Introduction

Small bowel (SB) capsule endoscopy (CE) is a first line procedure for exploring the SB and has numerous indications. Endoscopic GastroIntestinal PlacemenT (EGIPT) of SB CE is sometimes necessary. The experience of EGIPT is large in the pediatric population but limited in adults.

Aims & Methods

We aimed to describe the safety, efficacy and outcomes of EGIPT of SB CE in adult patients.The international CApsule endoscopy REsearch (iCARE) group set up a retrospective multicentric study. Patients over 18 year-old who underwent EGIPT of SB CE before May 2022 were included. Data were collected from medical records and capsule recordings of each participating center. The primary endpoint was the technical success rate of the EGIPT procedures. The secondary endpoints included the adverse events (AE) rate, the duration of EGIPT procedure, the small bowel transit time (SBTT), the completion rate (CR), and the diagnostic yield (DY).

Results

A total of 630 patients were included (mean age 62.5 years old, 55.9% female) from 29 centers. Main indication for SB CE was suspected SB bleeding (70.6%). An impossible oral ingestion (41.8%) and a prolonged lodging of previous CE in the upper GI tract (34.5%) were the two most frequent indications for EGIPT. EGIPT technical success was achieved in 610 procedures (96.8%). Anesthesia was an independent factor of technical success (p<0.0001). AE occurred for 94 patients (14.9%), being severe in three patients. No death occurred. Mean procedure time was 7.2 ± 37.0 minutes. When technically successful, mean SBTT was 278.1 ± 137.9 minutes and EGIPT was associated with a high SB CE CR (84.4%) and with a substantial DY (61.1%). Completion rate was significantly higher when the capsule was delivered in the SB compared to when delivered in the stomach (p<0.0001).

Conclusion

EGIPT of SB CE is highly feasible, safe and comes with high completion rate and diagnostic yield. SBTT seems longer than when CE is orally ingested (220-250 minutes, according to largest series in the literature), most likely related to patient sedation. However, completion rate (84.4%) after SB CE-EGIPT seems similar to that after oral ingestion (83.0% in largest series) whereas DY seems higher (probably for better selected patients).
When indicated, EGIPT should be performed under anesthesia and the capsule should be delivered in the duodenum rather than in the stomach, for better SB examination outcomes.

References

1. Nass KJ, et al. Gastrointest Endosc. 2022;95(6):1078-1085
2. Liao Z, et al. Gastrointest Endosc. 2010;71(2):280-6
3. Cortegoso Valdivia P, et al. Diagnostics (Basel). 2022;12(5):1105.

Disclosure

Lecture fees for Medtronic

Introduction

Small bowel mucosal pathologies are a diagnostic challenge to clinicians. Video Capsule endoscopy (VCE) is currently the study of choice for the evaluation of the small intestine. Data on the effects of bowel preparation on mucosal visualization and diagnostic yields is scant. Most published studies suggest that bowel preparation methods (2-litre vs. 4-litre) are not superior.

Aims & Methods

This retrospective cross-sectional study analyzed data from 2018 to 2023. The main investigator reassessed all VCEs using 3-6 frames per second, single-image viewing. A nursing officer closely supervised the bowel preparation, adhering to unit protocols. The small intestine was divided into proximal and distal small intestines depending on the small intestinal transit time, and mucosal visualization was assessed according to the Brotz scoring system. Statistical significance was determined by Fisher’s exact (F) test and Chi-square (X2) test. A value of <0.05 was considered as significant.

Results

The sample size was 705, with a mean age of 56.9 (SD=18.2). 60.6% (n=427) were males. 39.3% had overt GI bleeding, 36.0% had occult GI bleeding, 16.3% had abdominal pain, 4.3% had chronic diarrhoea and 4.0 % had loss of weight as the indication for VCE. The mean gastric transit time was 01:13:52 ± 01:28:14 (hr.min.sec.), and the small intestine transit time mean was 05:12:59 ± 01:58:24 (hr.min.sec.). 38.3% consumed 59g x 2 PEG preparation in 2L of water; 11.9% consumed 59g x 3 PEG preparation in 3L of water; and 49.6% consumed 59g x 4 PEG preparation in 4L of water before VCE, followed by 6 hours of fasting. Mucosal visualization in the distal small intestine was significantly associated with the amount of PEG used, with 3×59 in 3 L of water accounting for a significantly higher percentage (32.1%) of adequate visualization (X2=11.82, p=0.003).However there was no significant association between the amount of PEG used and proximal bowel visualization (X²=5.38, p=0.068). The amount of PEG administered significantly influenced transit times (F=5.781, p=0.003). A post hoc Tukey test revealed that the use of 4x59g of PEG in 4L of water significantly increased small intestinal transit time compared to lower doses.
The diagnostic yield was 65.6%. 34.4% had P0 lesions, 21.1% had P1 lesions, and 44.5% had P2 lesions. 26.8% had vascular lesions (17.2% in the proximal and 5.6% in the distal and 3.0% in both proximal and distal small intestine), 32.6% had inflammatory lesions (15.4% in the proximal, 15.1% in the distal, and 2.1% in both proximal and distal small intestine), worm infestation 1.1%, and malignancies 2.4%, which were among the most common findings. Ulcers, the most common inflammatory lesion (22.3%), equally affected the proximal (10.2%) and distal (10.9%) small intestines. Additionally, patients who had poor mucosal visualization (Brotz < 7) had significantly lower odds of P1/P2 lesions compared to those with good mucosal visualization (Brotz ≥ 7) (OR = 0.573, SE = 0.187, p = 0.003).

Conclusion

VCE has a diagnostic yield of 65.6%, while the proximal small intestine was the most common area involved, and inflammatory lesions were the most common lesions in Sri Lankans. Ulcers were the most common inflammatory lesion, which were equally involved in both the proximal and distal small intestine. Higher PEG and water administration significantly increased the transit time, and 3× 59g PEG in 3L of water had a statistically significant effect on mucosal visualization in the distal small intestine. Poor mucosal visualization had significantly lower odds of P1/P2 lesions.

Introduction

Capsule endoscopy (CE) is an important non-invasive diagnostic modality for the evaluation of small bowel and colon. However, in patients with gastrointestinal tract anatomy altered by surgical interventions, there can be a higher risk of incomplete examination of small bowel and colon.

Aims & Methods

The aim of our study was to evaluate the rate of complete examination and diagnostic yield of CE, in patients with previous gastrointestinal surgery, as well as the impact of endoscopic placement of CE using the AdvanCE device.
Retrospective, cohort study, including patients submitted to CE of the small bowel or colon, detailing patients with previous gastrointestinal surgeries and with endoscopic placement of CE.

Results

A total of 642 patients was included, 17 with previous gastrointestinal surgery (2.6%), from which 9 with gastric bypass and Y-de-Roux (with 3 having esophagojejunostomy and 6 gastrojejunostomy), 3 patients with Bilroth II, 2 with Bilroth I e 3 patients with sleeve gastrectomy.
Endoscopic placement of CE was performed at the discretion of the responsible gastroenterologist and occurred in 8 patients (1.2%). It was 13.3 times more likely to be performed in patients with previous gastrointestinal surgery (11.8% vs 1.0%, p=0.017).
In patients without endoscopic placement of CE, the rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was comparable between those with and without previous gastrointestinal surgery: 86.7% vs 85.3% (p=1.000), 73.3% vs 78.1% (p=0.751) e 40% vs 38% (p=0.875), respectively.
In patients with gastrointestinal surgery, the rate of complete examination of the gastrointestinal tract was comparable between patients with and without endoscopic placement of CE: 50.0% vs 86.7% (p=0.331). The rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was not influenced by the different types of surgery, considering patients with gastric bypass vs Y-de-Roux vs Bilroth II: 75.0% vs 80.0% vs 66.7% (p=0.915), 50.0% vs 60.0% vs 66.7% (p=0.902) e 25.0% vs 20.0% vs 66.7% (p=0.363), respectively.

Conclusion

CE is effective, even in patients with previous gastrointestinal surgery, with diagnostic yield and rate of complete examination of the gastrointestinal tract similar to other patients, regardless of the type of surgery. Endoscopic placement of CE with AdvanCE device does not seem to improve outcomes in patients with previous gastrointestinal surgery.

Introduction

The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized.

Aims & Methods

Compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for intestinal preparation for SBCE.
A prospective, multicentre, randomized clinical trial including consecutive patients submitted to SBCE was conducted. All patients were instructed to comply with a clear liquid diet and 12-hour fasting before the exam. After ingesting water and 100 mg of simethicone and swallowing the capsule, once it reached the small bowel, patients ingested a booster, randomized into one of three protocols: 1) 1 liter of polyethylene glycol (PEG), 2) 1 liter of PEG and ascorbic acid, 3) 1 liter of water. The patients’ bowel preparation was evaluated with SB-CLEAR. Each patient responded to a questionnaire about their tolerability.

Results

A total of 261 patients were included, 96 patients (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (p=0.655, p=0.193 and p=0.589, respectively). The overall SB-CLEAR score was similar among the protocols (p=0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5±0.1 vs 2: 2.6±0.1 vs 3: 2.3±0.1, p=0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (p=0.850). The patients’ reported tolerability was higher in protocol 3 (protocol 1: 2.8±0.1 vs 2: 3.0±0.2 vs 3: 0.6±0.1, p<0.001).

Conclusion

Using 1 liter of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield versus PEG with or without ascorbic acid.

Introduction

Though small bowel capsule endoscopy (SBCE) has revolutionised the investigation of the small bowel, small lesions may still go undetected.

Aims & Methods

This was a multicentre study whose primary aim was to assess rates of detection of ampulla of Vater during SBCEs and identify any statistically significant variation between different levels of expertise and different reading speeds.
De-identified SBCE videos, selected randomly, each of 15 minutes duration from the 1^st duodenal image, were uploaded on secure virtual cloud following ethical approval, data protection clearance and patient consent. Patient age, indication for endoscopy and findings were recorded. The videos were reviewed by 7 gastroenterology experts and 6 trainees from 6 European centres. Data regarding detection of ampulla of Vater (AoV) was collected. Each video was analysed initially using the mouse-wheel and then at a speed of 10 frames per second (fps). Data was inputted into SPSS and statistical significance assessed via Kappa coefficient.

Results

Data was collected from 30 patients of whom 63.3% were males and whose median age was 63.5 years +/- 7.164. Commonest indications were iron deficiency anaemia (56.7%), small bowel Crohn’s disease (16.7%) and overt GI bleeding (13.3%). All patients were given a macrogol based osmotic laxative for bowel preparation.
The following mean detection rates of Ampulla of Vater were observed:

• trainees using mouse-wheel; 35% (10.5)
• trainees using 10fps; 21.6% (6.5)
• experts using mouse-wheel; 33.8% (10.1)
• experts using 10fps; 20.4% (6.1)

On only taking into consideration the ampullas detected by the standard, mean detection rates using mouse-wheel for trainees is 68.7% and 82.1% for experts, as compared to 50% for trainees and 55% for experts using 10fps, showing a decline in detection rate with higher reading speed.
Table 1. denotes Kappa and p values obtained by comparison of standard/trainee/expert rates in detection of ampulla of Vater.

	Mouse-wheel		10fps
	Kappa	P value	Kappa	P value
Standard vs Trainees	0.347	0.2	0.400	0.2
Standard vs Experts	0.621	0.2	0.513	0.2
Trainee group	0.135	0.75	0.109	0.2
Expert group	0.493	0.98	0.482	0.2
Trainees vs Experts	0.260	0.2	0.284	0.2

Table 1. Comparison of AoV detection

Mathematical comparison of ampulla detection in mouse-wheel vs 10fps amongst trainees resulted in Kappa 0.323 (p=0.018); and amongst experts resulted in Kappa 0.414 (p=0.01).

Conclusion

The results demonstrate that the rate of concordance in the detection of the ampulla amongst experts declines with a higher speed of reviewing a SBCE. This suggests that pathology may be potentially missed at higher reading speeds especially in the first part of the small bowel where sometimes a SBCE rushes through. A slower reading speed is advisable especially in those with limited experience in reviewing a SBCE.