Literature review and recommendations for clinical application of Colon Capsule Endoscopy

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

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

A global perspective on capsule endoscopy

A search of the internet today to quantify the estimated value of capsules from a global perspective, easily delivers figures stating around $200 million in 2014 to about $400 million by 2020, which would be approximately 10% of the gastrointestinal endoscopic market. Is this a steep rise within just six years or could the capsule market do even better? What chances does this offer and what are the key aspects for future success? By 2020, more than 1 billion people are aged sixty or older and around one third of them will live in what the UN calls "more developed regions". Naturally, this brings an increased demand for colorectal cancer screening and surgery. But keeping in mind that basically every healthcare system, in any country, is already operating at its limits, how do we secure future treatment for a growing community? Surely more competition will steadily bring down prices for capsules. However, that does not ease the amount of time that is spent to properly read any video and issue a valid diagnosis for every patient. This article intends to give an overview about the current global market for capsule endoscopy (CE) with a perspective on typical patients, their indications, and how the capsules are used and by whom. Further aspects, such as standardization of training, reading and future trends will also be elaborated on.

Diagnostic capability of colon capsule endoscopy for advanced colorectal cancer: A pilot study

BACKGROUND AND AIM

Colon capsule endoscopy (CCE) is a safe and effective method for detecting lesions in the colon. However, the sensitivity of CCE in detecting advanced colorectal cancer (CRC) has not been sufficiently evaluated. Therefore, the aim of the present study was to assess the sensitivity of CCE in detecting advanced CRC.

METHODS

Patients previously diagnosed with advanced CRC by conventional colonoscopy underwent CCE. Primary outcome measure was the sensitivity of CCE in detecting advanced CRC per patient and per lesion. Secondary parameters measured were the sensitivity of CCE in detecting polyps ≥6 mm and ≥10 mm in size in a per-lesion analysis and the safety of CCE.

RESULTS

Of the 21 advanced CRC lesions in 20 patients, 17 were detected by CCE. The per-patient and per-lesion sensitivities of CCE for detecting advanced CRC lesions were 85% (95% confidence interval [CI]: 62-97%) and 81% (95% CI: 58-95%), respectively. All advanced CRC lesions were diagnosed in the accessible region by CCE while the capsule was still functional. A significant association was found between incomplete CCE and failure to diagnose advanced CRC. No severe adverse events occurred.

CONCLUSION

The diagnostic capability of CCE in detecting advanced CRC was limited in cases of procedure incompletion. Refining procedures to increase CCE procedure completion rates are required to enhance CRC detection.

Capsule endoscopy--not just for the small bowel: a review

Video capsule endoscopy is being increasingly used to investigate the esophagus and colon as well as the small bowel. With the advancement of technology used in capsule endoscopy there have been marked improvements in diagnostic rates for colon capsule endoscopy in the detection of colonic polyps and colorectal cancer. It is also being increasingly used in the field if inflammatory bowel disease to investigate for mucosal inflammation and could potentially be used to assess mucosal healing. It also has role in completing the evaluation of colonic pathology in those in whom colonoscopy is incomplete. Esophageal capsule is preferred by patients over esophagogastroduodenoscopy (EGD) but as yet does not rival EGD in terms of diagnostic accuracy however the advent of magnetically steerable capsules may improve this. This review covers advances in the field of colon and esophageal capsule endoscopy; it covers diagnostic capabilities of these 2 tools as well as technical aspects of both procedures and preparation.

Current status of capsule endoscopy through a whole digestive tract

More than a decade has passed since small-bowel capsule endoscopy (CE) was first reported. Small-bowel CE is a non-invasive tool that allows visualization of the entire small-intestinal mucosa and facilitates detection of small-intestinal abnormalities. Several studies have shown benefit of small-bowel CE for certain disorders. Because it is non-invasive, CE has been applied to other organs including the esophagus, stomach, and colon. The main indications for esophageal CE (ECE) are screening for gastroesophageal reflux disease/Barrett's esophagus, and esophageal varices. However, the clinical benefit of ECE is unconfirmed. Magnetically guided CE (MGCE) was developed to visualize the gastric mucosa. MGCE is a new concept with room for improvement of capsule navigation and the preparation protocol. Recently, two new small-bowel CE tools were released. First-generation colon CE (CCE-1) has moderate sensitivity and specificity compared with colonoscopy for colorectal neoplasia surveillance. To obtain higher accuracy, a second-generation CCE (CCE-2) was developed with a high sensitivity for detecting clinically relevant polypoid lesions. A possible application of CCE is for inflammatory bowel disease. In the near future, CE may include diagnostic and therapeutic functions such as magnifying endoscopy systems, targeted biopsy forceps, and drug delivery systems.

One-day versus two-day cleansing for colon capsule endoscopy: a prospective randomized pilot study

BACKGROUND

Standard bowel cleansing for colon capsule endoscopy (CCE) requires a liquid diet and bowel laxatives for at least 2 days, which is a major drawback of this procedure and affects tolerance and acceptability.

OBJECTIVE

To compare the quality of colon cleanliness achieved with one-day versus two-day bowel preparation in outpatients undergoing CCE.

METHODS

Patients were randomly assigned to one of two groups: group I (one-day schedule, n=20) received a fiber-free diet and 3 L of polyethylene glycol (PEG) on day 0; group II (two-day schedule, n=20) received a liquid diet and 3 L of PEG in the evening of day -1, and 1L of PEG in the early morning of day 0. In both groups, the patients received 15 mg bisacodyl on day -1 and one or two additional sodium phosphate (NaP) boosters following capsule ingestion. Each colon segment was assessed for cleanliness using a four-point grading scale (excellent=1, good=2, fair=3, and poor=4). For the final analysis, colon cleanliness was rated as adequate (good or excellent) or inadequate (fair or poor).

RESULTS

Overall colon cleanliness was adequate in 94% (CI 91-97) of patients in group I versus 80% (CI 72-88) in group II (P=0.27). No significant differences were observed in the per-segment quality of colon cleansing between the two groups. CCE reached the rectum in 80% (CI 73-87) of patients in group I versus 75% (CI 67-83) in group II (p=0.59).

CONCLUSION

The quality of colon cleanliness achieved with one-day bowel preparation is equivalent to that of the standard two-day schedule in patients undergoing CCE.

New platforms and devices in colonoscopy

Gastrointestinal endoscopy is a rapidly evolving field. Techniques in endoscopy continue to become more sophisticated, as do the devices and platforms, particularly in colonoscopy and endoscopic resection. This article reviews new platforms for endoscopic imaging of the colon, and discusses new endoscopic accessories and developments in endoscopic resection.

Effects of colon capsule endoscopy on medical decision making in patients with incomplete colonoscopies

BACKGROUND & AIMS

Colon capsule endoscopy (CCE) is an orally ingested colon imaging tool used to evaluate patients with colonic disease. We evaluated the efficacy of CCE in helping physicians make decisions about patients with incomplete conventional colonoscopies (ICCs).

METHODS

In a prospective study, we analyzed data from 34 patients with nonocclusive ICC who were eligible for CCE between May 2010 and April 2011; patients with colectomy, occlusive lesions, or inadequate bowel cleansing for the colonoscopy were excluded. Two experienced observers who were blinded to colonoscopy findings analyzed the CCE data. Four months later, medical records were reviewed to determine the effects of CCE on medical decision making. CCE was considered conclusive when the findings facilitated a medical decision.

RESULTS

Bowel cleanliness was good or excellent for 22 patients (64.7%). CCE exceeded the most proximal point reached by conventional colonoscopy in 29 patients (85.3%). CCE findings allowed formulation of a specific medical plan for 20 patients (58.8%); 12 (35.2%) had irrelevant or no lesions, so the study was concluded; 7 (20.5%) underwent polypectomy or surgery for advanced colorectal neoplasia; and 1 (3%) was treated for Crohn's disease. Inconclusive CCEs resulted from poor preparation of the bowel (n = 12) and excessively slow (n = 1) or rapid (n = 1) capsule transit.

CONCLUSIONS

CCE might be an alternative procedure to complete colon examination in patients with nonocclusive ICC.

The race for mainstream gastrointestinal endoscopy: frontrunners

In recent years, gastrointestinal endoscopy has evolved and branched out from a primary naked-eye diagnostic technique to a multitude of sophisticated investigative and therapeutic procedures. While many of the new endoscopic techniques are currently too complex or expensive to make it to mainstream clinical practice, others are already bringing major progress to the management of digestive diseases. In this review we will discuss a selected group of the emerging techniques and technologies used to increase the diagnostic yield in the colon and small intestine, including Third Eye® Retroscopes®, colon capsule endoscopy, spiral enteroscopy and confocal laser endomicroscopy. We will also discuss over-the-scope clip devices, a relatively simple and inexpensive tool potentially capable of noninvasive closing intestinal perforations and allowing the removal of infiltrating tumors.

Role of capsule endoscopy as a screening tool for colorectal cancer

SUMMARY Colon capsule endoscopy is currently under evaluation to become a noninvasive colorectal cancer screening test. The sensitivity and specificity of colon capsule endoscopy for colorectal polyps and cancer are improving with ongoing technical refinements to the capsule and recording device, with sensitivity as high as 84% for polyps greater than 1 mm in size. Specificity for smaller polyps, however, remains suboptimal. Colon capsule endoscopy requires extensive bowel preparation to ensure adequate colon cleansing and complete colonic evaluation. The complication rate for colon capsule endoscopy is unclear, but may be lower than that for small bowel capsule endoscopy. The role of colon capsule endoscopy in colorectal cancer screening has not been fully defined, as technical, logistical and implementation issues remain.

Accuracy and safety of second-generation PillCam COLON capsule for colorectal polyp detection

PillCam COLON capsule endoscopy (CCE) (Given Imaging Ltd, Yoqneam, Israel) is one of the most recent diagnostic, endoscopic technologies designed to explore the colon. CCE is a noninvasive, patient-friendly technique that is able to explore the colon without requiring sedation and air insufflation. The first generation of CCE was released onto the market in 2006 and although it generated great enthusiasm, it showed suboptimal accuracy. Recently, a second-generation system (PillCam COLON 2) (CCE-2) has been developed to increase sensitivity for colorectal polyp detection. In this review, accuracy and safety data for CCE-2 are analyzed.