.84–0.91) / 88% (95% CI: 0.82–0.93), specificity: 94% (95% CI: 0.92–0.95) / 95.5% (95% CI: 0.94–0.97); positive likelihood ratio: 11.86 (95% CI: 5.53–25.46) / 23.07 (95% CI: 6.163–86.36); negative likelihood ratio: 0.14 (95% CI: 0.1–0.21) / 0.14 (95% CI: 0.09–0.21). The area under the summary receiver operating characteristic curve for polyps at least 6 and 10 mm was 96.3% and 96.7%, respectively. The only cancer missed by complete CCE-2 was shown at multiple frames in the unblinded review. In total, 125 (7.8%) patients presented mild adverse events mostly related to bowel preparation.

Conclusion

CCE-2 is demonstrated to be an effective and safe alternative method for colorectal cancer screening. Diagnostic performance of CCE-2 for polyps of at least 6 and 10 mm was similar. Completion rates still need to be improved.

Applicability of colon capsule endoscopy as pan-endoscopy: From bowel preparation, transit, and rating times to completion rate and patient acceptance

Background and study aims  Colon capsule endoscopy (CCE) has the potential to explore the entire gastrointestinal tract. The aim of this study was to assess the applicability of CCE as pan-endoscopy. Patients and methods  Healthy participants received CCE with bowel preparation (bisacodyl, polyethylene electrolyte glycol (PEG) + ascorbic acid) and booster regimen (metoclopramide, oral sulfate solution (OSS)). For each segment of the gastrointestinal tract, the following quality parameters were assessed: cleanliness, transit times, reading times, patient acceptance and safety of the procedure. When all gastrointestinal segments had cleansing score good or excellent, cleanliness of the whole gastrointestinal tract was assessed as good. Participants' expected and perceived burden was assessed by questionnaires and participants were asked to grade the procedure (scale 0-10). All serious adverse events (SAEs) were documented. Results  A total of 451 CCE procedures were analyzed. A good cleansing score was achieved in the stomach in 69.6%, in the SB in 99.1 % and in the colon in 76.6 %. Cleanliness of the whole gastrointestinal tract was good in 52.8 % of the participants. CCE median transit time of the whole gastrointestinal tract was 583 minutes IQR 303-659). The capsule reached the descending colon in 94.7 %. Median reading time per procedure was 70 minutes (IQR 57-83). Participants graded the procedure with a 7.8. There were no procedure-related SAEs. Conclusions  CCE as pan-endoscopy has shown to be a safe procedure with good patient acceptance. When cleanliness of all gastrointestinal segments per patient, completion rate and reading time will be improved, CCE can be applied as a good non-invasive alternative to evaluate the gastrointestinal tract.

Efficacy of bowel preparation regimens for colon capsule endoscopy: a systematic review and meta-analysis

Background and study aims  Colon capsule endoscopy (CCE) is an alternative to conventional colonoscopy (CC) in specific clinical settings. High completion rates (CRs) and adequate cleanliness rates (ACRs) are fundamental quality parameters if CCE is to be widely implemented as a CC equivalent diagnostic modality. We conducted a systematic review and meta-analysis to investigate the efficacy of different bowel preparations regimens on CR and ACR in CCE. Patients and methods  We performed a systematic literature search in PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library. Data were independently extracted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The primary outcome measures (CR, ACR) were retrieved from the individual studies and pooled event rates were calculated. Results  Thirty-four observational (OBS) studies (n = 3,789) and 12 randomized clinical trials (RCTs) (n = 1,214) comprising a total 5,003 patients were included. The overall CR was 0.798 (95 % CI, 0.764-0.828); the highest CRs were observed with sodium phosphate (NaP) + gastrografin booster (n = 2, CR = 0.931, 95 % CI, 0.820-0.976). The overall ACR was 0.768 (95 % CI, 0.735-0.797); the highest ACRs were observed with polyethylene glycol (PEG) + magnesium citrate (n = 4, ER = 0.953, 95 % CI, 0.896-0.979). Conclusions  In the largest meta-analysis on CCE bowel preparation regimens, we found that both CRs and ACRs are suboptimal compared to the minimum recommended standards for CC. PEG laxative and NaP booster were the most commonly used but were not associated with higher CRs or ACRs. Well-designed studies on CCE should be performed to find the optimal preparation regimen.

Multicentre, prospective, randomised study comparing the diagnostic yield of colon capsule endoscopy versus CT colonography in a screening population (the TOPAZ study)

OBJECTIVE

Colon capsule endoscopy (CCE) has shown promise for colorectal neoplasia detection compared with optical colonoscopy (OC), but has not been compared with other screening tests in average risk screening patients.

DESIGN

Patients 50 to 75 years of age (African Americans, 45-75 years) were randomised to CCE or CT colonography (CTC) and subsequent blinded OC. The primary endpoint was diagnostic yield of polyps ≥6 mm with CCE or CTC. Secondary endpoints included accuracy for size and histology, examination completeness, number/proportion of subjects with polyps and adenomas ≥6 mm and ≥10 mm, subject satisfaction and safety.

RESULTS

From 320 enrolled subjects, data from 286 (89.4%) were evaluable. The proportion of subjects with any polyp ≥6 mm confirmed by OC was 31.6% for CCE versus 8.6% for CTC (pPr non-inferiority and superiority=0.999). The diagnostic yield of polyps ≥10 mm was 13.5% with CCE versus 6.3% with CTC (pPr non-inferiority=0.9954). The sensitivity and specificity of CCE for polyps ≥6 mm was 79.2% and 96.3% while that of CTC was 26.8% and 98.9%. The sensitivity and specificity of CCE for polyps ≥10 mm was 85.7% and 98.2% compared with 50% and 99.1% for CTC. Both tests were well tolerated/safe.

CONCLUSION

CCE was superior to CTC for detection of polyps ≥6 mm and non-inferior for identification of polyps ≥10 mm. CCE should be considered comparable or superior to CTC as a colorectal neoplasia screening test, although neither test is as effective as OC.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov no: NCT02754661.

Lavage, Simethicone, and Prokinetics-What to Swallow with a Video Capsule

The development of new capsules now allows endoscopic diagnosis in all segments of the gastrointestinal tract and comes with new needs for differentiated preparation regimens. Although the literature is steadily increasing, the results of the conducted trials on preparation are sometimes conflicting. The ingestion of simethicone before gastric and small bowel capsule endoscopy for prevention of air bubbles is established. The value of a lavage before small bowel capsule endoscopy (SBCE) is recommended, although not supported by all studies. Ingestion in the morning before the procedure seems useful for the improvement of mucosa visualization. Lavage after swallowing of the capsule seems to improve image quality, and in some studies also diagnostic yield. Prokinetics has been used with first generation capsules to shorten gastric transit time and increase the rate of complete small bowel visualization. With the massively prolonged battery capacity of the new generation small bowel capsules, prokinetics are only necessary in significantly delayed gastric emptying as documented by a real-time viewer. Lavage is crucial for an effective colon capsule or pan-intestinal capsule endoscopy. Mainly high or low volume polyethylene glycol (PEG) is used. Apart from achieving optimal cleanliness, propulsion of the capsule by ingested boosts is required to obtain a complete passage through the colon within the battery lifetime. Boosts with low volume sodium picosulfate (NaP) or diatrizoate (gastrografin) seem most effective, but potentially have more side effects than PEG. Future research is needed for more patient friendly but effective preparations, especially for colon capsule and pan-intestinal capsule endoscopy.

Colon capsule endoscopy in clinical practice: lessons from a national 5-year observational prospective cohort

Background and study aims  Colon capsule endoscopy (CCE) has been proposed as an alternative to colonoscopy for screening patients at average risk of colorectal cancer (CRC). A prospective national cohort was developed to assess relevance of CCE in real-life practice and its short- and long-term impacts on clinical management. Patients and methods  All patients who underwent a CCE in France were prospectively enrolled from January 2011 to May 2016 and reached annually by phone until May 2017. All CCE and colonoscopy reports were systematically collected. Results  During the study period, 689 CCEs were analyzed from 14 medical centers. Median follow-up time was 35 months [IQR: 12-50]. Indication for CCE was mainly for elderly patients (median age: 70 years, IQR: [61-79]) due to anesthetic or colonoscopy contraindication (n = 307; 44.6 %). Only 337 CCEs (48.9 %) were both complete and with adequate bowel preparation. Advanced neoplasia (adenoma with high-grade dysplasia or CRC) was diagnosed following 32 CCEs (4.6 %). Among patients who underwent colonoscopy or therapeutic surgery following CCE, 18.8 % of all advanced neoplasias (6/32) had not been diagnosed by CCE mainly due to technical issues. Performing a colonoscopy in the case of significant polyps or insufficient bowel cleansing or after an incomplete CCE allowed the diagnosis of 96.9 % of all identified advanced neoplasias (31/32). Conclusions  Outside the scope of academic trials, improvement is needed to increase the reliability of CCE as less than half were considered optimal i. e. complete with adequate bowel cleansing. Most of missed colonic advanced neoplasia were due to incomplete CCE with distal neoplasia location.

Colon capsule endoscopy in colorectal cancer screening: a systematic review

INTRODUCTION

Primary colonoscopy and fecal immunochemical test (FIT) are the most commonly used colorectal cancer (CRC) screening modalities. Colon capsule endoscopy (CCE) might be an alternative. Data on the performance of CCE as a CRC screening tool in a screening population remain scarce. This is the first systematic review to provide an overview of the applicability of CCE as a CRC screening tool.

METHODS

A systematic search was conducted of literature published up to September 2020. Studies reporting on CRC screening by second-generation CCE in an average-risk screening population were included.

RESULTS

582 studies were identified and 13 were included, comprising 2485 patients. Eight studies used CCE as a filter test after a positive FIT result and five studies used CCE for primary screening. The polyp detection rate of CCE was 24 % - 74 %. For polyps > 6 mm, sensitivity of CCE was 79 % - 96 % and specificity was 66 % - 97 %. For polyps ≥ 10 mm, sensitivity of CCE was 84 % - 97 %, which was superior to computed tomographic colonography (CTC). The CRC detection rate for completed CCEs was 93 % (25/27). Bowel preparation was adequate in 70 % - 92 % of examinations, and completion rates varied from 57 % to 92 %, depending on the booster used. No CCE-related complications were described.

CONCLUSION

CCE appeared to be a safe and effective tool for the detection of CRC and polyps in a screening setting. Accuracy was comparable to colonoscopy and superior to CTC, making CCE a good alternative to colonoscopy in CRC screening programs, although completion rates require improvement.

Castor oil as booster for colon capsule endoscopy preparation reduction: A prospective pilot study and patient questionnaire

BACKGROUND

Preparation for colon capsule endoscopy (CCE) requires a large liquid laxative volume for capsule excretion, which compromises the procedure's tolerability.

AIM

To assess the safety and utility of castor oil-boosted bowel preparation.

METHODS

This prospective cohort study including 20 patients (age range, 16-80 years; six men and 14 women) suspected of having colorectal disease was conducted at Kindai University Hospital from September 2017 to August 2019. All patients underwent CCE because of the following inclusion criteria: previous incomplete colonoscopy in other facility (n = 20), history of abdominal surgery (n = 7), or organ abnormalities such as multiple diverticulum (n = 4) and adhesion after surgery (n = 6). The exclusion criteria were as follows: Dysphagia, history of allergic reactions to the drugs used in this study (magnesium citrate, polyethylene glycol, metoclopramide, and castor oil), possibility of pregnancy, possibility of bowel obstruction or stenosis based on symptoms, or scheduled magnetic resonance imaging within 2 wk after CCE. The primary outcome was the capsule excretion rate within the battery life, as evaluated by the total large bowel observation rate, large bowel transit time, and bowel creasing level using a five-grade scale in different colorectal segments. The secondary outcomes were complications, colorectal lesion detection rates, and patients’ tolerability.

RESULTS

The castor oil-based regimen was implemented in 17 patients. Three patients cancelled CCE because they could tolerate castor oil, but not liquid laxatives. The capsule excretion rate within the battery life was 88% (15/17). The mean large bowel transit time was 236 min. Approximately 70% of patients had satisfactory colon cleansing levels. CCE detected colon polyps (14/17, 82%) and colonic diverticulum (4/12, 33%). The sensitivity, specificity, and diagnostic accuracy rates for detecting colorectal polyps (size ≥ 6 mm) were 76.9%, 75.0%, and 76.4%, respectively. The sensitivity, specificity, and diagnostic accuracy rates for detection of diverticulum were 100% each. Twelve patients (71%) rated CCE as more than “good”, confirming the new regimen’s tolerability. No serious adverse events occurred during this study.

CONCLUSION

The castor oil-based regimen could reduce bowel preparation dose and improve CCE tolerability.

Scoring Systems for Clinical Colon Capsule Endoscopy-All You Need to Know

In the constantly developing era of minimal diagnostic invasiveness, the role of colon capsule endoscopy in colonic examination is being increasingly recognised, especially in the context of curtailed endoscopy services due to the COVID-19 pandemic. It is a safe diagnostic tool with low adverse event rates. As with other endoscopic modalities, various colon capsule endoscopy scores allow the standardisation of reporting and reproducibility. As bowel cleanliness affects CCE’s diagnostic yield, a few operator-dependent scores (Leighton–Rex and CC-CLEAR scores) and a computer-dependent score (CAC score) have been developed to grade bowel cleanliness objectively. CCE can be used to monitor IBD mucosal disease activity through the UCEIS and the panenteric CECDAIic score for UC and CD, respectively. CCE may also have a role in CRC screening, given similar sensitivity and specificity rates to conventional colonoscopy to detect colonic polyps ≥ 10 mm and CRC. Given CCE’s diagnostic yield and reproducible clinical scores with high inter-observer agreements, CCE is fast becoming a suitable alternative to conventional colonoscopy in specific patient populations.

Current status of colon capsule endoscopy

While both the annual incidence and mortality of colorectal cancer are slowly but steadily decreasing in the United States, the incidence of such malignancy is increasing in Japan. Thus, controlling colorectal cancer in Japan is a major concern. In 2006, colon capsule endoscopy was first introduced by Eliakim et al. First-generation colon capsule endoscopy had a moderate sensitivity for detecting polyps of more than 6 mm. Thus, second-generation colon capsule endoscopy was developed to achieve higher sensitivity. Colonoscopy is the gold standard tool for colorectal cancer surveillance. With an improvement in the imaging function, the performance of second-generation colon capsule endoscopy is almost as satisfactory as that of colonoscopy. Certain situations, such as incomplete colonoscopy and contraindication for use of sedation, can benefit from colon capsule endoscopy. Colon capsule endoscopy requires a more extensive bowel preparation than colonoscopy and computed tomography colonography because it requires laxatives not only for bowel cleansing but also for promoting the excretion of the capsule. Another problem with colon capsule endoscopy includes the burden of reading and interpretation and overlook of the lesions. Currently, the development of automatic diagnosis of colon capsule endoscopy using artificial intelligence is still under progress. Although the available guidelines do not support the use of colon capsule endoscopy for inflammatory bowel disease, the possible application of colon capsule endoscopy is ulcerative colitis. This review article summarizes and focuses on the current status of colon capsule endoscopy for colorectal cancer screening and the possibility for its applicability on inflammatory bowel disease.

Second-generation colon capsule endoscopy for detection of colorectal polyps: Systematic review and meta-analysis of clinical trials

Background and study aims  Adherence to colorectal cancer (CRC) screening is still unsatisfactory in many countries, thereby limiting prevention of CRC. Colon capsule endoscopy (CCE), a minimally invasive procedure, could be an alternative to fecal immunochemical tests or optical colonoscopy for CRC screening, and might increase adherence in CRC screening. This systematic review and meta-analysis evaluates the diagnostic accuracy of CCE compared to optical colonoscopy (OC) as the gold standard, adequacy of bowel preparation regimes and the patient perspective on diagnostic measures. Methods  We conducted a systematic literature search in PubMed, EMBASE and the Cochrane Register for Clinical Trials. Pooled estimates for sensitivity, specificity and the diagnostic odds ratio with their respective 95 % confidence intervals (CI) were calculated for studies providing sufficient data. Results  Of 840 initially identified studies, 13 were included in the systematic review and up to 9 in the meta-analysis. The pooled sensitivities and specificities for polyps ≥ 6 mm were 87 % (95 % CI: 83 %-90 %) and 87 % (95 % CI: 76 %-93 %) in 8 studies, respectively. For polyps ≥ 10 mm, the pooled estimates for sensitivities and specificities were 87 % (95 % CI: 83 %-90 %) and 95 % (95 % CI: 92 %-97 %) in 9 studies, respectively. A patients' perspective was assessed in 31 % (n = 4) of studies, and no preference of CCE over OC was reported. Bowel preparation was adequate in 61 % to 92 % of CCE exams. Conclusions  CCE provides high diagnostic accuracy in an adequately cleaned large bowel. Conclusive findings on patient perspectives require further studies to increase acceptance/adherence of CCE for CRC screening.

Capsule endoscopy - Recent developments and future directions

INTRODUCTION

Capsule endoscopy (CE) is an established modality in the diagnostic algorithm of small bowel (SB) pathology. Its use has expanded for investigation of upper and lower gastrointestinal diseases with similar prototypes.

AREAS COVERED

This review covers the role and recent advances of CE, as a non-invasive investigative tool.

EXPERT OPINION

The use of upper gastrointestinal CE is useful in patients who require surveillance for varices particularly in the current era of the COVID-19 pandemic. It has also shown high accuracy in the detection of upper gastrointestinal hemorrhage in patients presenting with a suspicion of hemorrhage. Findings on CE help to guide further management by device-assisted enteroscopy. The data on colon CE suggest comparable diagnostic accuracy to colonoscopy for polyp detection; however, more evidence is required in the high-risk group. Crohn's CE has become an integral part of the management of patients with Crohn's disease offering a comparative assessment tool post escalation of therapy. Artificial intelligence within CE has demonstrated similar if not better diagnostic yield compared to the human with a significantly shorter reading time. Artificial intelligence is likely to be in-built within CE reading platforms over the next few years minimizing reporting time and human error.

Imaging alternatives to colonoscopy: CT colonography and colon capsule. European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline - Update 2020

1: ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia.Strong recommendation, high quality evidence.ESGE/ESGAR do not recommend barium enema in this setting.Strong recommendation, high quality evidence. 2: ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors.Strong recommendation, low quality evidence.ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete.Weak recommendation, low quality evidence. 3: When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms.Strong recommendation, high quality evidence.Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation.Very low quality evidence.ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms.Strong recommendation, high quality evidence.In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms.Weak recommendation, low quality evidence. 4: Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors.Strong recommendation, high quality evidence.ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer.Weak recommendation, low quality evidence. 5: ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs.Strong recommendation, moderate quality evidence.ESGE/ESGAR also suggest the use of CCE in this setting based on availability.Weak recommendation, moderate quality evidence. 6: ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasibleWeak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in this setting.Very low quality evidence. 7: ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible.Weak recommendation, low quality evidence.There is insufficient evidence to recommend CCE in post-polypectomy surveillance.Very low quality evidence. 8: ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation.Strong recommendation, low quality evidence. 9: ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥ 6 mm detected at CTC or CCE.Follow-up CTC may be clinically considered for 6 - 9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia.Strong recommendation, moderate quality evidence.

Colon Capsule Endoscopy vs. CT Colonography Following Incomplete Colonoscopy: A Systematic Review with Meta-Analysis

Following incomplete colonoscopy (IC) patients often undergo computed tomography colonography (CTC), but colon capsule endoscopy (CCE) may be an alternative. We compared the completion rate, sensitivity and diagnostic yield for polyp detection from CCE and CTC following IC. A systematic literature search resulted in twenty-six studies. Extracted data included inter alia, complete/incomplete investigations and polyp findings. Pooled estimates of completion rates of CCE and CTC and complete colonic view rates (CCE reaching the most proximal point of IC) of CCE were calculated. Per patient diagnostic yields of CCE and CTC were calculated stratified by polyp sizes. CCE completion rate and complete colonic view rate were 76% (CI 95% 68-84%) and 90% (CI 95% 83-95%). CTC completion rate was 98% (CI 95% 96-100%). Diagnostic yields of CTC and CCE were 10% (CI 95% 7-15%) and 37% (CI 95% 30-43%) for any size, 13% (CI 95% 9-18%) and 21% (CI 95% 12-32%) for >5-mm and 4% (CI 95% 2-7%) and 9% (CI 95% 3-17%) for >9-mm polyps. No study performed a reference standard follow-up after CCE/CTC in individuals without findings, rendering sensitivity calculations unfeasible. The increased diagnostic yield of CCE could outweigh its slightly lower complete colonic view rate compared to the superior CTC completion rate. Hence, CCE following IC appears feasible for an introduction to clinical practice. Therefore, randomized studies investigating CCE and/or CTC following incomplete colonoscopy with a golden standard reference for the entire population enabling estimates for sensitivity and specificity are needed.

AGA White Paper: Roadmap for the Future of Colorectal Cancer Screening in the United States

The American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology convened a consensus conference in December 2018, entitled, "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The goal of the conference, which attracted more than 60 experts in screening and related disciplines, including the authors, was to envision a future in which colorectal cancer (CRC) screening and surveillance are optimized, and to identify barriers to achieving that future. This White Paper originates from that meeting and delineates the priorities and steps needed to improve CRC outcomes, with the goal of minimizing CRC morbidity and mortality. A one-size-fits-all approach to CRC screening has not and is unlikely to result in increased screening uptake or desired outcomes owing to barriers stemming from behavioral, cultural, and socioeconomic causes, especially when combined with inefficiencies in deployment of screening technologies. Overcoming these barriers will require the following: efficient utilization of multiple screening modalities to achieve increased uptake; continued development of noninvasive screening tests, with iterative reassessments of how best to integrate new technologies; and improved personal risk assessment to better risk-stratify patients for appropriate screening testing paradigms.

Diagnostic accuracy of computed tomography colonography in patients at high risk for colorectal cancer: a meta-analysis

AIM

The aim was to explore the diagnostic value of computed tomographic colonography (CTC) compared with conventional colonoscopy in individuals at high risk for colorectal cancer.

METHOD

PubMed, Embase, the Cochrane Library and the Web of Science were searched by two independent reviewers for potentially eligible studies published up to 31 October 2018 that were based on a per-patient analysis. stata, meta-disc and revman were used to perform this meta-analysis. A random-effect model was used, and a subgroup analysis was conducted to explore the sources of heterogeneity.

RESULTS

A total of 14 full-text articles, involving 3578 patients, were included in this meta-analysis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and the area under the summary receiver operating characteristic curve of CTC for detecting polyps ≥ 6 mm were 0.87 (95% CI 0.83-0.90), 0.90 (95% CI 0.86-0.93), 9.08 (95% CI 6.28-13.13), 0.14 (95% CI 0.11-0.18) and 0.94 (95% CI 0.92-0.96), respectively. For polyps ≥ 10 mm, the pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of CTC were 0.91 (95% CI 0.86-0.94), 0.98 (95% CI 0.95-0.99), 40.36 (95% CI 19.16-85.03), 0.90 (95% CI 0.06-0.14) and 0.98 (95% CI 0.96-0.99), respectively.

CONCLUSION

In this meta-analysis, CTC had high diagnostic accuracy for detecting polyps ≥ 6 mm and ≥ 10 mm in patients at high risk of developing colorectal cancer and it had a higher sensitivity and specificity for detecting polyps ≥ 10 mm than polyps ≥ 6 mm. However, the results should be used cautiously due to the significant heterogeneity.

Colon capsule endoscopy versus CT colonography in FIT-positive colorectal cancer screening subjects: a prospective randomised trial-the VICOCA study

BACKGROUND

Colon capsule endoscopy (CCE) and CT colonography (CTC) are minimally invasive techniques for colorectal cancer (CRC) screening. Our objective is to compare CCE and CTC for the identification of patients with colorectal neoplasia among participants in a CRC screening programme with positive faecal immunochemical test (FIT). Primary outcome was to compare the performance of CCE and CTC in detecting patients with neoplastic lesions.

METHODS

The VICOCA study is a prospective, single-centre, randomised trial conducted from March 2014 to May 2016; 662 individuals were invited and 349 were randomised to CCE or CTC before colonoscopy. Endoscopists were blinded to the results of CCE and CTC.

RESULTS

Three hundred forty-nine individuals were included: 173 in the CCE group and 176 in the CTC group. Two hundred ninety individuals agreed to participate: 147 in the CCE group and 143 in the CTC group. In the intention-to-screen analysis, sensitivity, specificity and positive and negative predictive values for the identification of individuals with colorectal neoplasia were 98.1%, 76.6%, 93.7% and 92.0% in the CCE group and 64.9%, 95.7%, 96.8% and 57.7% in the CTC group. In terms of detecting significant neoplastic lesions, the sensitivity of CCE and CTC was 96.1% and 79.3%, respectively. Detection rate for advanced colorectal neoplasm was higher in the CCE group than in the CTC group (100% and 93.1%, respectively; RR = 1.07; p = 0.08). Both CCE and CTC identified all patients with cancer. CCE detected more patients with any lesion than CTC (98.6% and 81.0%, respectively; RR = 1.22; p = 0.002).

CONCLUSION

Although both techniques seem to be similar in detecting patients with advanced colorectal neoplasms, CCE is more sensitive for the detection of any neoplastic lesion.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02081742 . Registered: September 16, 2013.

Colon capsule endoscopy versus CT colonography after incomplete colonoscopy. Application of artificial intelligence algorithms to identify complete colonic investigations

BACKGROUND

Guidelines suggest computed tomography colonography (CTC) following incomplete optical colonoscopy (OC). Colon capsule endoscopies (CCE) have been suggested as an alternative, although completion rates have been unsatisfactory. Introduction of artificial intelligence (AI)-based localization algorithms of the camera capsules may enable identification of incomplete CCE investigations overlapping with incomplete OCs.

OBJECTIVE

The study aims to investigate relative sensitivity of CCE compared with CTC following incomplete OC, investigate the completion rate when combining results from the incomplete OC and CCE, and develop a forward-tracking algorithm ensuring a safe completeness of combined investigations.

METHODS

In this prospective paired study, patients with indication for CTC following incomplete OC were included for CCE and CTC. Location of CCE abortion and OC abortion were registered to identify complete combined investigations. AI-based algorithm for localization of capsules were developed reconstructing the passage of the colon.

RESULTS

In 237 individuals with CTC indication; 105 were included, of which 97 underwent both a CCE and CTC. CCE was complete in 66 (68%). Including CCEs which reached most oral point of incomplete OC, 73 (75%) had complete colonic investigations; 78 (80%) had conclusive investigations. Relative sensitivity of CCE compared with CTC was 2.67 (95% confidence interval (CI) 1.76;4.04) for polyps >5 mm and 1.91 (95% CI 1.18;3.09) for polyps >9 mm. An AI-based algorithm was developed.

CONCLUSION

Sensitivity of CCE following incomplete OC was superior to CTC. Introducing and improving algorithm-based localization of capsule abortion may increase identification of overall complete investigation rates following incomplete OC.ClinicalTrials.gov identifier: NCT02826993.

The experience with colorectal cancer screening in the Czech Republic: the detection at earlier stages and improved clinical outcomes

OBJECTIVES

Colorectal cancer (CRC) remains a major health burden. Although screening is recommended and considered beneficial, further data on its positive effects are needed for worldwide implementation.

STUDY DESIGN

The aim of our national multicentre prospective observational study was to reveal and document clinicopathological differences in CRC diagnosed by screening and presented by disease symptoms as well as assess the efficiency of the screening programme in the Czech Republic.

METHODS

Between March 2013 and September 2015, a total of 265 patients were enrolled in 12 gastroenterology centres across the Czech Republic. Patients were divided into screening and symptomatic groups and compared for pathology status and clinical characteristics. Screening was defined as a primary screening colonoscopy or a colonoscopy after a positive faecal occult blood test in an average-risk population.

RESULTS

The distribution of CRC stages was significantly (statistically and clinically) favourable in the screening group (predominance of stages 0, I and II) compared with the non-screening group (P < 0.001). The presence of distant and local metastases was significantly less frequent in the screening group than in the symptomatic group (P < 0.001). Patients in the screening group had a higher probability of radical surgery (R0) than those diagnosed based on symptoms (P < 0.001). Systemic palliative treatment was indicated in two patients in the screening group compared with 23 patients in the non-screening group (P = 0.018).

CONCLUSION

CRC diagnosed by screening disclosed less advanced clinicopathological characteristics and results in patients with a higher probability of radical surgery (R0) than diagnoses established based on symptoms, with subsequent management differing accordingly between both groups. These results advocate the implementation of a suitable worldwide screening programme.

Colon Capsule Endoscopy: Indications, Findings, and Complications - Data from a Prospective German Colon Capsule Registry Trial (DEKOR)

Background/Aims

Reliable and especially widely accepted preventive measures are crucial to further reduce the incidence of colorectal cancer (CRC). Colon capsule endoscopy (CCE) might increase the screening numbers among patients unable or unwilling to undergo conventional colonoscopy. This registry trial aimed to document and determine the CCE indications, findings, complications, and adverse events in outpatient practices and clinics throughout Germany.

Methods

Patients undergoing CCE between 2010 and 2015 were enrolled in this prospective multicenter registry trial at six German centers. Patient demographics, outcomes, and complications were evaluated.

Results

A total of 161 patients were included. Of the CCE evaluations, 111 (68.9%) were considered successful. Pathological findings in the colon (n=92, 60.1%) and in the remaining gastrointestinal tract (n=38, 24.8%) were recorded. The main finding was the presence of polyps (n=52, 32.3%). Furthermore, five carcinomas (3.1%) were detected and histologically confirmed later. Adequate bowel cleanliness was more likely to be achieved in the outpatient setting (p<0.0001). Interestingly, 85 patients (55.6%) chose to undergo CCE based on personal motivation.

Conclusions

CCE seems to be a reliable and safe endoscopic tool for screening for CRC and detecting other diseases. Its patient acceptance and feasibility seems to be high, especially in the outpatient setting.

Colon capsule endoscopy

There are multiple indications for luminal imaging of the colon. From assessment of known disease, to diagnosing new pathology; intra-luminal visualisation is the mainstay of gastrointestinal diagnosis. Colonoscopy and radiological imaging are currently the most frequently deployed diagnostic methods. However, both have an associated risk profile, have significant resource pressures and are not universally tolerated. Colon capsule endoscopy (CCE) offers an adjunct to these diagnostic options. In this narrative review the utility of CCE is described. Its current uses, potential benefits and future developments are also discussed.

Advances in endoscopy for colorectal polyp detection and classification

While colonoscopy is considered the gold standard for colon cancer screening, recent advancements in endoscopes have allowed for improved visualization of the colonic mucosa and improved polyp detection rates. Newer technologies also allow for assessment of structural changes for polyp discrimination and determination of histologic type. Classification of polyps prevents the need for a histopathologic report, which requires the additional time and expertise of a pathologist and adds to the overall cost. This review considered advances in endoscopic technologies reported in PubMed over the past 12 years. Technologies that allow for increased visual field of colonic mucosa and may lead to improved colon polyp detection rates include cap-assisted colonoscopy, RetroView, extra-wide-angle view colonoscope, full-spectrum endoscopy, Third Eye Retroscope, NaviAid G-EYE balloon colonoscope, EndoRings, and Endocuff. Image-enhancing methods allow for pit pattern analysis of colorectal lesions, which enables the physician to classify colorectal polyps according to certain polyp characteristics. Image-enhancing methods include chromoendoscopy, autofluorescence, and virtual chromoendoscopy, including narrow band imaging, i-SCAN, flexible spectral imaging chromoendoscopy, and STORZ professional image enhancement systems. In addition, advancements have been made in in vivo microscopic evaluation of colonic epithelium, including confocal laser endomicroscopy, endocytoscopy, optical coherence tomography, spectroscopy, and autofluorescence spectroscopy. Colon capsule endoscopy also has a role in colon polyp detection and classification. The advancements in polyp detection and classification have great promise for earlier detection and removal of advanced adenomas before they advance to colorectal cancer.

Time-saving polyp detection in colon capsule endoscopy: evaluation of a novel software algorithm

BACKGROUND

Colon capsule endoscopy (CCE) is a reliable method to detect colonic polyps in the well-prepared colon. As CCE evaluation can be time consuming, a new software algorithm might aid in reducing evaluation time.

OBJECTIVES

The aim of the study was to evaluate whether it is feasible to reliably detect colon polyps in CCE videos with a new software algorithm the "collage mode" (Rapid 8 Software, Covidien/Medtronic®).

METHODS

Twenty-nine CCE videos were randomly presented to three experienced and to three inexperienced investigators. Videos were evaluated by applying the collage mode. Investigation time was documented and the results (≥one polyp vs. no polyp) were compared with the findings of two highly experienced central readers who read the CCE videos in the standard mode beforehand.

RESULTS

It took a median time of 9.8, 3.5, and 7.5 vs. 4.3, 4.6 and 12.5 min for experienced vs. inexperienced investigators to review the CCE videos. For detecting ≥one polyp vs. no polyp, sensitivity of 93.3%, 73.3%, and 93.3% was observed for the experienced and sensitivity of 46.7%, 33.3%, and 93.3% for the inexperienced CCE readers.

CONCLUSION

Collage mode might allow for a quick review of CCE videos with a high polyp detection rate for experienced CCE readers. Future prospective studies should include CCE collage mode for rapid polyp detection to further prove the feasibility of practical colon polyp detection by CCE and possibly support the role of CCE as a screening tool in CRC prevention.

Multicenter feasibility study of bowel preparation with castor oil for colon capsule endoscopy

BACKGROUND AND AIM

Extensive use of laxatives and incomplete excretion rates are problematic for colon capsule endoscopy (CCE). The aim of the present study was to determine the effectiveness of castor oil as a booster.

METHODS

At four Japanese hospitals, 319 examinees undergoing CCE were enrolled retrospectively. Before and after the introduction of castor oil, other preparation reagents were unchanged.

RESULTS

Of 319 examinees who underwent CCE, 152 and 167 examinees took regimens with castor oil (between November 2013 and June 2016) and without castor oil (between October 2015 and September 2017), respectively. Capsule excretion rates within its battery life in the groups with and without castor oil were 97% and 81%, respectively (P < 0.0001). Multivariate analysis showed that ages younger than 65 years (adjusted odds ratio [OR], 3.00; P = 0.0048), male gender (adjusted OR, 3.20; P = 0.0051), and use of castor oil (adjusted OR, 6.29; P = 0.0003) were predictors of capsule excretion within its battery life. Small bowel transit time was shorter and total volume of lavage and fluid intake was lower with castor oil than without (P = 0.0154 and 0.0013, respectively). Overall adequate cleansing level ratios with and without castor oil were 74% and 83%, respectively (P = 0.0713). Per-examinee sensitivity for polyps ≥6 mm with and without castor oil was 83% and 85%, respectively, with specificities of 80% and 78%, respectively.

CONCLUSION

Bowel preparation with castor oil was effective for improving capsule excretion rate and reducing liquid loading.

Booster medication to achieve capsule excretion in colon capsule endoscopy: a randomized controlled trial of three regimens

Background and study aims  To achieve a complete colon capsule endoscopy, the entire colon must be visualized, clean and filled with clear fluids. The primary aim was to compare three booster regimens in colon capsule endoscopy in achieving capsule excretion within recording time. Secondary aims were quality of bowel cleansing and completion rate (both adequate cleansing and capsule excretion). Patients and methods  Patients scheduled for follow-up colonoscopy due to previous neoplastic findings or familial history of colorectal cancer aged 18 to 70 years were eligible. Bowel preparation was 2-L split doses of polyethylene glycol. Patients were randomized to three booster regimens of either polyethylene glycol (Group A), sulfate-based solution (Group B) or polyethylene glycol with iodine oral contrast (Group C). Results  One hundred eighty participants were included and randomized into three groups of 60. Capsule excretion was 70 % (95 % CI: 58 - 80) in Group A, 73 % (95 % CI: 61 - 83) in Group B and in 68 % (95 % CI: 56 - 79) in Group C, no statistically significant differences. Bowel cleansing grade was statistically significant better in Group B compared to Group A ( P  = 0.03), but there were no statistically significant differences between Groups C and A ( P  = 0.40). Complete examination rate was 65 % (95 % CI: 53 - 77), 72 % (95 % CI: 61 - 83) and 62 % (95 % CI: 50 - 74) in Group A, B and C respectively, not statistically significant different. Conclusions  Sulfate-based solution resulted in statistically significant better bowel cleansing compared to polyethylene glycol. Overall the excretion and completion rate was suboptimal. Achieving a high completion rate using patient-tolerable and low-risk compounds is still a challenge.

Recent Advance in Colon Capsule Endoscopy: What's New?

Colon capsule endoscopy (CCE) is a relatively new diagnostic procedure for patients with suspected colonic diseases. This convenient,noninvasive method enables the physician to explore the entire colon without significant discomfort to the patient. However, while CCEcan be performed painlessly without bowel air insufflation, the need for vigorous bowel preparation and other technical limitationsexist. Due to such limitations, CCE has not replaced conventional colonoscopy. In this review, we discuss historical and recentadvances in CCE including technical issues, ideal bowel preparation, indications and contraindications and highlight further technicaladvancements and clinical studies which are needed to develop CCE as a potential diagnostic tool.

Can coffee or chewing gum decrease transit times in Colon capsule endoscopy? A randomized controlled trial

BACKGROUND

A high rate of complete colon capsule endoscopy (CCE) investigations is required for a more widespread use of CCE. The objective of this study was to assess if coffee or chewing gum can increase excretion of the colon capsule within battery life time (excretion rate).

METHODS

One hundred eighty six screening participants with a positive immunochemical fecal occult blood test were included in this single-centre randomized controlled trial with blinding of the investigators to the randomization. Participants received instant coffee, chewing gum or nothing in addition to the standard bowel preparation.

RESULTS

The intention was to include 57 participants in the coffee group, 61 in the chewing gum group and 60 in the control group, on 8 participants data were missing. A total of 165 participants were included in a per protocol analysis. Exclusion was due to not receiving the allocated intervention (8 coffee, 4 chewing gum) and technical failure of the capsule (1 coffee). The excretion rate was 58% in the coffee group (n = 48), 63% in the chewing gum group (n = 57) and 55% in the control group (n = 60, p > 0.2). Transit times were similar in all groups. The excretion rate was low in participants who had transit times over 10 h (14%). A strong correlation was found between adequate cleansing and excretion of the capsule. There were no serious adverse events related to the interventions or CCE investigations.

CONCLUSIONS

Chewing gum and coffee did not improve excretion rate in this study. An effect of chewing gum could not be proven, possibly due to sample size. Since chewing gum might improve excretion rates, is cheap and has no known side effects, it needs to be considered in future bowel preparation trials for CCE.

TRIAL REGISTRATION

NCT02303756 , registered on December 1st 2014.

Back-to-back colon capsule endoscopy and optical colonoscopy in colorectal cancer screening individuals

AIM

The aim was to determine the polyp detection rate and per-patient sensitivity for polyps > 9 mm of colon capsule endoscopy (CCE) compared with colonoscopy as well as the diagnostic accuracy of CCE.

METHOD

Individuals who had a positive immunochemical faecal occult blood test during screening had investigator blinded CCE and colonoscopy. Participants underwent repeat endoscopy if significant lesions detected by CCE were considered to have been missed by colonoscopy.

RESULTS

There were 253 participants. The polyp detection rate was significantly higher in CCE compared with colonoscopy (P = 0.02). The per-patient sensitivity for > 9 mm polyps for CCE and colonoscopy was 87% (95% CI: 83-91%) and 88% (95% CI: 84-92%) respectively. In participants with complete CCE and colonoscopy examinations (N = 126), per-patient sensitivity of > 9 mm polyps in CCE (97%; 95% CI: 94-100%) was superior to colonoscopy (89%; 95% CI: 84-94%). A complete capsule endoscopy examination (N = 134) could detect patients with intermediate or greater risk (according to the European guidelines) with an accuracy, sensitivity, specificity and positivity rate of 79%, 93%, 69% and 58% respectively, using a cut-off of at least one polyp > 10 mm or more than two polyps.

CONCLUSION

CCE is superior to colonoscopy in polyp detection rate and per-patient sensitivity to > 9 mm polyps, but only in complete CCE examinations. The rate of incomplete CCE examinations must be improved.

Applications of Colon Capsule Endoscopy

PURPOSE OF REVIEW

This is a review of colon capsule endoscopy (CCE) with a focus on its recent developments, technological improvements, and current and potential future indications.

RECENT FINDINGS

Based on the current literature, CCE II demonstrates comparable polyp detection rates as optical colonoscopy and CT colonography, and improved cost-effectiveness. The main limitation to patient acceptance is the requirement of a rigorous bowel preparation. Preliminary studies show good correlation between CCE and optical colonoscopy for assessment of colonic disease activity in inflammatory bowel disease (IBD). CCE II is currently FDA, approved as an adjunctive test in patients with prior incomplete colonoscopy, and in the evaluation of patients with suspected lower gastrointestinal bleeding. The test is approved in Europe as one of the options for average-risk colorectal cancer screening, and high-risk screening in patients with contraindications or unwilling to undergo colonoscopy. CCE has a potential role in the evaluation and monitoring of colonic disease activity in IBD. Future technological advances should focus on minimizing bowel preparation, improvement in reading times, and development of therapeutic capabilities. • With technological improvements, the second-generation colon capsule has a significantly higher sensitivity than the first-generation capsule for detection of colon polyps. • Colon capsule endoscopy has been approved in Europe as an option for average-risk colorectal cancer screening, and high-risk screening in patients with contraindications or unwilling to undergo colonoscopy. • Colon capsule endoscopy has received FDA approval as an option for colorectal cancer screening in patients with prior incomplete colonoscopy, and in evaluation of patients with suspected lower gastrointestinal bleeding. • Colon capsule endoscopy may have a role in evaluation and monitoring of inflammatory bowel disease. • Colon capsule endoscopy currently requires a bowel preparation that is more rigorous than colonoscopy.

Colon capsule endoscopy to screen for colorectal neoplasia in those with family histories of colorectal cancer

BACKGROUND AND AIMS

Colon capsule endoscopy (CCE) has been recognized as an alternative for colorectal cancer (CRC) screening in average-risk people. Our aim was to prospectively assess the accuracy of CCE as a screening tool in first-degree relatives (FDRs) of people with CRC by using optical colonoscopy (OC) with segmental unblinding as the reference standard.

METHODS

Consecutive patients admitted with a CRC diagnosis (index cases) were prospectively evaluated and invited to contact their FDRs. Available FDRs were invited to undergo CCE and OC on the following day, with segmental unblinding of CCE results. Sensitivity, specificity, and predictive values/negative predictive values (PPV/NPV) of CCE were assessed for detecting patients with any polyp ≥6 mm and ≥10 mm.

RESULTS

A total of 177 FDRs (median age 57.0 years, 54.8% female) identified from 211 index cases were included. Both CCE and OC were completed in all the included FDRs. Overall, CCE identified 51 of 56 FDRs with polyps ≥6 mm (sensitivity 91%; 95% CI, 81-96) and correctly classified as negative 107 of 121 participants without lesions ≥6 mm (specificity 88%; 95% CI, 81-93). Per-patient positive and negative predictive values for ≥6 mm lesions were 78% (95% CI, 67-87) and 95% (95% CI, 90-98), respectively. CCE detected 24 of 27 patients with polyps ≥10 mm and correctly classified as negative 142 of 150 patients, corresponding to 89% sensitivity and 95% specificity. Post-CCE referral rates to colonoscopy were 37% and 18%, respectively.

CONCLUSIONS

CCE is an accurate method to screen FDRs of patients with CRC and could be offered as an alternative to those who decline or are unfit for colonoscopy screening. (Clinical trial registration number: NCT01184781.).

Multicenter, randomized study to optimize bowel preparation for colon capsule endoscopy

AIM

To assess the cleansing efficacy and safety of a new Colon capsule endoscopy (CCE) bowel preparation regimen.

METHODS

This was a multicenter, prospective, randomized, controlled study comparing two CCE regimens. Subjects were asymptomatic and average risk for colorectal cancer. The second generation CCE system (PillCam^® COLON 2; Medtronic, Yoqneam, Israel) was utilized. Preparation regimens differed in the 1^st and 2^nd boosts with the Study regimen using oral sulfate solution (89 mL) with diatrizoate meglumine and diatrizoate sodium solution (“diatrizoate solution”) (boost 1 = 60 mL, boost 2 = 30 mL) and the Control regimen oral sulfate solution (89 mL) alone. The primary outcome was overall and segmental colon cleansing. Secondary outcomes included safety, polyp detection, colonic transit, CCE completion and capsule excretion ≤ 12 h.

RESULTS

Both regimens had similar cleansing efficacy for the whole colon (Adequate: Study = 75.9%, Control = 77.3%; P = 0.88) and individual segments. In the Study group, CCE completion was superior (Study = 90.9%, Control = 76.9%; P = 0.048) and colonic transit was more often < 40 min (Study = 21.8%, Control = 4%; P = 0.0073). More Study regimen subjects experienced adverse events (Study = 19.4%, Control = 3.4%; P = 0.0061), and this difference did not appear related to diatrizoate solution. Adverse events were primarily gastrointestinal in nature and no serious adverse events related either to the bowel preparation regimen or the capsule were observed. There was a trend toward higher polyp detection with the Study regimen, but this did not achieve statistical significance for any size category. Mean transit time through the entire gastrointestinal tract, from ingestion to excretion, was shorter with the Study regimen while mean colonic transit times were similar for both study groups.

CONCLUSION

A CCE bowel preparation regimen using oral sulfate solution and diatrizoate solution as a boost agent is effective, safe, and achieved superior CCE completion.

Video capsule colonoscopy in routine clinical practice

BACKGROUND

Colon capsule endoscopy (CCE) offers direct mucosal visualisation without sedation or gas insufflation required in conventional colonoscopy (CC). However, evidence for the role of CCE as an adjunct or alternative to CC remains equivocal. In this observational cohort study, we report our experience of using CCE to investigate patients with suspected colon pathology at a tertiary referral centre.

METHODS

From 2007-2015, consecutive patients requiring colonoscopy were recruited from a tertiary care centre in Malmo, Sweden. Data collected: patient demographics, indication for CCE, findings, bowel cleansing, colon transit time (CTT) and completeness of colon examination.

RESULTS

Seventy-seven patients (57 F/20 F, median age 56 years) were included. The reason for CCE was previously incomplete or refused CC in 39 and 26 cases, and follow up of previous findings in 12 cases, respectively. The main clinical indications were gastrointestinal (GI) bleeding (n=28; 36%) and suspected inflammatory bowel disease (IBD) or follow-up of known IBD (n=23; 30%). CCE was complete in 58/77 (75%) patients. In 3 patients the colon was not reached; in the other 16, the capsule reached the rectum (n=4), sigmoid (n=6), descending colon (n=5) and transverse colon (n=1). Findings were: normal CCE (n=15; 19%) colonic diverticula (n=29; 38%), polyps (n=17; 22%), active IBD (n=12; 16%), haemorrhoids (n=8; 10%), colonic angioectasia (n=4; 5%) and cancer (n=1; 1%). Small-bowel findings were recorded in 8 (10%) patients. All patients tolerated bowel preparation and CCE well. Two patients with an ulcerated small-bowel stricture and cancer respectively experienced temporary capsule retention with spontaneous resolution.

CONCLUSIONS

CCE is a well-tolerated alternative to CC, but requires technological improvement and optimisation of clinical practice to meet current reference standards. Although further technical development is required, CCE may complement or even replace CC for certain clinical indications.

Where do I see minimally invasive endoscopy in 2020: clock is ticking

Since it was introduced 17 years ago, capsule endoscopy has become an important diagnostic tool for the small bowel. Three generations of the original small bowel capsule have been developed since (PillCam SB3, Medtronic, USA), and four competitors were introduced for the small bowel. A non-video patency capsule (Agile patency capsule, Medtronic, USA) was also developed, in order to confirm patency and thus avoid retention in the GI tract. Moreover, capsules viewing other organs of the body (esophagus, colon) as well as three different magnetic guided capsules that visualize the stomach as good as optical endoscopy (OE) have been developed. Over 2,000 articles looking at the efficacy of the small bowel capsule in different clinical situations were published since then. Studies are comparing capsule endoscopy versus other modalities in various indications, looking at preparations aiming to improve the diagnostic yield and at technical aspects. The present paper, describes the available capsules in the market and my biased future expectations.

Clinical Practice Guidelines for the Use of Video Capsule Endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice.

METHODS

A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined.

CONCLUSIONS

CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.

Colon capsule endoscopy: toward the future

Colon capsule endoscopy is a wireless and minimally invasive technique for visualization of the whole colon. With recent improvements of technical features in second-generation systems, a more important role for colon capsule endoscopy is rapidly emerging. Although several limitations and drawbacks are yet to be resolved, its usefulness as a tool for colorectal cancer screening and monitoring disease activity in inflammatory bowel diseases has become more apparent with increased use. Further investigations, including multicenter trials, are required to evaluate the substantial role of the colon capsule in managing colorectal diseases.

Accuracy of First- and Second-Generation Colon Capsules in Endoscopic Detection of Colorectal Polyps: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Colon capsule endoscopy (CCE) is a noninvasive technique used to explore the colon without sedation or air insufflation. A second-generation capsule was recently developed to improve accuracy of detection, and clinical use has expanded globally. We performed a systematic review and meta-analysis to assess the accuracy of CCE in detecting colorectal polyps.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and other databases from 1966 through 2015 for studies that compared accuracy of colonoscopy with histologic evaluation with CCE. The risk of bias within each study was ascertained according to Quality Assessment of Diagnostic Accuracy in Systematic Reviews recommendations. Per-patient accuracy values were calculated for polyps, overall and for first-generation (CCE-1) and second-generation (CCE-2) capsules. We analyzed data by using forest plots, the I² statistic to calculate heterogeneity, and meta-regression analyses.

RESULTS

Fourteen studies provided data from 2420 patients (1128 for CCE-1 and 1292 for CCE-2). CCE-2 and CCE-1 detected polyps >6 mm with 86% sensitivity (95% confidence interval [CI], 82%-89%) and 58% sensitivity (95% CI, 44%-70%), respectively, and 88.1% specificity (95% CI, 74.2%-95.0%) and 85.7% specificity (95% CI, 80.2%-90.0%), respectively. CCE-2 and CCE-1 detected polyps >10 mm with 87% sensitivity (95% CI, 81%-91%) and 54% sensitivity (95% CI, 29%-77%), respectively, and 95.3% specificity (95% CI, 91.5%-97.5%) and 97.4% specificity (95% CI, 96.0%-98.3%), respectively. CCE-2 identified all 11 invasive cancers detected by colonoscopy.

CONCLUSIONS

The sensitivity in detection of polyps >6 mm and >10 mm increased substantially between development of first-generation and second-generation colon capsules. High specificity values for detection of polyps by CCE-2 seem to be achievable with a 10-mm cutoff and in a screening setting.

Review: capsule colonoscopy-a concise clinical overview of current status

The colon capsule endoscopy (CCE) was first introduced in 2007. Currently, the main clinical indications for CCE are completion of incomplete colonoscopy, polyp detection and investigation of inflammatory bowel disease (IBD). Although conventional colonoscopy is the gold standard in bowel cancer screening, incomplete colonoscopy remains a problem as lesions are missed. CCE compares favourably to computer tomography colonography (CTC) in adenoma detection and has therefore been proposed as a method for completing colonoscopy. However the data on CCE remains sparse and current evidence does not show its superiority over CTC or conventional colonoscopy in bowel cancer screening. CCE also seems to show good correlation with conventional colonoscopy when used to evaluate IBD, but there are not many published studies at present. Other significant limitations include the need for aggressive bowel preparation and the labour-intensiveness of CCE reading. Therefore, much further software and hardware development is required to enable CCE to fulfill its potential as a minimally-invasive and reliable method of colonoscopy.

PillCam colon capsule endoscopy (PCCE) in colonic diseases

Diseases affecting the colon are common worldwide and can cause a major health problem. Colorectal cancer (CRC) as well as Inflammatory bowel diseases represent a major cause of morbidity and mortality in western countries. PillCam colon capsule endoscopy (PCCE) is a novel and promising technology that can be useful for the screening and monitoring of colonic diseases. In the recent years many articles examined the use of various versions of PCCE-the 1st and 2nd generation versus various other endoscopic or radiologic modalities both for detection of colonic polyps or cancer and in both ulcerative colitis (UC) and Crohn's disease. The aim of the current review is to provide up to date information regarding the use and usefulness of this method in these disease.

Colon Capsule Endoscopy: Where Are We and Where Are We Going

Colon capsule endoscopy (CCE) is a noninvasive technique for diagnostic imaging of the colon. It does not require air inflation or sedation and allows minimally invasive and painless colonic evaluation. The role of CCE is rapidly evolving; for example, for colorectal screening (colorectal cancer [CRC]) in average-risk patients, in patients with an incomplete colonoscopy, in patients refusing a conventional colonoscopy, and in patients with contraindications for conventional colonoscopy. In this paper, we comprehensively review the technical characteristics and procedure of CCE and compare CCE with conventional methods such as conventional colonoscopy or computed tomographic colonography. Future expansion of CCE in the area of CRC screening for the surveillance of polyps and adenomatous lesions and for assessment of inflammatory bowel disease is also discussed.

Colon Capsule Endoscopy: Review and Perspectives

Colon capsule endoscopy utilizing PillCam COLON 2 capsule allows for visualization potentially of the entire colon and is currently approved for patients who cannot withstand the rigors of traditional optical colonoscopy (OC) and associated sedation as well as those that had an OC that was incomplete for technical reasons other than a poor preparation. We will then describe the prior experience and current status of colon capsule endoscopy.

Alternatives to Incomplete Colonoscopy

A thorough and complete colonoscopy is critically important in preventing colorectal cancer. Factors associated with difficult and incomplete colonoscopy include a poor bowel preparation, severe diverticulosis, redundant colon, looping, adhesions, young and female patients, patient discomfort, and the expertise of the endoscopist. For difficult colonoscopy, focusing on bowel preparation techniques, appropriate sedation and adjunct techniques such as water immersion, abdominal pressure techniques, and patient positioning can overcome many of these challenges. Occasionally, these fail and other alternatives to incomplete colonoscopy have to be considered. If patients have low risk of polyps, then noninvasive imaging options such as computed tomography (CT) or magnetic resonance (MR) colonography can be considered. Novel applications such as Colon Capsule™ and Check-Cap are also emerging. In patients in whom a clinically significant lesion is noted on a noninvasive imaging test or if they are at a higher risk of having polyps, balloon-assisted colonoscopy can be performed with either a single- or double-balloon enteroscope or colonoscope. The application of these techniques enables complete colonoscopic examination in the vast majority of patients.

Uptake of Colon Capsule Endoscopy vs Colonoscopy for Screening Relatives of Patients With Colorectal Cancer

BACKGROUND & AIMS

The efficacy of screening colonoscopy in first-degree relatives (FDRs) of patients with colorectal cancer (CRC) is limited by suboptimal uptake. We compared screening uptake of colon capsule endoscopy (CCE) vs colonoscopy in this population.

METHODS

We performed a prospective study of 329 asymptomatic FDRs of patients with CRC who were randomly assigned to groups examined by CCE (PillCam, second generation; n = 165) or colonoscopy (n = 164) at a tertiary hospital in Spain from July 2012 through December 2013. Crossover was permitted for patients who did not wish to undergo the assigned procedure. Subjects assigned to CCE who had a significant lesion (polyp ≥ 10 mm, >2 polyps of any size, or CRC) were invited to undergo colonoscopy.

RESULTS

One hundred twenty subjects in the CCE group and 113 in the colonoscopy group were eligible for inclusion. In the intention-to-screen analysis, uptake was similar between groups (55.8% CCE vs 52.2% colonoscopy; odds ratio [OR], 0.86; 95% confidence interval [CI], 0.51-1.44; P = .57); 57.4% of subjects crossed over from the CCE group, and 30.2% crossed over from the colonoscopy group (OR, 3.11; 95% CI, 1.51-6.41; P = .002). Unwillingness to repeat bowel preparation in the case of a positive result was the main reason that subjects assigned to the CCE group crossed over; fear of colonoscopy was the reason that most patients in this group crossed over. A significant lesion was detected in 14 subjects (11.7%) in the CCE group and 13 subjects (11.5%) in the colonoscopy group (OR, 1.02; 95% CI, 0.45-2.26; P = .96).

CONCLUSIONS

In a prospective study, similar numbers of FDRs of patients with CRC assigned to undergo CCE or colonoscopy agreed to participate, but most preferred to undergo colonoscopy. CCE was as effective as colonoscopy in detecting significant lesions; it could be a valid rescue strategy for subjects who reject screening colonoscopy. ClinicalTrials.gov number: NCT01557101.