Clinical trial: effectiveness of chewing-gum in accelerating capsule endoscopy transit time--a prospective randomized, controlled pilot study

Effect of chewing gum in bowel preparation for patients undergoing small bowel and colon capsule endoscopy: Systematic review with meta-analysis

Background and study aims Quality of bowel preparation and successful transit are critical factors for complete small bowel capsule endoscopy (SBCE) and colon capsule endoscopy (CCE). The aim of this systematic review with meta-analysis was to assess the impact of chewing gum as part of the bowel preparation regimen on the completion rate in both SBCE and CCE. Methods A systematic literature search was conducted in PubMed, Cochrane, Web of Science and Embase. Data were extracted upon quality assessment of included studies. Two reviewers conducted the screening process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Eighty-four studies met the search criteria and four randomized controlled trials were included in the meta-analysis, these were assessed for bias using Minors. Pooled completion rate of SBCE studies was defined as the primary outcome. Results Three randomized controlled trials were SBCE studies and one was a CCE study. The pooled completion rate (91%) was not significantly higher in SBCE patients who were given chewing gum after capsule ingestion compared to those who were not (85%). Variance information was not reported in all studies, and therefore, pooled transit time estimates could not be calculated. Conclusions Chewing gum has a good safety profile but has only been used as a booster in one CCE study and a few SBCE studies. More prospective randomized controlled trials, therefore, are needed to investigate the efficacy of chewing gum for achieving complete capsule examination.

Anxiolytic effects of chewing gum during preoperative fasting and patient-centered outcome in female patients undergoing elective gynecologic surgery: randomized controlled study

Although previous studies reported that chewing gum during the preoperative fasting has the benefits of alleviating anxiety and dry mouth, preoperative chewing gum has yet to be accepted as a standard practice due to conventional anesthetic custom. Our study aimed to prospectively evaluate the effects of gum chewing on preoperative anxiety and patient's discomfort in female patients undergoing gynecologic surgery. Ninety-four patients were enrolled and randomized either into conventional fasting group (control group) or chewing gum with fasting group (gum group). The control group was instructed to fast from 3 p.m. on the day before surgery. The gum group performed preoperative fasting in the same manner, but was encouraged to chew gum freely during the fasting period. The primary endpoint was the degree of preoperative anxiety. For the evaluation of preoperative anxiety, Amsterdam preoperative anxiety and information scale (APAIS) was used. Preoperative gastric fluid volume and acidity were also measured as the secondary outcomes. Preoperative anxiety using APAIS was significantly lower in the gum group compared to the control group (control group vs. gum group: 20.9 vs. 17.8, p = 0.009). However, there was no significant difference in the gastric fluid analysis between the groups. In the female patients for elective gynecologic surgery, chewing gum during the preoperative fasting period helped to alleviate preoperative anxiety without additional increase of pulmonary aspiration risks.Trial registration: KCT0004422 (05/11/2019, https://cris.nih.go.kr ; registration number).

Value of the diving method for capsule endoscopy in the examination of small-intestinal disease: a prospective randomized controlled trial

BACKGROUND AND AIMS

Video capsule endoscopy (VCE) is limited by poor image quality and incomplete small-bowel transit. This study was designed to evaluate the diving method for VCE in the examination of small-intestinal disease.

METHODS

From July 2017 to September 2017, eligible patients were randomly assigned to 2 groups, the diving group and the control group. For the diving group, 500 mL of water was administered every hour when the capsule reached the small bowel. The primary outcomes were image quality and positive findings. Secondary outcomes were the completion rate of examination, gastric transit time (GTT), small-bowel transit time (SBTT), lesion detection rate, adverse events, and patient satisfaction.

RESULTS

One hundred forty patients were included. The scores of endoscopic images in the proximal third and middle third of the small bowel in the diving group were significantly higher than that in the control group (3.47 ± .60 vs 3.11 ± .63 [P = .007] and 3.24 ± .59 vs 2.78 ± .74 [P = .002], respectively). The positive findings in the distal third of the small bowel were significantly different between the 2 groups (P = .005). The completion rate in the diving group was significantly higher (92.19% vs 76.32%, respectively; P = .012). The GTT, SBTT, and lesion detection rate were similar in 2 groups (P = .282, .067, and .577, respectively). No discomfort or adverse events were reported except for a few cases of frequent urination.

CONCLUSIONS

The diving method for VCE examination effectively improves the endoscopic view in the proximal and middle thirds of the small bowel and the positive findings in the distal small intestine and increases the completion rate. (Clinical trial registration number: ChiCTR-RDR-17011823.).

Preparation, Timing, Prokinetics, and Surface Agents in Video Capsule Endoscopy

There is a trend in data to support active preparation for video capsule endoscopy (VCE), but the timing of this remains unclear. Split dosing may be the most efficacious preparation. Study methodology continues to evolve, with increased use of standardized scales, with the addition of diagnostic yield as an outcome. The use of adjuncts has not been detrimental, but their value has not been proved to improve outcomes of VCE.

Effectiveness of Improved Use of Chewing Gum During Capsule Endoscopy in Decreasing Gastric Transit Time: A Prospective Randomized Controlled Study

Background/Aim: Chewing gum throughout small bowel capsule endoscopy (SBCE) increases completion rates (CRs) but decreases small bowel transit time (SBTT) and diagnostic yield (DY). We determined the effects of chewing gum early during SBCE on gastric transit time (GTT), SBTT, CR, DY, and gastroscopy intervention. Methods: We prospectively enrolled patients (ages 16-80 years) undergoing SBCE between January and June 2019. Patients were randomized to a chewing gum group (103 patients) and a control group (102 patients). Patients in the former group chewed one piece of gum for ~15 min every 30 min during the first hour of SBCE. Two gastroenterologists blinded to the study group examined the data. Results: GTT was shorter in the chewing gum group (19.0 min, interquartile range: 17.0-52.0 min) than in the control group [42.5 min (23.25-60 min); P = 0.01]. SBTT was similar in the two groups [318.5 min (239.5-421.3 min) vs. 287.0 min (216.0-386.0 min); P = 0.08]. Gastroscopy rate was lower in the chewing gum group (15.53 vs. 32.35%, P = 0.005). CR (95.15 vs. 89.22%, P = 0.114) and DY (66.02 vs. 59.80%, P = 0.359) did not differ between the groups. The number of abnormal-lesion types detected per patient was higher in the chewing gum group [1.0 (0.0-2.0) vs. 2.0 (0.0-2.0); P = 0.049]. Conclusions: Chewing gum early during SBCE significantly reduced GTT and gastroscopy intervention, with no influence on SBTT (Trial number: NCT03815136).

Repeatability of small bowel transit time in capsule endoscopy in healthy subjects

BACKGROUND

There are no reports to prove the repeatability of gastric transit time (GTT) and small bowel transit time (SBTT) in capsule endoscopy (CE).

OBJECTIVE

To clarify the repeatability and factors that affect GTT/SBTT in CE.

METHODS

We analyzed the data of 150 healthy subjects from our previous randomized controlled trial that compared small intestinal injuries between two 14-day treatment groups: 1) celecoxib and 2) loxoprofen + lansoprazole. Correlation of GTT/SBTT with pre- and post-treatment CE was analyzed. In addition, the associations of pre-treatment CE SBTT with physical factors, post-treatment CE SBTT and the presence of small intestinal mucosal injuries were analyzed.

RESULTS

Analyses of 148 subjects pre-treatment CE and 146 subjects post-treatment CE were performed. There were no significant differences between mean GTT and SBTT before and after treatment. Both GTT (𝜌 = 0.22, p < 0.01) and SBTT (𝜌 = 0.47, p < 0.0001) showed positive correlations between pre- and post-treatment CE. In pre-treatment CE, physical factors and the presence of small intestinal mucosal injury had no associations with SBTT.

CONCLUSIONS

Moderate correlation in SBTT and slight correlation in GTT were shown on repeated CE. The factors affecting SBTT were not clarified in this analysis.

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.

Sham Feeding with Bacon Does Not Alter Transit Time or Complete Examination Rate During Small Bowel Capsule Endoscopy

BACKGROUND

During capsule endoscopy (CE) studies, the complete examination rate (CER) can be increased by prolonging capsule battery life or reducing gastric transit time (GTT) and/or small bowel transit time (SBTT). However, despite enhanced battery life, 10% of studies remain incomplete. Previously studied interventions to reduce SBTT and enhance CER have produced conflicting results. We hypothesize that this may be a consequence of an insufficiently potent stimulus of small bowel motility.

AIMS

To examine whether potent stimulation of the cephalic response of digestion during small bowel CE reduces GTT and/or SBTT and thus increases the CER.

METHODS

A single-blind randomized trial was performed to evaluate the effect of bacon sham feeding on GTT, SBTT and CER.

RESULTS

Baseline characteristics were similar between 63 sham fed patients and 59 controls. The median GTT was 17 min (9-65) in the bacon group and 25 min (14-55) in the control group. The median SBTT was 199 min (119-316) and 222 min (151-287), respectively. Cox proportional hazards model demonstrated no significant difference between groups for GTT (rate ratio 1.03, 95% CI 0.71-1.51, P = 0.87) or SBTT (rate ratio 1.02, 95% CI 0.70-1.49, P = 0.93). Although the taste of bacon was considered favorably by 72% of participants, taste did not correlate with GTT (ρ = 0.03, P = 0.83) or SBTT (ρ = - 0.115, P = 0.33). The CER was 91 and 95% in the bacon and control groups, respectively (P = 0.35).

CONCLUSION

Bacon sham feeding has no effect on GTT, SBTT or CER and cannot be recommended in clinical practice.

A Single-Center Randomized Controlled Trial Evaluating Timing of Preparation for Capsule Enteroscopy

Background/Aims

Intestinal lavage (IL) administration immediately before capsule enteroscopy (CE) is superior to lavage the day before the procedure. We aimed to determine the effect of IL timing on CE diagnostic yield.

Methods

Patients referred for CE were randomized prospectively into two equal groups according to the timing of IL with 2 L of polyethylene glycol solution. Group A and B underwent IL over 2 hours beginning 14 and 4 hours, respectively, before the scheduled CE. The primary outcome measure was preparation quality, measured with a predetermined validated grading scale.

Results

A total of 34 patients were randomized. The frequency of mucosal abnormalities (77% vs. 82%, p=not significant [NS]) and diagnostic yield (47% vs. 53%, p=NS) were similar between the two groups. Moreover, no significant association between the quality of small bowel preparation and the timing at which the purgative for IL was administered was observed (overall fluid transparency, p=0.936; overall mucosal invisibility, p=0.091).

Conclusions

Day-before IL is equivalent to same-day IL in terms of overall preparation quality, proportion of complete studies to cecum, small bowel transit time, frequency of identified mucosal abnormalities, and overall diagnostic yield.

Effect of longer battery life on small bowel capsule endoscopy

AIM

To determine if longer battery life improves capsule endoscopy (CE) completion rates.

METHODS

A retrospective study was performed at a tertiary, university-affiliated hospital in Vancouver, Canada. Patients who underwent CE with either PillCam™ SB2 or SB2U between 01/2010 and 12/2013 were considered for inclusion. SB2 and SB2U share identical physical dimensions but differ in their battery lives (8 h vs 12 h). Exclusion criteria included history of gastric or small bowel surgery, endoscopic placement of CE, interrupted view of major landmarks due to technical difficulty or significant amount of debris, and repeat CE using same system. Basic demographics, comorbidities, medications, baseline bowel habits, and previous surgeries were reviewed. Timing of major landmarks in CE were recorded, and used to calculate gastric transit time, small bowel transit time, and total recording time. A complete CE study was defined as visualization of cecum. Transit times and completion rates were compared.

RESULTS

Four hundred and eight patients, including 208 (51.0%) males, were included for analysis. The mean age was 55.5 ± 19.3 years. The most common indication for CE was gastrointestinal bleeding (n = 254, 62.3%), followed by inflammatory bowel disease (n = 86, 21.1%). There was no difference in gastric transit times (group difference 0.90, 95%CI: 0.72-1.13, P = 0.352) and small bowel transit times (group difference 1.07, 95%CI: 0.95-1.19, P = 0.261) between SB2U and SB2, but total recording time was about 14% longer in the SB2U group (95%CI: 10%-18%, P < 0.001) and there was a corresponding trend toward higher completion rate (88.2% vs 93.2%, OR = 1.78, 95%CI 0.88-3.63, P = 0.111). There was no statistically significant difference in the rates of positive findings (OR = 0.98, 95%CI: 0.64-1.51, P = 0.918).

CONCLUSION

Extending the operating time of CE may be a simple method to improve completion rate although it does not affect the rate of positive findings.

Chewing gum for postoperative recovery of gastrointestinal function

BACKGROUND

Ileus commonly occurs after abdominal surgery, and is associated with complications and increased length of hospital stay (LOHS). Onset of ileus is considered to be multifactorial, and a variety of preventative methods have been investigated. Chewing gum (CG) is hypothesised to reduce postoperative ileus by stimulating early recovery of gastrointestinal (GI) function, through cephalo-vagal stimulation. There is no comprehensive review of this intervention in abdominal surgery.

OBJECTIVES

To examine whether chewing gum after surgery hastens the return of gastrointestinal function.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid), MEDLINE (via PubMed), EMBASE (via Ovid), CINAHL (via EBSCO) and ISI Web of Science (June 2014). We hand-searched reference lists of identified studies and previous reviews and systematic reviews, and contacted CG companies to ask for information on any studies using their products. We identified proposed and ongoing studies from clinicaltrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform and metaRegister of Controlled Trials.

SELECTION CRITERIA

We included completed randomised controlled trials (RCTs) that used postoperative CG as an intervention compared to a control group.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data and assessed study quality using an adapted Cochrane risk of bias (ROB) tool, and resolved disagreements by discussion. We assessed overall quality of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Studies were split into subgroups: colorectal surgery (CRS), caesarean section (CS) and other surgery (OS). We assessed the effect of CG on time to first flatus (TFF), time to bowel movement (TBM), LOHS and time to bowel sounds (TBS) through meta-analyses using a random-effects model. We investigated the influence of study quality, reviewers' methodological estimations and use of Enhanced Recovery After Surgery (ERAS) programmes using sensitivity analyses. We used meta-regression to explore if surgical site or ROB scores predicted the extent of the effect estimate of the intervention on continuous outcomes. We reported frequency of complications, and descriptions of tolerability of gum and cost.

MAIN RESULTS

We identified 81 studies that recruited 9072 participants for inclusion in our review. We categorised many studies at high or unclear risk of the bias' assessed. There was statistical evidence that use of CG reduced TFF [overall reduction of 10.4 hours (95% CI: -11.9, -8.9): 12.5 hours (95% CI: -17.2, -7.8) in CRS, 7.9 hours (95% CI: -10.0, -5.8) in CS, 10.6 hours (95% CI: -12.7, -8.5) in OS]. There was also statistical evidence that use of CG reduced TBM [overall reduction of 12.7 hours (95% CI: -14.5, -10.9): 18.1 hours (95% CI: -25.3, -10.9) in CRS, 9.1 hours (95% CI: -11.4, -6.7) in CS, 12.3 hours (95% CI: -14.9, -9.7) in OS]. There was statistical evidence that use of CG slightly reduced LOHS [overall reduction of 0.7 days (95% CI: -0.8, -0.5): 1.0 days in CRS (95% CI: -1.6, -0.4), 0.2 days (95% CI: -0.3, -0.1) in CS, 0.8 days (95% CI: -1.1, -0.5) in OS]. There was statistical evidence that use of CG slightly reduced TBS [overall reduction of 5.0 hours (95% CI: -6.4, -3.7): 3.21 hours (95% CI: -7.0, 0.6) in CRS, 4.4 hours (95% CI: -5.9, -2.8) in CS, 6.3 hours (95% CI: -8.7, -3.8) in OS]. Effect sizes were largest in CRS and smallest in CS. There was statistical evidence of heterogeneity in all analyses other than TBS in CRS.There was little difference in mortality, infection risk and readmission rate between the groups. Some studies reported reduced nausea and vomiting and other complications in the intervention group. CG was generally well-tolerated by participants. There was little difference in cost between the groups in the two studies reporting this outcome.Sensitivity analyses by quality of studies and robustness of review estimates revealed no clinically important differences in effect estimates. Sensitivity analysis of ERAS studies showed a smaller effect size on TFF, larger effect size on TBM, and no difference between groups for LOHS.Meta-regression analyses indicated that surgical site is associated with the extent of the effect size on LOHS (all surgical subgroups), and TFF and TBM (CS and CRS subgroups only). There was no evidence that ROB score predicted the extent of the effect size on any outcome. Neither variable explained the identified heterogeneity between studies.

AUTHORS' CONCLUSIONS

This review identified some evidence for the benefit of postoperative CG in improving recovery of GI function. However, the research to date has primarily focussed on CS and CRS, and largely consisted of small, poor quality trials. Many components of the ERAS programme also target ileus, therefore the benefit of CG alongside ERAS may be reduced, as we observed in this review. Therefore larger, better quality RCTS in an ERAS setting in wider surgical disciplines would be needed to improve the evidence base for use of CG after surgery.

The effect of chewing gum on small-bowel transit time in capsule endoscopy: a prospective, randomized trial

BACKGROUND

Approximately 1 in 6 capsule endoscopies (CEs) does not visualize the entire small bowel at completion of the examination because of limited battery life.

OBJECTIVE

To determine whether chewing gum can reduce the small-bowel transit time and increase CE completion rates.

DESIGN

Prospective, single-blind, randomized, controlled trial.

SETTING

A tertiary university-affiliated hospital.

PATIENTS

Consecutive patients 19 years of age and older undergoing outpatient small-bowel CE from October 2010 to July 2012 were assessed for eligibility. Those with previous gastric or small-bowel surgery or ileostomy, dysphagia prohibiting capsule ingestion, diabetes mellitus with evidence of end-organ damage, use of narcotics or prokinetics within 5 days before the procedure, clinical hyper-/hypothyroidism, and symptoms suggestive of acute bowel obstruction were excluded.

INTERVENTION

Gum chewing for at least 20 minutes every 2 hours starting at the time of capsule ingestion.

MAIN OUTCOME MEASUREMENTS

Small-bowel transit time, gastric transit time, and completion rate were measured.

RESULTS

Chewing gum did not have any significant effect on gastric transit time (rate ratio 1.06; 95% CI, 0.73-1.55; P = .75), small-bowel transit time (rate ratio 0.91; 95% CI, 0.62-1.35; P = .65), or completion rate (91.67% chewing gum vs 88.71% control, P = .58) of CE.

LIMITATION

Single-center study involving relatively healthy subjects. Procedures were done on an outpatient basis so participants were not monitored for adherence to protocol.

CONCLUSIONS

Chewing gum does not speed up capsule transit or increase completion rate of CE in patients without risk factors for incomplete studies. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01241825.).

Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis

BACKGROUND

The use of purging for bowel cleansing prior to small-bowel capsule endoscopy (SBCE) has now been established in clinical practice. Despite that, the number of incomplete SBCEs is still around 15-20%. To date, the use of prokinetics in SBCE - aiming to improve completion rate (CR) - remains a contentious issue resulting in lack of consensus among capsule experts.

METHODS

Extensive medical literature searches were conducted (to November 2012), using suitable MeSH terms and keywords, in search of studies that compared capsule ingestion with prokinetic agents vs. controls or placebo. We examined the effects of prokinetic administration on SBCE CR (primary end point), as well as on the following secondary end points: diagnostic yield (DY), gastric transit time (GTT) and small-bowel transit time (SBTT) by meta-analysis of all relevant studies.

RESULTS

A total of 17 eligible studies (14 prospective, 3 retrospective) were identified, including 1028 individuals who ingested the capsule with no prokinetic vs. 876 who received a prokinetic. Overall, there was a higher CR in patients who ingested the capsule with prokinetics vs. controls (OR [95% CI]: 1.96 [1.38-2.78]). Of the two most readily available prokinetics, metoclopramide was associated with superior SBCE CR vs. control (OR [95% CI]: 2.8 [1.35-3.21]), while erythromycin showed no benefit (OR [95% CI]: 1.36 [0.61-3.03]). Where prokinetics were used alone, neither metoclopramide nor erythromycin showed any benefit on CR. There was no benefit of prokinetics (over controls) on DY. However, metoclopramide had a significant effect on GTT and SBTT.

LIMITATIONS

The majority of the included studies were heterogeneous, and the effect of prokinetics on image quality and mucosal visualization was not examined.

CONCLUSION

Our pooled data shows that the use of prokinetics for capsule ingestion improves CR in SBCE. This effect appears to be particularly evident with metoclopramide, when used concurrently with purging and/or use of real-time monitoring. In a small number of studies, erythromycin showed - through its gastrokinetic effect - marginal benefit. No prokinetic has a beneficial effect on SBCE DY.

A prospective randomized controlled trial of sugared chewing gum on gastrointestinal recovery after major colorectal surgery in patients managed with early enteral feeding

BACKGROUND

A number of small prospective studies with conflicting results have evaluated the effect of sugar-free chewing gum on postoperative GI recovery in patients initially maintained nil per os after major colorectal surgery.

OBJECTIVE

We sought to evaluate the effect of sugared chewing gum in combination with early enteral feeding on recovery of GI function after major colorectal surgery to ascertain any additive effects of this combination.

DESIGN

This was a randomized prospective study.

SETTING

This study was conducted at a single-institution tertiary referral center.

PATIENTS

Patients undergoing major colorectal surgery were included.

INTERVENTIONS

Patients were randomly assigned to sugared chewing gum (Gum) (instructed to chew 3 times daily; 45 minutes each time for 7 days postoperatively) or No Gum after major colorectal surgery.

MAIN OUTCOME MEASURES

The primary outcome measured was time to tolerating low residue diet without emesis for 24 hours. The secondary outcomes measured were time to flatus, time to bowel movement, postoperative hospital stay, postoperative pain, nausea, and appetite.

RESULTS

One hundred fourteen patients (60 No Gum; 54 Gum) were included in our analysis after randomization. There was no significant difference in time to tolerating a low-residue diet, time to flatus, time to bowel movement, length of postoperative hospital stay, postoperative complications, postoperative pain, nausea, or appetite between patients assigned to Gum or No Gum. There was an increased incidence of bloating, indigestion, and eructation in the Gum group (13%) in comparison with the No Gum group (2%) (p = 0.03).

LIMITATIONS

Study subjects and investigators were not blinded. Multiple types of operations may cause intergroup variability.

CONCLUSIONS

There does not appear to be any benefit to sugared chewing gum in comparison with no gum in patients undergoing major colorectal surgery managed with early feeding in the postoperative period. There may be increased incidence of bloating, indigestion, and eructation, possibly related to swallowed air during gum chewing.

Relationship between gastric transit time and complete examination rate of the capsule endoscopy examinations

AIM: To investigate the right timing for intervention when capsule endoscope transits for a relatively long time in the stomach.

METHODS: The following items were analyzed in 109 patients who underwent capsule endoscopy (CE) examinations: the relationship between gastric transit time (GTT) and complete examination rate (CER); the correlation between GTT and small bowel transit time (SBTT); the difference in GTT between groups of complete and incomplete examinations; and the risk of incomplete examination in patients with strictures of the small intestine.

RESULTS: No difference was found in CER among groups with GTT ≤ 30 min, 30-60 min, 60-90 min, or > 90 min (P = 0.971). Injection of metoclopramide in patients with longer GTT resulted in shorter SBTT compared to their counterparts with shorter GTT (t = -2.027, P = 0.046). No difference was found in GTT between groups of complete and incomplete examinations [45.6 min ± 35.8 min (n = 85) vs 42.0 min ± 36.4 min (n = 24), P = 0.665]. The risk of incomplete examination in patients with strictures of the small intestine was 6.588-fold higher than those without strictures (OR = 6.588, 95% CI = 1.866-23.258, P = 0.004).

CONCLUSION: Too early delivery of capsule endoscope in the duodenum might not improve CER. This procedure should be considered only if the retention of CE in the stomach exceeds 90 min, and it is better to be completed within 30 min.

New vision in video capsule endoscopy: current status and future directions

Now, more than 10 years after the approval of video capsule endoscopy (VCE), the technology has become an essential component in the management of several clinical conditions. Currently, two capsules are approved in the USA for visualizing the small bowel mucosa, one capsule is authorized for oesophageal assessment and several others are in use or under evaluation worldwide. New investigations have focused on optical improvements, advances in intestinal cleansing and risk reduction strategies to optimize VCE methodologies in clinical care. Established indications diagnosed using VCE include unexplained gastrointestinal bleeding, small bowel Crohn's disease (in adults and children >10 years old), localization of small bowel tumours and a broad range of miscellaneous abnormalities. Investigations are ongoing to determine the utility of VCE in colon cancer screening, assessment of oesophageal disorders and diagnosis of coeliac disease. Active research is in progress into ways to improve the efficacy of VCE recording interpretation, prolong imaging time and further enhance optics and imaging methods. To expand the potential utility of VCE, novel devices that can manoeuvre within or insufflate the gut lumen, tag or biopsy suspect lesions, or target drug delivery to specific sites are in development. To facilitate these advances, consortia have been organized to promote innovative VCE technologies.

Gum chewing during pre-anesthetic fasting

Many ad hoc fasting guidelines for pre-anesthetic patients prohibit gum chewing. We find no evidence that gum chewing during pre-anesthetic fasting increases the volume or acidity of gastric juice in a manner that increases risk, nor that the occasional associated unreported swallowing of gum risks subsequent aspiration. On the contrary, there is evidence that gum chewing promotes gastrointestinal motility and physiologic gastric emptying. Recommendations against pre-anesthetic gum chewing do not withstand scrutiny and miss an opportunity to enhance comfort and sense of wellbeing for patients awaiting anesthesia. Gum chewing during the pre-anesthetic nil per os (NPO) period would also permit the development of gum-delivered premedications and should be permitted in children old enough to chew gum safely. Gum chewing should cease when sedatives are given and all patients should be instructed to remove any chewing gum from the mouth immediately prior to anesthetic induction.

Use of an external real-time image viewer coupled with prespecified actions enhanced the complete examinations for capsule endoscopy

BACKGROUND AND AIM

  The clinical utility of capsule endoscopy (CE) is often limited by incomplete small-bowel transit. The aim was to determine whether the use of an external real-time viewer could reduce delays caused by delayed gastric emptying of the capsule or delayed intestinal transit and also improve the rate of positive findings.

METHODS

  We compared the proportion of completed exams and positive results among a group of patients studied before introduction of real-time viewer and a group in which capsule transit through the esophagus, stomach, and small bowel was regularly monitored and actions (e.g. administration of water or intravenous metoclopramide) were taken if it was delayed.

RESULTS

  One hundred procedures in the viewer group and 100 control procedures in the age-matched controls were analyzed. In the viewer group, additional water intake (22 cases) and/or administration of metoclopramide (26 cases) were required. Endoscopic-assisted duodenal placement of the capsule was required in three cases. Overall one-third (n=33) of cases required viewer-prompted interventions. The completion rate (86% vs 66%, P=0.002) and the rate of positive findings (80% vs 67%, P=0.04) were significantly higher in the viewer group compared to the no viewer group.

CONCLUSIONS

  Checking the progress of the capsule with the external real-time viewer improved the diagnostic yield and completion rate of CE.

Advances in complete small-bowel examination by capsule endoscopy

Capsule endoscopy (CE) has a battery life of 8 h, during which time complete small-bowel examination can be achieved in most cases. However, in 10-30% of cases, the capsule cannot reach the ileocecal valve before the end of the life of the capsule's battery due to factors other than mechanical bowel obstruction. Incomplete examination of the entire small bowel leaves room for missing lesions. Some studies have shown that diabetes mellitus can lead to gastroparesis and increase gastric transit time (GTT), while history of abdominal surgery can increase small bowel transit time (SBTT). Therefore, these two factors can decrease the rate of complete small-bowel examination by CE. Purgative bowel cleansing can improve the detectability and image quality of CE, but has no significant impact on GTT, SBTT and CR. Prokinetic drugs, real-time CE, right lateral position, and chewing-gum are all under research for increasing CR. In future studies, emphasis should be placed in improving the diagnostic ability of CR and ensuring optimal intervention for patients with high risk factors for incomplete small-bowel examination.

Small bowel capsule endoscopy performance in octogenarians: a case-control study

BACKGROUND AND STUDY AIMS

Capsule endoscopy is a high-sensitive tool for the investigation of suspected small bowel disorders, but its effectiveness in elderly patients is unknown. We sought to determine capsule endoscopy feasibility and diagnostic yield in octogenarians.

PATIENTS AND METHODS

Records of patients ≥ 80 years old (Group A) were retrieved from a database of 827 consecutive capsule endoscopy performed on as many patients. Capsule endoscopy failures, complications, diagnostic yield, and findings were recorded and compared with those of patients younger than 80 (Group B), randomly extracted from the same database in a > 2:1 ratio.

RESULTS

Group A consisted of 79 patients, 84 ± 6 years old and Group B of 188, 44 ± 11 years old (p < .0001). We visualized the entire small bowel in 59 (74.6%) patients of Group A and in 169 (89%) of Group B (odds ratio = 0.33, 95% confidence interval: 0.16-0.66, p = .0025), mainly for capsule failures in reaching the duodenum; this event occurred in 10 patients of Group A and in 3 of Group B (odds ratio = 9, 95% confidence interval: 2.4-33.4, p = .0004). The rate of adverse events and diagnostic yield did not differ between the two groups. Inflammatory and neoplastic lesions were more common in Group A (odds ratio = 2.60, 95% confidence interval: 1.07-6.28, p = .03 and odds ratio = 2.01, 95% confidence interval: 1.02-3.97, p = .04, respectively).

CONCLUSIONS

In octogenarians, small bowel capsule endoscopy may be troublesome for capsule failure in reaching the duodenum. However, the diagnostic yield of small bowel capsule endoscopy and the rate of clinically significant lesions are high.

Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery

BACKGROUND

Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. Chewing is a form of sham feeding reported to stimulate bowel motility. This analysis examines the value of chewing-gum therapy in treatment of postoperative ileus.

METHODS

A search for randomized, controlled trials studying elective gastrointestinal surgery was undertaken using MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists. Outcomes were extracted including time to first flatus and bowel motion, length of stay, and complications. Statistical analysis was undertaken using the weighted mean difference (WMD) and random-effects model with 95% confidence intervals (CI).

RESULTS

Seven studies with 272 patients were included. For time to first flatus the analysis favored treatment with a WMD of 12.6 h (17%) reduction (95% CI -21.49 to -3.72; P = 0.005). For time to first bowel motion, treatment was favored with a WMD of 23.11 h (22%) reduction (95% CI -34.32 to -11.91; P < 0.001). For length of stay, the analysis showed a nonsignificant trend toward treatment with WMD of 23.88 h (12%) reduction (95% CI -53.29 to +5.53; P = 0.11). There were no significant differences in complication rates.

CONCLUSIONS

Chewing-gum therapy following open gastrointestinal surgery is beneficial in reducing the period of postoperative ileus, although without a significant reduction in length of hospital stay. These outcomes are not significant for laparoscopic gastrointestinal surgery.

Endoscopic capsule placement improves the completion rate of small-bowel capsule endoscopy and increases diagnostic yield

BACKGROUND

The methods for increasing the rate of complete small-bowel examinations by capsule endoscopy (CE) demonstrate conflicting results, and it is unknown whether improving the completion rate of CE transit is correlated with improvement in diagnostic yield.

OBJECTIVE

The aim of this study was to determine whether a higher rate of complete small-bowel examinations results in a higher diagnostic yield of CE.

DESIGN

Case-control comparison.

SETTING

Tertiary care university hospital.

PATIENTS

A total of 273 patients underwent conventional CE (group A), and 261 patients underwent real-time CE (group B). Furthermore, the patients in groups A and B were divided into 2 subgroups by pyloric transit time (A1, A2 and B1, B2, respectively).

INTERVENTIONS

After swallowing the capsule, each patient was monitored with a real-time viewer in group B, and the patients underwent endoscopic placement if the capsule was delayed in the esophagus or stomach.

MAIN OUTCOME MEASUREMENTS

Pyloric transit time, small-bowel transit time, the rate of complete small-bowel examinations, and the diagnostic yield.

RESULTS

The rate of complete small-bowel examinations was significantly higher in group B than in group A (87.4% vs 78.0%, respectively; P = .004). The diagnostic yield was significantly higher in group B2 than in group A2 (60.0% vs 41.7%, respectively; P = .019).

LIMITATIONS

Nonrandomized study.

CONCLUSIONS

Endoscopic placement improves the rate of complete small-bowel examinations, resulting in a higher diagnostic yield of CE.

Can we improve the diagnostic yield of small bowel video-capsule endoscopy?

Video-capsule endoscopy has revolutionized the examination of small bowel mucosa. However, this modality is relatively young and its diagnostic yield is low. Herein, we discuss different approaches to improve examination's diagnostic yield. There are strong data supporting some of them while there is speculation about the rest. As capsule endoscopy continues to evolve there is also a strong belief that technology will overcome at least some of the obstacles that hamper capsule endoscopy's diagnostic yield sometime in the near future.

Enhanced diagnostic yield with prolonged small bowel transit time during capsule endoscopy

BACKGROUND

The effect of small bowel transit time (SBTT) on diagnostic yield during capsule endoscopy (CE) has not been previously evaluated. Our study aim was to assess the effect of SBTT on the likelihood of detecting intestinal pathology during CE.

METHODS

We reviewed collected data on CE studies performed at Johns Hopkins Hospital from January 2006 to June 2007. In patients investigated for anemia or obscure bleeding, the following lesions were considered relevant: ulcers, erosions, AVMs, red spots, varices, vascular ectasias, and presence of blood. In patients with diarrhea or abdominal pain, ulcers, erosions, and blood were considered relevant. Age, gender, study indication, hospital status, and quality of bowel preparation were identified as candidate risk factors affecting SBTT. Univariate logistic and linear regression analyses were performed to study the effect of SBTT on diagnostic yield.

RESULTS

Total of 212 CE studies were analyzed; most were in outpatients (n=175, 82.9%) and with excellent bowel preparation (n=177, 83.5%). Mean SBTT was 237.0 min (3.9 hrs). Age, gender, bowel prep, hospital status, and study indication did not significantly affect SBTT. However, increased SBTT was independently associated with increased diagnostic yield; OR=1.7 in SBTT=2-4 hr (p=0.41), OR=1.8 in SBTT=4-6 hrs (p=0.30), OR=9.6 in SBTT=6-8 hrs (p=0.05).

CONCLUSION

Prolonged SBTT during CE (>6 hr) is associated with an increased diagnostic yield. This may be due to a positive effect on image quality during a "slower" study. The use of promotility agents may adversely affect the ability of CE to detect significant intestinal pathology.