Video capsule colonoscopy in routine clinical practice

Multicenter prospective feasibility study on compliance, safety, and acceptance of small bowel and colon capsule endoscopy in the out-of-clinic setting in Japan

OBJECTIVES

We aimed to determine the compliance, safety, and acceptance of colon capsule endoscopy (CCE) and small bowel capsule endoscopy (SBCE) in an out-of-clinic setting remotely supported by medical staff.

METHODS

We enrolled 30 examinees (24 with CCE and six with SBCE) who had not undergone CE at six gastroenterological centers. All examinees were provided with instructions on equipment and bowel preparations.

RESULTS

CCE was performed at home (n = 16) or at the workplace (n = 8). Compliance with data-recorder alerts was 100% for bowel preparation and 79% for equipment operation. Total capsule colonoscopy was achieved in 83.3%. The overall adequate endoscopic cleansing rate was 83.3%, and abnormalities, including colorectal polyps, were detected in 37.5%. CCE malfunction, such as the inability to automatically detect the small bowel mucosa occurred in one (4.2%). One experienced mild abdominal pain that required no treatment. Inquiries were present from half of the examinees. The proportions of examinees who desired and refused CCE at the next examination were 67% and 4%, respectively. SBCE was performed at home (n = 4) or at the workplace (n = 2). Compliance with the procedures was 100%. Whole small bowel images were recorded for all examinees. The overall adequate endoscopic clearness rate was 100%. One abnormality was detected. Inquiries were present from half of the examinees. There were no adverse events or malfunctions. The proportion of examinees who reported "quite easy" and "fairly easy" was 66%.

CONCLUSION

CCE and SBCE with all procedures in the out-of-clinic setting supported by remote consultations were feasible. A multicenter prospective study of the safety and acceptance of capsule endoscopy examinations at home (HomeCam-J study) (jRCTs042220163).

Nationwide multicenter prospective study on the usefulness, safety, and acceptability of colon capsule endoscopy in Japan

BACKGROUND AND AIMS

We determined the factors influencing total capsule colonoscopy, adequate cleansing, and detectability of second-generation colon capsule endoscopy (CCE) for colorectal polyps or tumors (CRTs), adverse events, and acceptability.

METHODS

Among 44 Japanese hospitals, 1006 patients with suspected or documented colorectal diseases who underwent CCE were enrolled prospectively.

RESULTS

The total capsule colonoscopy rate was 86.1%. Age younger than 63 years (adjusted odds ratio [aOR], 1.525), male sex (aOR, 1.496), inflammatory bowel disease (aOR, 1.889), lavage intake on day -1 (aOR, 1.625), ≥1800-mL lavage intake on day 0 (aOR, .595), prokinetics on day 0 (aOR, .608), and ≥30-mL castor oil booster on day 0 (aOR, 1.734) were significant independent predictors. The overall adequate cleansing rate was 65.5%. Constipation (aOR, .527), lavage intake on day -1 (aOR, 1.822), laxative intake on day -1 (aOR, 2.616), and ≥1900-mL lavage intake on day 0 (aOR, 1.449) were significant independent predictors. The detection rates for patients with CRTs ≥6 mm and ≥10 mm were 92% (95% confidence interval, 84-97) and 89% (95% confidence interval, 78-96), respectively. Inadequate cleansing in the ascending colon (aOR, .184), ≥6-mm CRT in the transverse colon (aOR, 4.703), and ≥6-mm CRT in the left-sided colon (aOR, 32.013) were significant independent predictors. CCE retention occurred in 2 patients (.20%) requiring endoscopic and surgical interventions. In total, 63% of patients desired CCE for their next colonoscopy.

CONCLUSIONS

CCE was relatively safe, well tolerated, and useful for detecting colorectal lesions when adequate bowel preparation was made. (Clinical trial registration number: UMIN000021936.).

The Effectiveness of a Very Low-Volume Compared to High-Volume Laxative in Colon Capsule Endoscopy

Colon capsule endoscopy (CCE) is a promising modality for colonic investigations, but completion rates (CR) and adequate cleansing rates (ACR) must be improved to meet established standards for optical colonoscopy. Improvements should be made with patient acceptability in mind. We aimed to compare a very low-volume polyethylene glycol (PEG) laxative to a conventional high-volume laxative. We carried out a single-center retrospective comparative cohort study including patients referred for CCE. One hundred and sixty-six patients were included in the final analysis, with eighty-three patients in each group. We found a CR and ACR of 77% and 67% in the high-volume group and 72% and 75% in the very low-volume group, respectively. In the high-volume group, 54% had complete transit and adequate cleansing, whereas this was the case for 63% in the very low-volume group. No statistically significant difference in CR, ACR, or a combination of the two was found. A very low-volume bowel preparation regimen was non-inferior to a high-volume regimen before CCE in terms of CR and ACR.

Video Capsule Endoscopy in Gastroenterology

Video capsule endoscopy (VCE) is a wireless technology used by gastroenterologists for various indications in their clinical practice. There has been significant improvement in this technology since its start about two decades ago. Specific video capsules have been made to evaluate the small bowel, colon, and esophagus. Now pan-enteric video capsule is available to assess both the small bowel and colon. VCE is a non-invasive procedure that has been tremendously evaluated for various gastrointestinal disorders, particularly small intestinal bleeding. There are specific contraindications and complications of VCE. This procedure has the technical part and video reading part. Newer software programs will come to reduce the reading time. Artificial intelligence is also coming for quick and accurate diagnosis of any positive findings during VCE. VCE is an important diagnostic test in the field of gastroenterology. Although it is an addition to optical endoscopic procedures to visualize the gastrointestinal mucosa, it has advantages and disadvantages.

Endorobots for Colonoscopy: Design Challenges and Available Technologies

Colorectal cancer (CRC) is the second most common cause of cancer death worldwide, after lung cancer (Sung et al., 2021). Early stage detection is key to increase the survival rate. Colonoscopy remains to be the gold standard procedure due to its dual capability to optically inspect the entire colonic mucosa and to perform interventional procedures at the same time. However, this causes pain and discomfort, whereby it requires sedation or anaesthesia of the patient. It is a difficult procedure to perform that can cause damage to the colonic wall in some cases. Development of new technologies aims to overcome the current limitations on colonoscopy by using advancements in endorobotics research. The design of these advanced medical devices is challenging because of the limited space of the lumen, the contorted shape, and the long tract of the large bowel. The force applied to the colonic wall needs to be controlled to avoid collateral effects such as injuries to the colonic mucosa and pain during the procedure. This article discusses the current challenges in the colonoscopy procedure, the available locomotion technologies for endorobots used in colonoscopy at a prototype level and the commercial products available.

Video Capsule Endoscopy and Ingestible Electronics: Emerging Trends in Sensors, Circuits, Materials, Telemetry, Optics, and Rapid Reading Software

Real-time monitoring of the gastrointestinal tract in a safe and comfortable manner is valuable for the diagnosis and therapy of many diseases. Within this realm, our review captures the trends in ingestible capsule systems with a focus on hardware and software technologies used for capsule endoscopy and remote patient monitoring. We introduce the structure and functions of the gastrointestinal tract, and the FDA guidelines for ingestible wireless telemetric medical devices. We survey the advanced features incorporated in ingestible capsule systems, such as microrobotics, closed-loop feedback, physiological sensing, nerve stimulation, sampling and delivery, panoramic imaging with adaptive frame rates, and rapid reading software. Examples of experimental and commercialized capsule systems are presented with descriptions of their sensors, devices, and circuits for gastrointestinal health monitoring. We also show the recent research in biocompatible materials and batteries, edible electronics, and alternative energy sources for ingestible capsule systems. The results from clinical studies are discussed for the assessment of key performance indicators related to the safety and effectiveness of ingestible capsule procedures. Lastly, the present challenges and outlook are summarized with respect to the risks to health, clinical testing and approval process, and technology adoption by patients and clinicians.

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

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

Balloon-Assisted Colonoscopy after Incomplete Conventional Colonoscopy-Experience from Two European Centres with A Comprehensive Review of the Literature

Background: Conventional colonoscopy (CC) allows access for colonic investigation and intervention; in the small group in whom CC is unsuccessful alternative imaging is often sufficient. There remains a subset, however, requiring full colonic visualisation or intervention. Balloon-assisted colonoscopy (BAC) gives a further option when access is difficult. Aims: This study aims to present the experience with BAC of two European tertiary referral centres. Methods: Procedures were carried out under local protocol over 15-years (2006–2020). Markers of procedural quality such as caecal intubation, complications and comfort were retrospectively compiled and analysed. Published evidence was summarised for comparison. Results: 122 procedures were undertaken, with polyps the most frequent indication and 90.2% having at least one previously incomplete CC. Features associated with difficult colonoscopy were common, including intraabdominal surgery (32.0%). 92.6% reached the caecum; completion was higher (96.3%) in those failing CC due to discomfort and lower in those failing due to anatomical difficulties (90.7%) or previous surgery (84.6%). Mean time to the caecum was 20.9 minutes and mean midazolam and fentanyl doses were 2.6 mg and 49.9 µg with low discomfort scores. Conclusion(s): Balloon-assisted colonoscopy is successful in >90% of patients, is well-tolerated, and is safe.

Adherence to European Society of Gastrointestinal Endoscopy recommendations of endoscopists performing small bowel capsule endoscopy in Italy

BACKGROUND

The European Society of Gastrointestinal Endoscopy (ESGE) has recently issued a technical review focused on small bowel capsule endoscopy (SBCE).

AIM

To compare SBCE current practice in Italy to ESGE technical recommendations.

MATERIAL AND METHODS

A dedicated per-centre semi-quantitative questionnaire was prepared by a group of SBCE experts. One-hundred-fifty Centres were invited to participate in the data collection concerning SBCEs performed between June 2016 and June 2017. Data were compared with ESGE recommendations.

RESULTS

120 Centres participated in the data collection. Current practices agreed with ESGE recommendations in 56.3% (9/16) of the issues evaluated. Differences between ESGE recommendations and current practice concerned the management of patients with pacemakers or cardiac implantable defibrillators (which was in agreement with ESGE recommendations in 31.7% and 15.8% of Centres, respectively), the SBCE setting (only 51% of SBCEs were performed as outpatients procedures), the assessment of capsule excretion (timing and modality were in agreement with ESGE recommendation in 20.0% of Centres), and in the involvement of trained nurses or fellows in training as pre-readers (7/120; 5.8%).

CONCLUSIONS

Although SBCE is widely used and largely available in Italy, there are still some technical, practical and organizational issues that can be modified to bridge the gap between current practice and ESGE guideline recommendations.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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