Wireless endoscopy

The CathCam: A Novel Angioscopic Solution for Endovascular Interventions

Peripheral arterial diseases are commonly managed with endovascular procedures, which often face limitations in device control and visualization under X-ray fluoroscopy guidance. In response, we developed the CathCam, an angioscope integrated into an expandable cable-driven parallel mechanism to enhance real-time visualization, precise device positioning and catheter support for successful plaque crossing. The primary objective of this study was to assess and compare the performance of the novel CathCam with respect to conventional catheters and the CathPilot (i.e., CathCam without the angioscope), for applications in crossing chronic total occlusions (CTO). We first assessed the system in 3D-printed phantom models, followed by an ex vivo evaluation with CTO samples from a patient's superficial femoral artery. We measured and compared success rates, crossing times, and fluoroscopy times in both experiments. The CathCam demonstrated a 100% success rate in phantom experiments and a 75% success rate in ex vivo experiments with CTO samples, compared to conventional catheters, with 35% and 25% success rates, respectively. The average crossing times for the CathCam and the conventional catheter were 31 s and 502 s for the phantom experiments and 210 s and 511 s for the actual CTO lesions. The Cathcam also showed to be a reliable endovascular imaging approach in an in vivo experiment. Compared to conventional catheters, the CathCam significantly increased the success rate and reduced crossing and fluoroscopy times in both phantom and ex vivo setups. CathCam can potentially improve clinical outcomes for minimally invasive endovascular interventions by offering high-resolution real-time imaging alongside accurate device control.

Preparation of small bowel capsule endoscopy (SBCE) with simethicone: A meta-analysis

BACKGROUND

It is disputed about optimal bowel preparation for small bowel capsule endoscopy (SBCE). This meta-analysis aimed to investigate the role of simethicone in intestinal preparation for SBCE.

METHODS

We searched four databases (PubMed, web of science, Embase, and Scopus databases) for relevant studies. Studies evaluating the effect of simethicone as an adjunct to SBCE bowel preparation were included. The random-effects model was applied to calculate the risk estimates. Primary outcomes include the degree of gas bubbles and small bowel visualization quality (SBVQ). Secondary outcomes include diagnostic yield (DY), gastric transit time (GTT), small bowel transit time (SBTT), and completion rate (CR).

RESULTS

A total of 10 studies were included (8 RCTs, 1 prospective, and 1 retrospective study). Compared with the control group, the simethicone group showed significant improvements in the degree of gas bubbling (RR = 2.05, 95%CI:1.56-2.71, P < 0.001, I² = 62%) and SBVQ (RR = 1.41, 95%CI: 1.20-1.65, P < 0.001, I² = 16%). Subgroup analysis showed that the SBVQ of simethicone group was better than fasting (RR = 2.62, 95% CI:1.49-4.59, P < 0.001, I² = 0%), mannitol (RR = 1.35, 95% CI: 1.14-1.59, P < 0.001, I² = 0%) and PEG group (RR = 1.32, 95%CI:1.06-1.65, P = 0.01, I² = 0%). No significant associations were found for DY, GTT, SBTT, and CR.

CONCLUSIONS

Simethicone for bowel preparation is useful to improve visualization and reduce the gas bubbling of SBCE.

Diffusion of an innovation: growth in video capsule endoscopy in the U.S. Medicare population from 2003 to 2019

Background

Video capsule endoscopy (VCE), approved by the U.S. Food and Drug Administration (FDA) in 2001, represented a disruptive technology that transformed evaluation of the small intestine. Adoption of this technology over time and current use within the U.S. clinical population has not been well described.

Methods

To assess the growth of capsule endoscopy within the U.S. Medicare provider population (absolute growth and on a population-adjusted basis), characterize the providers performing VCE, and describe potential regional differences in use. Medicare summary data from 2003 to 2019 were used to retrospectively analyze capsule endoscopy use in a multiple cross-sectional design. In addition, detailed provider summary files were used from 2012 to 2018 to characterize provider demographics.

Results

VCE use grew rapidly from 2003 to 2008 followed by a plateau from 2008 to 2019. There was significant variation in use of VCE between states, with up to 10-fold variation between states (14.6 to 156.1 per 100,000 enrollees in 2018). During this time, the adjusted VCE use on a population-adjusted basis declined, reflecting saturation of growth.

Conclusions

Growth of VCE use over time follows an S-shaped diffusion of innovation curve demonstrating a successful diffusion of innovation within gastroenterology. The lack of additional growth since 2008 suggests that current levels of use are well matched to overall population need within the constraints of reimbursement. Future studies should examine whether this lack of growth has implications for access and healthcare inequities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07780-2.

Feasibility of Upper Gastrointestinal Examination in Home Care Setting with a Magnetically Assisted Capsule Endoscopy System: A Retrospective Study

The magnetic assisted capsule endoscope (MACE) with a hand-held magnetic field navigator (MFN) for upper gastrointestinal examination achieved satisfactory results in a healthy volunteer study. We evaluated the feasibility of upper gastrointestinal examination in the home care setting with the MACE system. Home care patients with upper gastrointestinal symptoms that received an MACE exam were enrolled in the study. MACE procedure time; completeness of observation of important anatomical landmarks; endoscopic diagnosis; patient tolerance during the procedure; and patient data, including age, sex, comorbidities, symptoms, body weight, and height, were retrieved from hospital information system for data analysis. A total of 16 participants were enrolled with a mean age 74.3 ± 15.4 years (47 to 99 years). One patient failed to swallow the capsule and was excluded. The average procedure time was 23.7 ± 10.0 min (14.1 to 42.5 min) to complete each endoscopic exam for the remaining 15 patients. The overall maneuverability in the esophagus, stomach, and duodenum was 93.75%, 87.5%, and 75%, respectively. Overall completeness in the aforementioned regions was 93.75%, 81.25%, and 75%, respectively. No severe adverse events were noted. The results clearly demonstrate the promise of using this MACE system to perform endoscopic examination outside the hospital for patients confined to the community and home.

Scattering-Based Light-Sheet Microscopy for Rapid Cellular Imaging of Fresh Tissue

BACKGROUND AND OBJECTIVES

Light-sheet microscopy (LSM) is a novel imaging technology that has been used for imaging fluorescence contrast in basic life science research. In this paper, we have developed a scattering-based LSM (sLSM) for rapidly imaging the cellular morphology of fresh tissues without any exogenous fluorescent dyes.

STUDY DESIGN/MATERIALS AND METHODS

In the sLSM device, a thin light sheet with the central wavelength of 834 nm was incident on the tissue obliquely, 45° relative to the tissue surface. The detection optics was configured to map the light sheet-illuminated area onto a two-dimensional imaging sensor. The illumination numerical aperture (NA) was set as 0.0625, and the detection NA 0.3.

RESULTS

The sLSM device achieved a light sheet thickness of less than 6.7 µm over 284 µm along the illumination optical axis. The detection optics of the sLSM device had a resolution of 1.8 µm. The sLSM images of the swine kidney ex vivo visualized tubules with similar sizes and shapes to those observed in histopathologic images. The swine duodenum sLSM images revealed cell nuclei and villi architecture in superficial lesions and glands in deeper regions.

CONCLUSIONS

The preliminary results suggest that sLSM may have the potential for rapidly examining the freshly-excised tissue ex vivo or intact tissue in vivo at microscopic resolution. Further optimization and performance evaluation of the sLSM technology will be needed in the future. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Variation in small bowel transit time on capsule endoscopy

Background

Small bowel motility remains inadequately understood because of the complex and various functions as well as its anatomical position. The aimed of the study was to investigate the small bowel transit time (SBTT) of capsule endoscopy (CE) and to analyze the clinical factors affecting SBTT.

Methods

SBTT was analyzed in patients who underwent small bowel CE. Factors contributing to SBTT and CE retention were investigated.

Results

Among 397 patients enrolled in this study, 336 (84.6%) completed CE. The mean SBTT (± standard deviation) was 282.1±132.2 min. According to the univariate and multivariate analyses, aging and small bowel stenosis extended SBTT. In 38 patients who underwent multiple CE studies, considerable variation in SBTT were observed [mean of standard deviations (SDs) =97.97 min, SD of the SDs =81.99 min]. CE retention was observed in 61 patients (13.3%), and it was statistically associated to small bowel lesion.

Conclusions

Aging and small bowel stenosis were associated with longer SBTT. Furthermore, SBTT analyzed by CE should be interpreted carefully considering the intra-individual differences in SBTT.

Optimizing the performance of magnet-controlled capsule endoscopy based on radiological and gastroscopic modeling

Routine use of magnet-controlled capsule endoscopy of the stomach has been limited by the inadequate views of specific stomach regions. In the present study, radiology and upper gastrointestinal endoscopy (UGIE) were used to determine optimal subject body positioning and suitable external control magnet placement for capsule endoscopy. Healthy adult volunteers were subjected to upper gastrointestinal X-ray radiography (n=5), spiral computed tomography with volume reconstruction (n=4) or UGIE (n=1). Stomach fundus-to-body (FB) and body-to-antrum (BA) angles were compared when subjects were supine, prone, lying on their left side and on their right side, and when they were standing upright. Vertical distances from the surface of the body to the distal points of the fundus and antrum were also compared in this range of subject positions. Obtuse angles were considered the most beneficial for capsule movement and short vertical distances were considered desirable for optimizing magnetic force. The FB angle was sharply acute in the supine position, relatively open where subjects were on their side, and almost 180° in the standing position. The BA angle was obtuse in the standing position but acute in all other positions. With the subject in any position, the left lower lateral chest had the shortest distance to the fundus, while the ventral wall was closest to the antrum. The present modeling analysis indicates that standing is superior to all decubitus positions for magnetic-capsule endoscopy, including the commonly used supine position. Both the abdominal anterior wall and left lateral lower chest appeared to be advantageous locations for external control magnet placement.

Comparison of small bowel findings using capsule endoscopy between Crohn's disease and intestinal tuberculosis in Korea

Background

Little is known about capsule endoscopy (CE) findings in patients with intestinal tuberculosis who exhibit small bowel lesions. The aim of the present study was to distinguish between Crohn’s disease (CD) and intestinal tuberculosis based on CE findings.

Methods

Findings from 55 patients, who underwent CE using PillCam SB CE (Given Imaging, Yoqneam, Israel) between February 2003 and June 2015, were retrospectively analyzed.

Results

CE revealed small bowel lesions in 35 of the 55 patients: 19 with CD and 16 with intestinal tuberculosis. The median age at diagnosis for patients with CD was 26 years and 36 years for those with intestinal tuberculosis. On CE, three parameters, ≥10 ulcers, >3 involved segments and aphthous ulcers, were more common in patients with CD than in those intestinal tuberculosis. Cobblestoning was observed in five patients with CD and in none with intestinal tuberculosis. The authors hypothesized that a diagnosis of small bowel CD could be made when the number of parameters in CD patients was higher than that for intestinal tuberculosis. The authors calculated that the diagnosis of either CD or intestinal tuberculosis would have been made in 34 of the 35 patients (97%).

Conclusion

The number of ulcers and involved segments, and the presence of aphthous ulcers, were significantly higher and more common, respectively, in patients with CD than in those with intestinal tuberculosis. Cobblestoning in the small bowel may highly favor a diagnosis of CD on CE.

Human gastric magnet-controlled capsule endoscopy conducted in a standing position: the phase 1 study

Background

Current magnet-controlled capsule endoscopy (MCE) for the stomach is not yet satisfactory with respect to navigation control, especially in the gastric fundus and cardia. A newly developed MCE system conducted in a standing rather than supine position may improve capsule maneuverability within the stomach. The aim of this phase 1 study was to assess the feasibility and safety of this system for examining the human stomach in healthy volunteers.

Methods

A cohort of 31 healthy volunteers were enrolled. Each swallowed a capsule after drinking water and gas producing agents intended to produce distention. Under the newly developed standing MCE system, subjects were examined endoscopically while standing with external guide magnets placed on the abdominal wall and left lower chest. Safety, gastric preparation, maneuverability, visualization of anatomical landmarks and the gastric mucosa, and examination time were the primary parameters assessed. The gastric preparation and examination procedures were well accepted by the subjects and there were no adverse events.

Results

Gastric examination took 27.8 ± 8.3 min (12–45 min). Gastric cleanliness was good in 24 participants (77.4%) and moderate in 7 participants (22.6%). Gastric distention was good in all of 31 participants (100%). Capsule maneuverability was also graded as good in all 31 subjects (100%), and manipulation in the fundus and cardia regions was as easy as that in the antrum and body. Visualization of the gastric cardia, fundus, body, angulus, antrum and pylorus was assessed subjectively as complete in all 31 subjects (100%). Visualization of the gastric mucosa was also good (> 75%) in all 31 subjects (100%). In areas where the mucosa could not be visualized, the low visibility was due to opaque fluid or foam. Polyps and erosive lesions were found in 25 subjects.

Conclusion

MCE of the stomach conducted in a standing position is feasible and safe with satisfactory maneuverability.

Effect of egualen sodium hydrate on small-intestinal mucosal damage induced by low-dose aspirin: a prospective randomized clinical trial

Low-dose aspirin, which is widely used to reduce the risk of cardio- and cerebrovascular thrombosis, often induces gastroenteropathy by increasing the permeability of the mucosa. However, therapeutic strategies for patients with low-dose aspirin-induced small intestinal injury have not been determined. We evaluated the preventative effect of egualen sodium hydrate, a gastro-protective agent that suppresses indomethacin-induced small-intestinal damage in rats, against small-intestinal mucosal damage induced by low-dose aspirin in healthy adult male volunteers. Participants were randomly allocated to receive aspirin 100 mg/kg daily (control group, n = 10) or aspirin 100 mg/kg plus egualen sodium 30 mg daily (egualen sodium group, n = 10). Small intestinal mucosal injury was evaluated by capsule endoscopy two weeks after initiation of drug administration. Fecal analyses (occult blood test, immunochemical test, transferrin measurement and calprotectin measurement) were carried out before and after treatment. Egualen sodium significantly suppressed the total number of small intestinal injuries detected by capsule endoscopy and the positive ratio for the fecal occult blood test. Daily use of 30 mg of egualen sodium showed a preventative effect on low-dose aspirin-induced small intestinal injury. Since acid suppression therapy was reported to exacerbate NSAIDs-induced enteropathy via dysbiosis, egualen sodium may be useful for patients treated with low-dose aspirin.

Physical activity during video capsule endoscopy correlates with shorter bowel transit time

BACKGROUND AND STUDY AIM

 Video capsule endoscopy (VCE) is limited by reliance on bowel motility for propulsion, and lack of physical activity has been proposed as a cause of incomplete studies. Our aim was to prospectively investigate the association between physical activity and VCE bowel transit.

PATIENTS AND METHODS

 Ambulatory outpatients receiving VCE were eligible for the study. A pedometer was attached at the time of VCE ingestion and step count was recorded at the end of the procedure. VCE completion was assessed by logistic regression models, which included step count (500 steps as one unit). Total transit time was analyzed by Cox proportional hazards models. The hazard ratios (HR) with 95 % confidence interval (CI) indicated the "hazard" of completion, such that HRs > 1 indicated a reduced transit time.

RESULTS

 A total of 100 patients were included. VCE was completed in 93 patients (93 %). The median step count was 2782 steps. Step count was not significantly associated with VCE completion (odds ratio 1.45, 95 %CI 0.84, 2.49). Pedometer step count was significantly associated with shorter total, gastric, and small-bowel transit times (HR 1.09, 95 %CI 1.03, 1.16; HR 1.05, 95 %CI 1.00, 1.11; HR 1.07, 95 %CI 1.01, 1.14, respectively). Higher body mass index (BMI) was significantly associated with VCE completion (HR 1.87, 95 %CI 1.18, 2.97) and shorter bowel transit times (HR 1.05, 95 %CI 1.02, 1.08).

CONCLUSIONS

 Increased physical activity during outpatient VCE was associated with shorter bowel transit times but not with study completion. In addition, BMI was a previously unreported clinical characteristic associated with VCE completion and should be included as a variable of interest in future studies.

Management of small bowel polyps: A literature review

Despite the small bowel comprising 90% of the mucosal surface area of the gastrointestinal tract, it is a rare site for neoplasia and only accounts for a little over 3% of the tumors that arise in the digestive tract. Benign small bowel lesions include lipomas, lymphangiomas, leiomyomas, neurofibromas, nodular lymphoid hyperplasia and adenomas, many of which are precursors to malignant lesions. Several polyposis syndromes are associated with small bowel polyps as well, including familial adenomatous polyposis syndrome, lynch syndrome, Peutz-Jeghers syndrome, Cowden syndrome and juvenile polyposis syndrome. Our aim was to review non-malignant small bowel polyps and discuss the prevalence, typical location, clinical presentation, diagnosis, endoscopic and histologic description and lastly management of each of these lesions.

WITHDRAWN: The Role of capsule endoscopy and device assisted enteroscopy for small bowel lesions in hereditary hemorrhagic telangiectasia

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Multidetector CT enterography of focal small bowel lesions: a radiological-pathological correlation

Focal small bowel lesions present a diagnostic challenge for both the radiologist and gastroenterologist. Both the detection and characterization of small bowel masses have greatly improved with the advent of multidetector CT enterography (MD-CTE). As such, MD-CTE is increasingly utilized in the workup of occult gastrointestinal bleeding. In this article, we review the spectrum of focal small bowel masses with pathologic correlation. Adenocarcinoma, the most common primary small bowel malignancy, presents as a focal irregular mass occasionally with circumferential extension leading to obstruction. Small bowel carcinoid tumors most commonly arise in the ileum and are characterized by avid enhancement and marked desmoplastic response of metastatic lesions. Aneurysmal dilatation of small bowel is pathognomonic for lymphoma and secondary findings of lymphadenopathy and splenomegaly should be sought. Benign small bowel masses such as leiomyoma and adenoma may be responsible for occult gastrointestinal bleeding. However, primary vascular lesions of the small bowel remain the most common cause for occult small bowel gastrointestinal bleeding. The arterial phase of contrast obtained with CTE aids in recognition of the vascular nature of these lesions. Systemic conditions such as Peutz-Jeghers syndrome and Crohn's disease may be suggested by the presence of multiple small bowel lesions. Lastly, potential pitfalls such as ingested material should be considered when faced with focal small bowel masses.

Clinical utility of double-balloon enteroscopy in suspected Crohn's disease: a single-centre experience

BACKGROUND

Small bowel Crohn's disease has a heterogeneous presentation leading to a delay in diagnosis. Capsule endoscopy is now a well-established diagnostic tool; however, few studies have evaluated the role of double-balloon enteroscopy (DBE) in patients with suspected Crohn's disease. Histology obtained at DBE is useful in addition to clinical symptoms, blood parameters and capsule endoscopy findings to aid diagnosis and further management.

OBJECTIVE

The aim of this study was to evaluate the impact of DBE and histology on the management of patients with suspected small bowel Crohn's disease.

METHODS

DBE procedures including histology for suspected Crohn's disease from 2006 to 2014 were retrospectively reviewed. Follow-up data for all patients were collected.

RESULTS

In our series of 399 double-balloon enteroscopies, 122 procedures were performed in 100 patients for suspected Crohn's disease. Positive DBE findings were found in 60% of patients. Forty-five per cent of patients were treated as Crohn's disease on the basis of a combination of histology, endoscopic appearance, clinical symptoms and blood parameters. Histology was diagnostic of Crohn's disease in 8% and supportive of it in 15%. In 12%, an alternative diagnosis was made, of whom two patients were diagnosed with small bowel malignancy on histology.After a median follow-up period of 27 months, the actual prevalence for a new diagnosis of Crohn's disease in our study was 38%.

CONCLUSION

DBE has a useful place in clarifying the diagnosis in patients with suspected Crohn's disease. Although histology can be nondiagnostic, the combination of the macroscopic appearance with clinical correlation is useful in the diagnosis and management.

Current applications and potential future role of wireless capsule technology in Crohn's disease

BACKGROUND

The development of capsule technology has modified our approach to the diagnosis of gastrointestinal disease. The relatively rapid uptake of capsule endoscopy as an important clinical tool can be largely ascribed to a number of key factors, including the fact that it is a relatively easy examination to perform in an outpatient setting. It has been established as an integral part of the investigation pathway for obscure gastrointestinal bleeding and suspected small bowel Crohn's disease (CD). CURRENT USE OF CAPSULE ENDOSCOPY: Small bowel CD can be a challenging entity to diagnose. Capsule endoscopy has been shown to be both useful and safe in patients with both suspected and established small bowel CD. In suspected disease, capsule endoscopy has both a high diagnostic yield and negative predictive value. Capsule findings lead to changes in management in up to 73% of patients with established CD. However, while the technology appears capable of detecting subtle mucosal changes not readily apparent on alternate imaging modalities, the question of what actually constitutes small bowel CD as described by capsule is an issue that remains unresolved to date. Thus, capsule endoscopy is best utilised in tandem with advanced imaging and endoscopic techniques such as balloon- assisted enteroscopy.

FUTURE DEVELOPMENTS

The development of a capsule capable of viewing the colon coupled with improvements in image quality and battery life are likely to lead to the increasing uptake of this technology. In the future, 'interactive' capsules with the ability to view the entire gastrointestinal tract may be a reality.

Capsule endoscopy: High negative predictive value in the long term despite a low diagnostic yield in patients with suspected Crohn's disease

INTRODUCTION

The role of small bowel capsule endoscopy (SBCE) in Crohn's disease (CD) has expanded with greater understanding of the technology. The ability of SBCE to differentiate CD from other causes of inflammation has been questioned. Longitudinal studies are required to assess the long-term impact and significance of SBCE findings in suspected CD. This study aimed to determine the long-term clinical accuracy of SBCE in patients referred with suspected CD.

METHODS

A retrospective review was carried out on SBCE procedures performed for suspected CD since 2010. Only patients with at least 6 months of documented follow up were included. A chart review was undertaken to record SBCE findings/correlate with subsequent diagnosis and outcome.

RESULTS

In all, 95 patients with sufficient follow up were identified. The mean follow up was 13 months (range 8-24). In total, 72 (76%) SBCEs were negative and 23 (24%) positive for CD. Of the 72 negative tests, two patients (3%) were later diagnosed with CD. The negative predictive value is 96%. There was a strong positive correlation between results of WCE and subsequent clinical diagnosis.

CONCLUSIONS

SBCE appears capable of safely out-ruling CD, with only 3% of negative SBCE investigations being diagnosed with CD after 15 months.

Diagnostic and therapeutic utility of double-balloon enteroscopy in children

OBJECTIVES

Diagnostic and therapeutic benefits of double-balloon enteroscopy (DBE) have been documented in adults, with few data available on pediatric patients. We evaluated the diagnostic and therapeutic utility of DBE in children.

METHODS

A prospective assessment of 113 DBE procedures in 58 consecutive children younger than 18 years (36 boys, 22 girls; median age 12.7 years, range 1-18 years) was performed for a variety of suspected small bowel (SB) disorders from January 2008 to August 2012 in a tertiary referral center for pediatric patients. All of the children had undergone upper gastrointestinal endoscopy and ileocolonoscopy. A total of 19 patients had undergone radiological investigations for SB (n = 11 magnetic resonance imaging; n = 5 barium enterography; n = 3 computed tomography) and 54 patients had undergone wireless capsule endoscopy (WCE).

RESULTS

The overall median (range) examination time was 92.5 (45-275) minutes. The median (range) estimated insertion length of SB distal to pylorus was 230 (80-450) cm and proximal to ileocecal valve was 80 (5-275) cm. The common indications for DBE were polyposis syndromes (n = 21) and obscure gastrointestinal bleeding (n = 16). The findings included polyps (n = 19), mucosal ulcers and erosions (n = 8), submucosal elevations with white nodules (n = 4), and angioma/angiodysplasia (n = 2). The overall diagnostic yield for SB lesions using DBE was 70.7% (41/58) and for WCE was 77.7% (42/54). Endotherapeutic intervention was successfully used in 46.5% (n = 27/58). The endoscopic, medical, and surgical contributions to change in management by DBE were 72.4% (n = 42/58). Three complications (5.2%) were noted with uneventful recovery.

CONCLUSIONS

The diagnostic yield of DBE was comparable to WCE, but with the addition of therapeutic possibility and histological yield. We believe this technique could be a valuable addition to existing endoscopic techniques, complementary to WCE, and may be considered as an alternative diagnostic and therapeutic option in the SB in children.

The AirScope: A Novel Wireless Laparoscope

The modern laparoscope relies on Hopkins’ glass rod lenses, a fiber-optic light source, a video camera, and external cables. This paper discusses the feasibility of developing an experimental prototype of a completely wireless laparoscope by making use of the latest in electronic and optic miniaturization. Design requirements were defined to mimic a standard 10 mm adult laparoscope. An 8 mm diameter (CMOS) camera was used, which delivered standard definition TV resolution at an image refresh rate of 30 Hz. A wide-angle lens was chosen, and a focusing mechanism was designed. Instead of a fiber-optic cable, illumination was achieved using four miniature LED lights. A 2.4 GHz wireless transmission with adequate range for use in an operating theater was chosen. A wireless receiver on a standard personal computer was used to drive a video monitor using off the shelf image processing software. A built-in rechargeable battery powered the wireless laparoscope. Flicker-free in vitro wireless video transmission was achieved. The laparoscope was made waterproof with a front cover lens and can be gas or chemically sterilized. The prototype laparoscope weights 78 g as compared with 900 g for a typical 10 mm laparoscope, camera, fiber-optic, and camera cables. Drawbacks of the prototype include reduced resolution of the video image as compared to high definition (HD) TV quality available on the most recent commercial camera systems. This experimental prototype has illustrated the feasibility of wireless endoscopy systems. The expected benefits include improved ergonomic maneuverability, reduced weight, and decreased electric power requirements.

Path-loss estimation of wireless channels in capsule endoscopy from X-ray CT images

The paper describes an estimation method of path-loss for capsule endoscopy using wireless communications to send images from digestive tract. This method is based on the use of a set of X-ray computer tomography (CT) images of the patient. In order to evaluate this method, we conducted a measurement of received signal strength (RSS) by introducing a signal generator (SG) in esophagus and duodenum of a participant. As a result of comparisons, the method provides estimates on path-loss for the participant with estimation errors of less than 6 dB in 75% measurement positions.

Aspirin-induced small bowel injuries and the preventive effect of rebamipide

AIM: To evaluate the influence of taking low-dose aspirin for 4 wk on small intestinal complications and to examine the preventive effect of rebamipide.

METHODS: This study was conducted as a single-center, randomized, double-blind, cross-over, placebo-controlled study. Eleven healthy male subjects were enrolled. Each subject underwent video capsule endoscopy after 1 and 4 wk of taking aspirin and omeprazole, along with either rebamipide or placebo therapy. The primary endpoint was to evaluate small bowel damage in healthy subjects before and after taking low-dose aspirin for 4 wk.

RESULTS: The number of subjects with mucosal breaks (defined as multiple erosions and/or ulcers) were 1 at 1 wk and 1 at 4 wk on the jejunum, and 6 at 1 wk (P = 0.0061) and 7 at 4 wk on the ileum (P = 0.0019). Rebamipide significantly prevented mucosal breaks on the ileum compared with the placebo group (P = 0.0173 at 1 wk and P = 0.0266 at 4 wk).

CONCLUSION: Longer-term, low-dose aspirin administration induced damage in the small bowel. Rebamipide prevented this damage, and may be a candidate drug for treating aspirin-induced small bowel complications.

Capsule endoscopy in nonresponsive celiac disease

BACKGROUND

Nonresponsive celiac disease (CD) is defined by persistent or recurrent symptoms, common after treatment with a gluten-free diet (GFD).

OBJECTIVE

To evaluate the utility of capsule endoscopy (CE) in nonresponsive CD.

DESIGN

Case-control study.

SETTING

Tertiary-care center.

PATIENTS

Forty-two consecutive patients with nonresponsive CD and 84 age- and sex-matched CD-free controls who underwent CE were included. In addition, capsules taken after treatment with a GFD were retrospectively evaluated in 30 patients with uncomplicated CD.

INTERVENTION

CE.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy of CE for the detection of mucosal abnormalities in nonresponsive CD.

RESULTS

Macroscopic features of villous atrophy were detected in 13 of 42 patients (31%) with nonresponsive CD compared with none among 84 CD-free controls and 14 of 30 patients (47%) with uncomplicated CD. Among nonresponsive CD cases, the overall sensitivity and specificity of CE for the detection of any degree of villous atrophy as graded by histology were 56% and 85%, respectively. Single or multiple erosions/ulcerations of the gut were observed in 19% of nonresponsive CD patients, 18% of CD-free controls, and 31% of patients with uncomplicated CD (P = .35). The presence of erosions/ulcerations was associated with increased aspirin/nonsteroidal anti-inflammatory drug use in nonresponsive CD (P =.05). Two severe complications (ulcerative jejunitis and adenocarcinoma) were detected by CE in nonresponsive CD.

LIMITATIONS

Single-center, retrospective study.

CONCLUSIONS

Mucosal abnormalities were observed by CE in patients with both nonresponsive CD and uncomplicated CD. CE can detect severe complications in patients with nonresponsive CD.

Gastric emptying is delayed in transgastric NOTES: a randomized study in swine

AIM

The aim of this study was to evaluate the restoration of gastrointestinal motility after NOTES using capsule endoscopy (CE).

MATERIALS AND METHODS

Twenty adult Yorkshire pigs were randomly assigned to four groups: transgastric NOTES (gNOTES), transrectal NOTES (rNOTES), transvaginal NOTES (vNOTES), and laparoscopy (LAP). At the end of a 30-min peritoneoscopy with identification of seven predetermined organs, an array of eight receivers and the recorder were attached to the abdominal wall. The CE was delivered into the antrum with the help of an endoscope and a polypectomy snare. Animals were kept alive for 14 d.

RESULTS

Median time for surgery was longer in gNOTES (56 min, range 47-63) and vNOTES (54 min, range 44-79) than in LAP (32 min, range 32-33; P < 0.05 and P < 0.01) and in rNOTES (45.5 min, range 33-56) (P = ns). This increase was related to a larger incision and longer closure times. Images from the CE were successfully retrieved in 19 cases. The CE was retained in the stomach in all animals in gNOTES (459 min; range 360-600), but only in one animal in rNOTES and vNOTES and in none in the LAP group. Failure of passage of the CE beyond the stomach was associated with gNOTES and longer closure of the incision. Animals in the gNOTES group gained less weight than the others and this change was statistical significant when compared with vNOTES animals (1.7 kg, range -1.98 to 4.5 versus 8.4 kg, range 5.8 to 11.45; P < 0.01).

CONCLUSION

Gastric emptying is delayed after gNOTES peritoneoscopy compared with rNOTES, vNOTES, and LAP and this effect is associated with less weight gain.

Prospective, randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding

BACKGROUND

Video capsule endoscopy is the first-intention examination in patients with obscure GI bleeding. The new MiroCam capsule, when using electric-field propagation for transmission, has been poorly evaluated in a clinical setting, in contrast with the PillCam SB2 capsule.

OBJECTIVE

To evaluate the diagnostic concordance (κ value) between PillCam SB2 and MiroCam capsule examinations performed in the same patients.

DESIGN AND SETTING

Prospective, randomized study in 7 endoscopy units.

PATIENTS AND INTERVENTION

Eighty-three consecutive patients, ingesting the 2 capsules at a 1-hour interval.

RESULTS

Seventy-three patients were analyzed (10 technical issues). There were 31 concordant negative cases (42.4%) and 30 concordant positive cases (41.1%). The study showed satisfactory diagnostic concordance between the 2 systems (κ = 0.66). In 12 patients (16.4%), the final diagnosis was different: 9 patients had positive findings on MiroCam examination but no image detected with PillCam SB2, 2 had positive findings on PillCam examination only, and 1 patient had 2 different diagnoses. A positive diagnosis was obtained in 46.6% and 56.2% of patients with PillCam SB2 and MiroCam capsule, respectively, so that the procedures identified 78.6% and 95.2% of positive cases, respectively (P = .02). Small-bowel transit time and capsule reading time were significantly longer in MiroCam procedures.

LIMITATIONS

Technical failures possibly related to capsule interference.

CONCLUSION

This study shows at least comparable efficiency of the MiroCam compared with the PillCam SB2 capsule system for the diagnosis of obscure GI bleeding.

Evaluation of gastrointestinal injury and blood flow of small bowel during low-dose aspirin administration

Low-dose acetylsalicylic acid has been widely used. We evaluated small bowel and gastric injuries during acetylsalicylic acid administration using video capsule endoscopy and gastroduodenal endoscopy. We also investigated blood flow using contrast-enhanced ultrasonography. Six healthy volunteers were enrolled in this preliminary study. The subjects were administered 100 mg of enteric-coated aspirin daily for 14 days. Video capsule endoscopy and gastroduodenal endoscopy were simultaneously performed before administration and on days 1, 3, 7 and 14. Contrast-enhanced ultrasonography was performed before administration and on day 2, and 8. Video capsule endoscopy after administration of low-dose acetylsalicylic acid revealed small bowel mucosal damages of petechiae and erythema in all cases, and denuded area in one case. The total number of lesions in the small bowel increased according to duration of low-dose acetylsalicylic acid administration. However, the total number of lesions in the stomach peaked on day 3. Contrast-enhanced ultrasonography showed that the time-intensity curve peak value and Areas under the curves after acetylsalicylic acid administration were reduced. We observed not only gastric mucosal injuries but also small intestinal injuries with short-term low-dose acetylsalicylic acid administration. Acetylsalicylic acid administration also caused a decrease in small intestinal blood flow. Contrast-enhanced ultrasonography is useful for evaluation blood flow in the small bowel mucosa.

Capsule endoscope localization based on computer vision technique

To build a new type of wireless capsule endoscope with interactive gastrointestinal tract examination, a localization and orientation system is needed for tracking 3D location and 3D orientation of the capsule movement. The magnetic localization and orientation method produces only 5 DOF, but misses the information of rotation angle along capsule's main axis. In this paper, we presented a complementary orientation approach for the capsule endoscope, and the 3D rotation can be determined by applying computer vision technique on the captured endoscopic images. The experimental results show that the complementary orientation method has good accuracy and high feasibility.

Low-complexity video compression for capsule endoscope based on compressed sensing theory

Recently, the notions of Compressed Sensing (CS) have attracted attention as an innovative concept in signal processing. In this exploratory paper, a CS-based video compression approach suitable for wireless capsule endoscopy is proposed. In general, the amount of video data generated by capsule endoscopy is so large that video compression is the best way to lower the communication bandwidth and save the RF transmitting power. However, due to power limitation and small size conditions, traditional video compression techniques are not appropriate. Applying state-of-the-art CS theory may significantly reduce power consumption and memory of video compressor, thanks to its low computational complexity. The proposed approach is based on YUV color space conversion, blocking, zigzag scan and CS measuring. Experimental results show the feasibility of the proposed idea and that future improving works are necessary.

Double balloon enteroscopy in children: diagnosis, treatment, and safety

AIM

To assess the feasibility and utility of double balloon enteroscopy (DBE) in the management of small bowel diseases in children.

METHODS

Fourteen patients (10 males) with a median age of 12.9 years (range 8.1-16.7) underwent DBE; 5 for Peutz-Jeghers syndrome (PJ syndrome), 2 for chronic abdominal pain, 4 for obscure gastrointestinal (GI) bleeding, 2 with angiomatous malformations (1 blue rubber bleb nevus syndrome) having persistent GI bleeding, and 1 with Cowden's syndrome with multiple polyps and previous intussusception. Eleven procedures were performed under general anesthesia and 3 with deep sedation.

RESULTS

The entire small bowel was examined in 6 patients, and a length between 200 cm and 320 cm distal to pylorus in the remaining 8. Seven patients had both antegrade (trans-oral) and retrograde (trans-anal and via ileostomy) examinations. One patient underwent DBE with planned laparoscopic assistance. The remaining 6 had trans-oral examination only. The median examination time was 118 min (range 95-195). No complications were encountered. Polyps were detected and successfully removed in all 5 patients with PJ syndrome, in a patient with tubulo-villous adenoma of the duodenum, in a patient with significant anemia and occult bleeding, and in a patient with Cowden's syndrome. A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy, and in 1 with a discrete angioma which was treated with argon plasma coagulation. The source of bleeding was identified in a further patient with varices. DBE was normal or revealed minor mucosal friability in the remaining 3 patients. Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved.

CONCLUSION

Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children, allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.

Double balloon enteroscopy in children: Diagnosis, treatment, and safety

AIM: To assess the feasibility and utility of double balloon enteroscopy (DBE) in the management of small bowel diseases in children.

METHODS: Fourteen patients (10 males) with a median age of 12.9 years (range 8.1-16.7) underwent DBE; 5 for Peutz-Jeghers syndrome (PJ syndrome), 2 for chronic abdominal pain, 4 for obscure gastrointestinal (GI) bleeding, 2 with angiomatous malformations (1 blue rubber bleb nevus syndrome) having persistent GI bleeding, and 1 with Cowden’s syndrome with multiple polyps and previous intussusception. Eleven procedures were performed under general anesthesia and 3 with deep sedation.

RESULTS: The entire small bowel was examined in 6 patients, and a length between 200 cm and 320 cm distal to pylorus in the remaining 8. Seven patients had both antegrade (trans-oral) and retrograde (trans-anal and via ileostomy) examinations. One patient underwent DBE with planned laparoscopic assistance. The remaining 6 had trans-oral examination only. The median examination time was 118 min (range 95-195). No complications were encountered. Polyps were detected and successfully removed in all 5 patients with PJ syndrome, in a patient with tubulo-villous adenoma of the duodenum, in a patient with significant anemia and occult bleeding, and in a patient with Cowden’s syndrome. A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy, and in 1 with a discrete angioma which was treated with argon plasma coagulation. The source of bleeding was identified in a further patient with varices. DBE was normal or revealed minor mucosal friability in the remaining 3 patients. Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved.

CONCLUSION: Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children, allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.

The utility of capsule endoscopy in patients with suspected Crohn's disease

OBJECTIVES

In patients with suspected Crohn's disease (CD), little is known about the test characteristics of capsule endoscopy (CE) in the diagnosis of this condition. We sought to determine the utility of CE for the subsequent diagnosis of CD in patients suspected to have this condition.

METHODS

All patients who underwent CE at a single tertiary-care center for investigation of suspected small bowel CD, and who had a 12-month follow-up, were included in the study. All patients had undergone other investigations that were normal or equivocal. The test characteristics of CE were determined on the basis of capsule findings of small bowel ulcers and a subsequent new diagnosis of CD within 12 months of CE.

RESULTS

The study included 102 patients with 12-month follow-up data. The majority (75%) met the established criteria to define "suspected Crohn's disease" as an indication for CE. Most had undergone computed tomography scan or small bowel follow-through (92%) and colonoscopy (99%) before CE. There were abnormal CE findings suggestive of CD in 39 patients. The prevalence rate of a new diagnosis of CD by 12 months in the study population was 13%. Using the presence of more than 3 ulcers as the criterion for an abnormal CE study, the sensitivity of CE for the diagnosis of CD was 77%, the specificity was 89%, the positive predictive value (PPV) was 50%, and the negative predictive value (NPV) was 96%.

CONCLUSIONS

In patients with suspected CD, CE has a high sensitivity and a NPV for this condition. The PPV varies depending on the patient population and the criteria for a CE diagnosis of CD.

Wireless capsule endoscopy versus enteroclysis in the diagnosis of small-bowel Crohn's disease

OBJECTIVES

The aim of this study was to prospectively compare the diagnostic yield of wireless capsule endoscopy (WCE) and enteroclysis in the detection of Crohn's disease (CD) of the small bowel.

METHODS

Twenty-nine patients with known CD (group 1) suspected to have more extensive small-bowel involvement and 26 patients, who were suspected to suffer from CD but did not have an earlier history of it (group 2) were prospectively evaluated with enteroclysis and WCE. Each examiner was blinded to the results of other investigations.

RESULTS

Enteroclysis was unsuccessful in two patients from group 1 8 and six patients from group 2, respectively. In group 1, abnormal findings consistent with CD were detected in 20 patients by using WCE and in 11 patients by using enteroclysis, out of the total 27, at per-protocol analysis (74.1 vs. 40.7%, P<0.05). Of the 11 patients who had ileal CD on enteroclysis, three had more extensive small-bowel disease, which was detected only by WCE. In group 2, WCE showed findings consistent with CD in 13 of 20 patients, in contrast with enteroclysis, which was positive for CD in only six of 20 patients (65 vs. 30%, P<0.05). Three more patients had findings compatible with CD on WCE, but they failed their enteroclysis. Overall, a new diagnosis of CD was made in 16 patients.

CONCLUSION

WCE has a higher diagnostic yield than enteroclysis in the detection of CD of the small bowel, both in patients with known and newly suspected CD.

BioMEMS -Advancing the Frontiers of Medicine

Biological and medical application of micro-electro-mechanical-systems (MEMS) is currently seen as an area of high potential impact. Integration of biology and microtechnology has resulted in the development of a number of platforms for improving biomedical and pharmaceutical technologies. This review provides a general overview of the applications and the opportunities presented by MEMS in medicine by classifying these platforms according to their applications in the medical field.

Biochromoendoscopy: molecular imaging with capsule endoscopy for detection of adenomas of the GI tract

BACKGROUND

Current capsule endoscopy (CE) provides minimally invasive technology for GI imaging but has limited ability to discriminate different types of polyps. Near infrared fluorescent (NIRF) probes activated by biomarkers upregulated in adenomas (eg, cathepsin B) are potentially powerful tools to distinguish premalignant or malignant lesions from benign or inflammatory lesions.

OBJECTIVES

To examine whether CE can be integrated with NIRF probes to detect adenomas and whether cathepsin B-activated NIRF probes are activated by benign or inflammatory lesions.

DESIGN

Mouse models of adenomas, hyperplactic/lymphoid polyps, and acute or chronic intestinal inflammation were injected intravenously with a cathepsin B-activated probe (Prosense 680). Dissected intestine was imaged with CE under white or NIRF light. For NIRF excitation (680 nm), dichroic and emission (700 nm) filters were combined with CE when images were recorded. Prosense 680 samples with or without protease were used as positive and negative controls. CE-based imaging data were verified by using and independent imaging system (Xenogen IVIS system).

MAIN OUTCOME MEASUREMENTS

Proof of principal that CE integrated with NIRF probes can detect and discriminate adenomas from other lesions.

RESULTS

CE-based NIRF imaging with Prosense 680 readily visualized adenomas, including in the colitis model. NIRF signals of different intensities were detected. Prosense 680 was not activated by benign or inflammatory lesions.

LIMITATION

Optical filters external to the capsule were used.

CONCLUSIONS

We demonstrate proof of the principle that biochromoendoscopy-CE combined with molecular probes--provides a novel approach that differentiates adenomas from benign polyps and inflammatory lesions.

Efficacy of rebamipide for diclofenac-induced small-intestinal mucosal injuries in healthy subjects: a prospective, randomized, double-blinded, placebo-controlled, cross-over study

BACKGROUND

Although obscure gastrointestinal bleeding cannot be detected by colonoscopy or upper endoscopy, wireless video capsule endoscopy (VCE) is capable of imaging it. Few data are available on medical therapy for patients with nonsteroidal anti-inflammatory drug (NSAID)-induced small-intestinal mucosal injuries. The aim of this study was to compare prevention by rebamipide and placebo of NSAID-induced smallintestinal injury in healthy subjects.

METHODS

Ten healthy subjects who provided written informed consent were enrolled. Rebamipide or placebo plus diclofenac was administered with omeprazole for 7 days, and for an additional 7-day period with treatments reversed in the same subjects, with a 4-week washout period between treatments. VCE of the small intestine was performed four times, before and after each of the two study periods.

RESULTS

The number of subjects with small-intestinal mucosal injuries was higher in the placebo group (8/10) than in the rebamipide group (2/10) (P = 0.023). Two cases of ulcer and one of bleeding were observed in the placebo group, while no ulcer or bleeding was observed in the rebamipide group.

CONCLUSIONS

Rebamipide had significantly higher efficacy than placebo in preventing NSAID-induced small-intestinal mucosal injury.

Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy

BACKGROUND

Small bowel mass lesions (SBML) are a relatively common cause of obscure gastrointestinal bleeding (OGIB). Their detection has been limited by the inability to endoscopically examine the entire small intestine. This has changed with the introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE) into clinical practice.

STUDY AIM

To evaluate the detection of SBML by DBE and CE in patients with OGIB who were found to have SBML by DBE and underwent both procedures.

METHODS

A retrospective review of a prospectively collected database of all patients undergoing DBE for OGIB at seven North American tertiary centers was performed. Those patients who were found to have SBML as a cause of their OGIB were further analyzed.

RESULTS

During an 18 month period, 183 patients underwent DBE for OGIB. A small bowel mass lesion was identified in 18 patients. Of these, 15 patients had prior CE. Capsule endoscopy identified the mass lesion in five patients; fresh luminal blood with no underlying lesion in seven patients, and non-specific erythema in three patients. Capsule endoscopy failed to identify all four cases of primary small bowel adenocarcinoma.

CONCLUSIONS

Double balloon enteroscopy detects small bowel mass lesions responsible for OGIB that are missed by CE. Additional endoscopic evaluation of the small bowel by DBE or intraoperative enteroscopy should be performed in patients with ongoing OGIB and negative or non-specific findings on CE.

Reproducibility of wireless capsule endoscopy in the investigation of chronic obscure gastrointestinal bleeding

BACKGROUND

Capsule endoscopy (CE) is a valuable tool in the diagnostic evaluation of obscure gastrointestinal bleeding, but limited information is available on the reproducibility of CE findings.

OBJECTIVE

To compare two successive CE studies with push enteroscopy (PE) in patients presenting with chronic obscure gastrointestinal bleeding.

METHODS

A prospective study was conducted. Ten patients (seven men and three women) with chronic obscure gastrointestinal bleeding and no contraindications for CE were eligible and completed the trial. For each patient, the first capsule was administered on day 1, the second capsule was administered on day 2 and PE was performed on day 3. Endoscopists were blinded to the capsule findings. Capsule findings were assessed independently by two investigators blinded to PE findings.

RESULTS

A potential small intestinal bleeding source was found in 60% of the patients when all the studies were combined. A bleeding source was found in four patients in both CE studies. The second CE also identified a bleeding source in a fifth patient. Interobserver agreement by kappa analysis was 0.642 to 1.000 (P < or 05) for the CE studies. PE identified a potential small bowel bleeding site in four patients, including one patient who had negative CE studies.

CONCLUSIONS

This study confirmed the reproducibility of CE findings on successive studies. Some patients did not have a source of bleeding in the small intestine, and all studies found this.

Ethical aspects of capsule endoscopy

Capsule endoscopy is the most recent innovation in gastrointestinal endoscopy. The capsule contains a video camera that photographs the bowel for 8 h after the capsule has been orally ingested and transmits the images for interpretation to a computerized workstation. Ethical considerations of the use of capsule endoscopy should cover the following main issues: justification of the procedure, its potential benefits and harm, and patient autonomy. Capsule endoscopy has several advantages over traditional endoscopy. The procedure is painless, does not require sedation, is easy to perform and for the first time enables exploration of the entire small bowel at high magnification. However, the clinician cannot control its passive advance along the bowel. In addition, the examination may be incomplete, as the capsule reaches the cecum in only 80% of cases. This paper discusses the problems related to the new endoscopic procedure, the diagnostic yield in comparison with other procedures, proper indications for the procedure, outcome and complications.

Mucosal atrophy in celiac disease: extent of involvement, correlation with clinical presentation, and response to treatment

BACKGROUND & AIMS

Wireless capsule endoscopy provides an opportunity to study the macroscopic features in celiac disease by providing a magnified view of the intestinal mucosa. In this study, we evaluated the following: (1) the distribution of atrophy in untreated celiac disease, (2) the correlation between extent of changes and clinical manifestations, (3) the accuracy and interobserver agreement of wireless capsule endoscopy assessment, and (4) the effect of gluten withdrawal.

METHODS

Thirty-eight consecutive patients with untreated biopsy-proven celiac disease underwent wireless capsule endoscopy. Each subject was invited to undergo repeat testing after at least 6 months of gluten withdrawal. The video images of each patient were reviewed independently by 2 investigators.

RESULTS

Thirty-five (92%) subjects had visible atrophy detected by capsule endoscopy. Twenty-two (59%) subjects showed an extensive enteropathy, 12 (32%) had enteropathy limited to the duodenum, and only 1 had a jejunal enteropathy. No association was shown between the extent of the lesion and clinical manifestations. Capsule endoscopy had a better overall sensitivity for the detection of atrophy as compared with upper endoscopy (92% vs 55%, P = .0005), with a specificity of 100%. The overall interobserver agreement for the 2 reviewers was relatively high (% total agreement, 86.5%). After gluten withdrawal, the extent and the pattern of atrophy improved both qualitatively and quantitatively.

CONCLUSIONS

Celiac disease affects a highly variable portion of the small intestine starting at the duodenum. The extent of visible enteropathy does not explain differences in clinical presentation. Most subjects with visually detected villous atrophy showed a clinically significant improvement after gluten withdrawal.

Mucosal atrophy in celiac disease: extent of involvement, correlation with clinical presentation, and response to treatment

BACKGROUND & AIMS

Wireless capsule endoscopy provides an opportunity to study the macroscopic features in celiac disease by providing a magnified view of the intestinal mucosa. In this study, we evaluated the following: (1) the distribution of atrophy in untreated celiac disease, (2) the correlation between extent of changes and clinical manifestations, (3) the accuracy and interobserver agreement of wireless capsule endoscopy assessment, and (4) the effect of gluten withdrawal.

METHODS

Thirty-eight consecutive patients with untreated biopsy-proven celiac disease underwent wireless capsule endoscopy. Each subject was invited to undergo repeat testing after at least 6 months of gluten withdrawal. The video images of each patient were reviewed independently by 2 investigators.

RESULTS

Thirty-five (92%) subjects had visible atrophy detected by capsule endoscopy. Twenty-two (59%) subjects showed an extensive enteropathy, 12 (32%) had enteropathy limited to the duodenum, and only 1 had a jejunal enteropathy. No association was shown between the extent of the lesion and clinical manifestations. Capsule endoscopy had a better overall sensitivity for the detection of atrophy as compared with upper endoscopy (92% vs 55%, P = .0005), with a specificity of 100%. The overall interobserver agreement for the 2 reviewers was relatively high (% total agreement, 86.5%). After gluten withdrawal, the extent and the pattern of atrophy improved both qualitatively and quantitatively.

CONCLUSIONS

Celiac disease affects a highly variable portion of the small intestine starting at the duodenum. The extent of visible enteropathy does not explain differences in clinical presentation. Most subjects with visually detected villous atrophy showed a clinically significant improvement after gluten withdrawal.

Controlled navigation of endoscopic capsules: concept and preliminary experimental investigations

This paper describes a technique to control the navigation of traditional wireless endoscopic capsules and reports preliminary proof-of-concept investigations. These capsules are used for noninvasive explorations of the digestive tube. At present, their motion cannot be controlled and they proceed by means of the visceral peristalsis. In order to enable motion controls, the technique proposed here adopts magnetic shells which are to be applied to available capsules, immediately before their use. The shells are used to control the capsule movement by means of external magnetic fields. This solution is readily applicable to any endoscopic capsule, avoiding internal modifications. Prototype elastic shells made of silicone elastomers mixed with magnetic particles were fabricated. They were tested with the most diffused capsule (model M2A, Given Imaging Ltd., Yoqneam, Israel), by studying the performance of the capsule/shell complex in simplified experimental conditions. Bench tests permitted to demonstrate controlled translations, rotations, and rototranslations of the capsule/shell complex within tubular structures coated with pieces of bovine tissues. The use of a new instrumentation, recently developed for cardiovascular treatments, is proposed as a potential means enabling the application of controlled magnetic fields for intrabody navigations.

Clinical application of wireless capsule endoscopy in pediatric patients for suspected small bowel diseases

Capsule endoscopy (CE) has been demonstrated to be safe and well tolerated in adults with suspicion of small intestinal diseases with negative results of gastroscopy and colonoscopy. However, its value in pediatric patients has not yet been well studied. This study aimed to evaluate the results and safety of CE in pediatric patients with suspicion of small bowel disorders. There were 16 consecutive children and adolescents (12 boys, 4 girls) and 15 adults (9 men, 6 women) referred to us for suspected small bowel diseases from August 2002 to September 2005. Among the pediatrics, six patients were less than 10 years old. Technique for capsule placement, gastric transit time, small bowel transit time, excretion time of capsule endoscopy, capsule findings, and complications were recorded. All 16 pediatric patients described that the capsule was easy to swallow except for three children. Finally we delivered the capsule under gastroscopy with overtube for these three children. No capsule retention occurred during our study. Median recording time was 7 h 44 min (range 6 h 51 min-9 h 11 min). Median gastric transit time was 83.5 min (range 4-296 min). Median small bowel transit time was 270 min (range 142-484 min). Median excretion time of capsule was 33.9 h (range 12-96 h). There was no significant difference in excretion time of capsule, gastric transit time and small bowel transit time between pediatric patients and adult patients (P > 0.05). CE was positive in 12 patients, including Crohn's disease (4), hemangioma (2), angiodysplasia (2), Meckel diverticulum (1), polyp (1), aphthous ulcer in ascending colon (1), and cobblestone appearance of ileal mucosa. CE has been performed safely in a small series of pediatric patients after ingestion or endoscopic placement of the capsule. The high yield of abnormal findings was comparable to those of adult patients.

Microtechnologies in medicine: an overview

Microsystems technology (MST) has become a significant enabler of novel medical devices and implants over the last years. Typical examples are MST units in cardiac rhythm management devices or in hearing implants. A classification of medical MST applications can be made according to their relationship with the anatomy that is based on the kind and duration of interaction with the human body: Class 1: Extra-corporeal devices such as telemetric health monitoring systems or point of care testing systems. Class 2: Intra-corporeal devices such as intelligent surgical instruments. Class 3: Temporarily incorporated or ingested devices, such as telemetric endoscopes. Class 4: Long-term implantable devices such as telemetric implants. Medical applications of MST are growing at double-digit compounded growth rates, leading to a forecasted global market volume of over USD 1 billion in 2006 or 2007, making MST devices a relevant segment of the medical technology market. The clinical foundation for promoting the use of MST in medicine is mainly based on the significant potential of MST to enable products that improve early disease detection and the monitoring of chronic illnesses. This refers to a number of the most important health problems such as cardiovascular disease, hypertension, diabetes and cancer, to name just a few. More recently microrobotics has become a relevant research area for enabling the atraumatic transport of MST-enhanced diagnostic and therapeutic devices inside the human body.

Wireless capsule endoscopy in children: a study to assess diagnostic yield in small bowel disease in paediatric patients

BACKGROUND AND AIM

Small bowel disease in the paediatric population is varied and to date has relied on indirect l modalities such as small bowel follow-through with attendant radiation exposure. Wireless capsule endoscopy (WCE) has the potential to provide a safer and more effective means of investigating the paediatric small bowel. The aim of our study was to prospectively assess the diagnostic yield of WCE compared with standard investigation in children with suspected small bowel disease.

METHODS

Twenty-eight consecutive patients, median age 12.5 y (range, 9.4-15.9) with suspected small bowel disease were investigated with WCE. This included 16 patients with suspected small bowel Crohn disease (CD) (10 newly diagnosed; 6 known cases), 6 with obscure or occult gastrointestinal bleeding (GIB), 3 with Peutz-Jegher polyposis (PJP), 2 with protein-losing enteropathy and 1 with recurrent abdominal pain. All of the patients had preceding upper gastrointestinal endoscopy (OGD) and ileocolonoscopy, and 24 had a barium meal and follow-through (BMFT). Images were downloaded and analysed and results compared with the endoscopic and radiological findings.

RESULTS

Three patients were unable to swallow the capsule (1 CD, 1 PJP and 1 GIB). Two of these patients (1 GIB, 1 PJP) had the capsule placed in the stomach endoscopically and completed the WCE uneventfully thereafter. In 3 patients (CD group) the capsule remained in the stomach and/or proximal duodenum and no small bowel images were obtained. Hence, 24 patients had successful completion of the WCE through the small bowel, 23 of whom had clinically relevant findings identified. In all patients with CD who had successful WCE studies (12/16), small bowel disease was identified (11/12 active disease, 1/12 chronic disease). A possible small bowel bleeding source was identified in all 6 patients with GIB. Two patients with GIB also underwent push enteroscopy and 1 of these had a bleeding source identified. The 2 patients with protein-losing enteropathy had extensive patchy lymphangiectasia of the jejunum and ileum, not detected at OGD. The patient with abdominal pain had an intussusception of the upper jejunum. The 2 PJP patients had small bowel polyps identified, which were not detected at BMFT. WCE was more sensitive for small bowel pathology than both BMFT (19 vs 5; 26% sensitivity compared with WCE) and endoscopic investigations (23 vs 10; 43.4% sensitivity compared with WCE). Two patients with CD had delayed capsule transit.

CONCLUSIONS

WCE led to a positive alteration in management in 18/24 (75%) of patients whose small bowel was examined by WCE and in 18/28 (64.3%) who were admitted to the study. WCE was safe, well tolerated, and more sensitive than radiological and standard endoscopic modalities in the detection of small bowel CD distribution, GIB source, and presence of polyps in children.