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INCOMPLETE SMALL BOWEL CAPSULE ENDOSCOPY: RISK FACTORS AND COST-EFFECTIVENESS OF REAL-TIME MONITORING

Matilde Topa 1, Alessandro Rimondi 1, Andrea Sorge 1, Veronica Smania 1, Lucia Scaramella 2, Nicoletta Nandi 1, Flaminia Cavallaro 2, Maurizio Vecchi 1, Luca Elli 2, Gian Eugenio Tontini 1

Affiliations

1 Università degli Studi di Milano, Milan, Italy

2 Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy

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Abstract

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).

Conference

UEG Week Copenhagen 2023

Topics

Oesophagus

Submission format

Abstract

Session

Endoscopy and beyond (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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	EVT (n=22)	SEMS (n=22)	p-value
Total number of procedures	125	78
Adjuvant endoscopic treatment	1 (4.5%)	5 (22.7%)	0.07
Mean number of procedures per patient	4.4 ± 3.2	2.2 ± 1.6	0.05
Hospitalization (days)	45.3 ± 18.0	52.6 ± 29.2	0.01
Efficacy outcomes Resolution Failure Re-do surgery In-hospital mortality	20 (91%) 2 (9%) 1(4.5%) 1 (4.5%)	16 (72.7%) 6 (27.3%) 4 (18.2%) 1 (9.1%)	0.11
Technical success*	125 (100%)	78 (100%)	1.00
Intraprocedural AE* Bleeding Perforation Sedation-related Ulcers	2 (1.6%) 1 (0.8%) 0 (0%) 1 (0.8%) 0	2 (2.5%) 0 0 0 2 (0.9%)	0.64
Migration*	2 (1.6%)	12 (15.3%)	0.0001
Follow-up (days)	396.9 ± 89.3	556.7 ± 178.4

	Colonoscopy Finding Marked “Normal”	Colonoscopy -Moderate to Severe inflammation	Histopathology Moderate-Severe inflammation	Sensitivity	Specificity	P value
RECTUM	81%	19%	26%	68.18	94.87	0.028
COLON	86%	14%	27.4%	45.83	96.05	0.019
ILEUM	57%	17%	19%	85.71	94.19	0.021