Introduction

Auditing processes and outcomes is essential for the quality of healthcare services. Performance metrics for small bowel capsule endoscopy (SBCE) were defined by the European (ESGE) and American (ASGE) Societies in 2018 and 2022, respectively. This study aimed to evaluate compliance with these parameters in the periods following their publication.

Aims & Methods

Patients who underwent SBCE in two periods (2018-2019 and 2022-2023) in a tertiary Portuguese hospital were retrospectively evaluated. The bowel preparation protocols and the gastroenterologists responsible for video evaluation were the same in both periods. Clinical and procedure-related data were collected.

Results

A total of 348 capsule enteroscopies were included, 241 performed in the first period (2018-2019) and 107 in the second (2022-2023). All ESGE criteria were met in 63.9% of cases in the first period, and in 84.1% in the second. ASGE parameters were met in 59.8% and 73.8%, respectively. The indication was appropriate in 93.7%, with no difference between periods (p=0.180). In cases of overt bleeding, the timing was appropriate in 62.5% (considering 48 hours) or 84.4% (14 days), with a trend towards performing SBCE earlier in the second period. Patency testing was performed in 85.9% of patients with risk factors for retention, with significant improvement in the second period (80.1 versus 99.0%, p<0.01). Intestinal preparation was performed in 90.8% and was classified as adequate in 82.2% (p=0.132). Documentation of transit time was higher in the second period (74.3% versus 88.8%, p=0.04), while percentages of incomplete small bowel study (3.7%) or retention (0.9%), description of complications (97.1%), and written post-procedure recommendations (94.5%) did not differ. The overall diagnostic yield was 51.7% (p=0.536), with the use of standardized terminology being higher in the second period (71.7% versus 98.1%, p<0.01).

Conclusion

Significant improvement was observed in quality metrics between periods. However, there is room for improvement in the selection of patients for patency testing, timely placement in cases of bleeding (target >90%), and description of transit times (target >98%).

References

Leighton, Jonathan A., et al. "Quality indicators for capsule endoscopy and deep enteroscopy." Gastrointestinal Endoscopy 96.5 (2022): 693-711.
Spada, Cristiano, et al. "Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative." Endoscopy 51.06 (2019): 574-598.

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

Capsule endoscopy is the first-line examination for digestive bleeding with likely origin in the small bowel, in hemodynamically stable patients. In the 2022 update, ESGE guidelines recommend that, in the context of overt bleeding, capsule enteroscopy should be performed as soon as possible, ideally within the first 48 hours. In the previous guidelines, published in 2015, the recommended window was 14 days.

Aims & Methods

This study aimed to evaluate the improvement in yield offered by the new recommendations regarding the timing of urgent capsule enteroscopy. Patients with suspected overt middle gastrointestinal bleeding between January 2005 and November 2022 were retrospectively analyzed. Diagnostic and therapeutic yield, rebleeding rate, and mortality were compared when capsule enteroscopy was performed within the first 48 hours, within the first 14 days, or between the 3rd and 14th day after admission.

Results

A total of 138 patients were included (58.7% men, median age 66 years), 87 of whom (63.0%) underwent capsule enteroscopy within the first 48 hours after hospital admission. The median follow-up was 55 months (5-180). The diagnostic yield (presence of blood or lesions with bleeding potential) was slightly higher when capsule enteroscopy was performed within the first 48 hours (81.6% versus 76.5%, p=0.349). On the other hand, capsule enteroscopy within the first 48 hours was significantly associated with higher therapeutic yield (endoscopic, radiologic, or surgical treatment) - 54.0% versus 39.2%, p=0.02. The rebleeding rate was significantly lower in patients undergoing enteroscopy within 48 hours after admission (19.5% versus 29.4%, p=0.04). On the other hand, overall mortality at 36 months did not differ between strategies (21.8% and 25.5%, p=0.401).

Conclusion

Performing capsule endoscopy within the first 48 hours, as recommended by recently published guidelines, is associated with favourable short- and long-term clinical outcomes.

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.

Introduction

Small-bowel capsule endoscopy (SBCE) is a first-line examination tool for the study of the small bowel (SB), yet the optimal bowel preparation regimen remains uncertain. Despite multiple systematic reviews & meta-analyses evaluating the role of purgative versus fasting-only preparation regimens for enhancing mucosal visualisation, findings have been inconsistent, resulting in considerable variation in clinical practice. This emphasises the need for a comprehensive and unified synthesis of existing evidence to standardise the preparation regimen, ultimately enhancing the diagnostic performance of SBCE.

Aims & Methods

The primary outcome was to assess SB mucosal cleansing quality, diagnostic yield, and SBCE completion rate when comparing purgative regimens to a fasting-only regimen. Secondary outcomes included SB transit time (SBTT) and the influence of preparation timing and fasting duration on procedural efficacy.
We performed a comprehensive systematic search of 3 databases (EMBASE, MEDLINE, and PubMed) to identify systematic reviews (SR), with or without meta-analysis, comparing purgative versus fasting preparation regimens in adult patients undergoing SBCE. The methodological quality of the included SRs was assessed using the AMSTAR-2 tool, and the certainty of evidence was appraised according to the GRADE approach. To assess overlap between SRs, we applied the Corrected Covered Area (CCA) method. Due to substantial overlap of primary studies across SRs, we conducted an umbrella meta-analysis using a random effect model following data extraction and synthesis from all the unique primary studies included within the SRs.

Results

Ten SRs comprising 57 primary studies and 9,636 participants were included after duplicate removal. Compared to fasting, purgative preparation showed only a marginal improvement in SBCE completion rate (RR = 1.02; 95% CI: 1.00–1.02), but significantly improved cleansing adequacy (RR = 1.26; 95% CI: 1.14–1.39); polyethylene glycol (PEG) being the only laxative demonstrating a significant effect. Regarding dosage timing, same-day laxative dosing showed the most significant benefit in cleansing quality (RR = 1.75; 95% CI: 1.33–2.29), followed by post-ingestion regimens (RR = 1.59; 95% CI: 1.17–2.16). Post-capsule ingestion of laxatives also significantly accelerated SBTT. While the overall diagnostic yield did not differ with purgative use, subgroup analysis revealed a statistically significant benefit with same-day preparation (RR = 1.30; 95% CI: 1.07–1.57). Additionally, no difference in cleansing quality was observed between the 2L and 4L PEG subgroups.

Conclusion

This study demonstrates that purge, particularly with PEG, is superior to fasting-only regimens in achieving adequate SB cleansing and completion in SBCE. Notably, a same-day regimen significantly enhances both cleansing quality and diagnostic yield, suggesting that the timing of ingestion may be more critical than the laxative’s dosage.

References

1. Belsey J, Crosta C, Epstein O, Fischbach W, Layer P, Parente F, et al. Meta-analysis: efficacy of small bowel preparation for small bowel video capsule endoscopy. Curr Med Res Opin. 2012;28(12):1883-90.
2. Gkolfakis P, Tziatzios G, Dimitriadis GD, Triantafyllou K. Meta-analysis of randomized controlled trials challenging the usefulness of purgative preparation before small-bowel video capsule endoscopy. Endoscopy. 2018;50(7):671-83.
3. Kotwal VS, Attar BM, Gupta S, Agarwal R. Should bowel preparation, antifoaming agents, or prokinetics be used before video capsule endoscopy? A systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2014;26(2):137-45.
4. Marmo C, Riccioni ME, Pennazio M, Antonelli G, Spada C, Costamagna G. Small bowel cleansing for capsule endoscopy, systematic review and meta- analysis: Timing is the real issue. Dig Liver Dis. 2023;55(4):454-63.
5. Niv Y. Efficiency of bowel preparation for capsule endoscopy examination: a meta-analysis. World J Gastroenterol. 2008;14(9):1313-7.
6. Rokkas T, Papaxoinis K, Triantafyllou K, Pistiolas D, Ladas SD. Does purgative preparation influence the diagnostic yield of small bowel video capsule endoscopy?: A meta-analysis. Am J Gastroenterol. 2009;104(1):219-27.
7. Wu S, Gao YJ, Ge ZZ. Optimal use of polyethylene glycol for preparation of small bowel video capsule endoscopy: a network meta-analysis. Curr Med Res Opin. 2017;33(6):1149-54.

Disclosure

Nil

Introduction

The latest ESGE technical review guideline advocates real-time monitoring in the first hour of small bowel capsule endoscopy (SBCE) to ensure entire small bowel visualization. However, a survey demonstrated poor adherence to this statement in clinical practice, and supporting data are scarce.

Aims & Methods

We aimed to evaluate predictive factors of incomplete SBCE and to ascertain the importance and cost-effectiveness of real-time monitoring.
We retrospectively included consecutive patients who ingested SBCE (PillCam SB3) at our tertiary referral center from 2013 to 2020. Clinical and endoscopic characteristics were analyzed. Real-time monitoring was not applied according to local protocol. Prolonged gastric transit time (GTT) was defined when the capsule crossed the pylorus > 2 hours from ingestion, and prolonged small bowel transit time (SBTT) when cecum was reached > 6 hours from pylorus crossing. A logistic regression analysis was done to find significative risk factors associated with incomplete SBCE. Exclusion criteria included: capsule retention, endoscopic delivery of capsule, and major technical issues (i.e., eating within a standard gastric transit time of the capsule or major recording issues).

Results

A total of 859 SBCE were analyzed, with a completion rate of 94.5%. A prolonged GTT and a prolonged SBTT were found in respectively 46 (5.4%) and 152 (17.6%) procedures. At multivariate analysis, one modifiable (prolonged GTT[p=0.02]) and two unmodifiable risk factors (inpatient status [p<0.01] and history of incomplete SBCE [p=0.02]) were associated with a higher rate of incomplete SBCE, with increased odds ratio of 3.0 (CI95%= 1.2-7.4), 2.3 (CI95%= 1.2–4.2), and 3.7 (CI95%= 1.2-11.9), respectively. Pretest probability of SBCE completion rate was 90.5% and 95.7% in patients with and without unmodifiable risk factors (p=0.01).
Considering the rates of prolonged GTT, the number of patients to be monitored with real-time viewer to identify and treat one patient with prolonged GTT is 14.5 in patients with unmodifiable risk factors for incomplete SBCE and 20.3 in patients without risk factors for incomplete SBCE (p=0.27).
Direct cost for 1-hour real-time monitoring and intervention in case of prolonged GTT (i.e., dedicated room, nurse, +/- metoclopramide and IV access) are equal to circa 35 €. If all patients of our cohort would undergo real-time monitoring, the expense would be equal to 30065 €. Given that in our cohort 6 patients had an incomplete SBCE, the cost of RTM to prevent one incomplete SBCE would be equal to 5010 €. If RTM would be limited to patients with unmodifiable risk factors for incomplete SBCE, the total cost would be equal to 6615 €. In this sub-group only 2 patients had an incomplete SBCE, therefore, to prevent one incomplete SBCE, the total expense would be 3307 €.

Baseline Characteristics	Incomplete SBCE Patients number = 47	Complete SBCE Patients number = 812	p-value
Age (median, years)	63.0 (IQR 50.0 – 70.0)	58.0 (IQR 42.0 – 72.0)	0.36
Female	61.7% (29)	60.6% (492)	1
Inpatient	36.2% (17)	19.2 % (156)	<0.01*
Diabetes Narcotics ESKD Neurological disorders Small bowel Crohn’s disease	10.6% (5) 8.5% (4) 2.1% (1) 4.3% (2) 2.1% (1)	9.7% (79) 5.2% (42) 5.8% (47) 4.1% (33) 1.1% (9)	0.80 0.31 0.51 1 0.43
Prolonged gastric transit time	12.8% (6)	4.9% (40)	0.02*
Previous incomplete SBCE	8.5% (4)	2.1% (17)	0.02*

Conclusion

The inpatient status, a prolonged GTT and a previous incomplete SBCE are risk factors for incomplete SBCE. According to our direct costs analysis, the number needed to treat one prolonged GTT to decrease the rate of incomplete SBCE appears to be cost-effective in patients with unmodifiable risk factors (i.e., inpatient status and history of incomplete SBCE).