Acute Small Bowel Perforation Caused by Obstruction of a Novel Tag-Less AgileTM Patency Capsule

Nationwide multicenter study on adverse events associated with a patency capsule: Additional survey of appropriate use of patency capsule study

BACKGROUND AND AIM

The PillCam patency capsule (PC) without a radio frequency identification tag was released to preclude retention of the small bowel capsule endoscope (CE) in Japan in 2012. We conducted a multicenter study to determine tag-less PC-related adverse events (AEs).

METHODS

We first conducted a retrospective survey using a standardized data collection sheet for the clinical characteristics of PC-related AEs among 1096 patients collected in a prospective survey conducted between January 2013 and May 2014 (Cohort 1). Next, we retrospectively investigated additional AEs that occurred before and after Cohort 1 within the period June 2012 and December 2014 among 1482 patients (Cohort 2).

RESULTS

Of the 2578 patients who underwent PC examinations from both cohorts, 74 AEs occurred among 61 patients (2.37%). The main AEs were residual parylene coating in 25 events (0.97%), PC-induced small bowel obstruction, suspicious of impaction, in 23 events (0.89%), and CE retention even after patency confirmation in 10 events (0.39%). Residual parylene coating was significantly associated with Crohn's disease (P < 0.01). Small bowel obstruction was significantly associated with physicians with less than 1 year of experience handling the PC and previous history of postprandial abdominal pain (P < 0.01 and P < 0.03, respectively). CE retention was ascribed to erroneous judgment of PC localization in all cases.

CONCLUSIONS

This large-scale multicenter study provides evidence supporting the safety and efficiency of a PC to preclude CE retention. Accurate PC localization in patients without excretion and confirmation of previous history of postprandial abdominal pain before PC examinations is warranted (UMIN000010513).

Retention of small bowel capsule endoscopy

PURPOSE OF REVIEW

Capsule endoscopy is widely recognized as a safe and effective procedure to evaluate the small bowel and/or the colon noninvasively. Although infrequent, capsule retention is the most feared adverse event related to this technique. A better knowledge of risk factors, improvement of patients' selection and precapsule patency assessment may further contribute to reducing the incidence of capsule retention, even in patients at increased risk for this complication.

RECENT FINDINGS

This review addresses the main risk factors for capsule retention, strategies for risk reduction such as patients' selection, dedicated cross-sectional imaging and rational use of the patency capsule, as well as management options and outcomes in the case of capsule retention.

SUMMARY

Capsule retention is infrequent, and it is usually manageable conservatively with favorable clinical outcomes. Patency capsules and dedicated small-bowel cross-sectional techniques such as CT or MR enterography should be used selectively and are both effective in decreasing the rate of capsule retention. However, none of them can completely eliminate the risk of retention.

Small bowel obstruction: what a gastroenterologist needs to know

PURPOSE OF REVIEW

Intrabdominal adhesions and intestinal hernias are the commonest cause of small bowel obstruction. Small bowel diseases, which cause small bowel obstruction, are rarer and often poses a challenge to gastroenterologists to diagnose and treat. In this review, small bowel diseases, which predispose to small bowel obstruction, are focused on, and their challenges in diagnosis and treatment.

RECENT FINDINGS

Diagnosis of causes of partial small bowel obstruction is improved with computed tomography (CT) and magnetic resonance (MR) enterography. In fibrostenotic Crohn's strictures and NSAID diaphragm disease, endoscopic balloon dilatation can delay the need for surgery if the lesion is short and accessible; however, many may still inevitably require surgery. Biologic therapy may reduce the need for surgery in symptomatic small bowel Crohn's disease wherein the strictures are predominantly inflammatory. In chronic radiation enteropathy, only refractory small bowel obstruction and those with nutritional difficulties warrant surgery.

SUMMARY

Small bowel diseases causing bowel obstruction are often challenging to diagnose and require numerous investigations over a period of time, which often culminate with surgery. Use of biologics and endoscopic balloon dilatation can help to delay and prevent surgery in some instances.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

Indications and Limitations Associated with the Patency Capsule Prior to Capsule Endoscopy

The retention of the capsule used during small bowel capsule endoscopy (SBCE) is a serious complication that can occur in patients with known or suspected small bowel stenosis, and a prior evaluation of the patency of the gastrointestinal (GI) tract is therefore essential. Patency capsule (PC) is a non-diagnostic capsule the same size as the diagnostic SBCE. To date, there are no clear guidelines regarding the contraindications for undergoing a PC evaluation prior to SBCE. Each small bowel disorder has specific occasions to inhibit the progress of PC and SBCE, even though they do not have any stenotic symptoms or abnormalities on imaging. In this review, we summarize the indications and limitations of PC prior to SBCE, especially the contraindications, and discuss clinical scenarios in which even PC should be avoided, and therefore such areas of stenosis should be evaluated by alternative modalities. We thus propose this new algorithm to evaluate the patency of the GI tract for patients with suspected and known small bowel stenosis in order that they may undergo SBCE safely.

Adverse events of video capsule endoscopy over the past two decades: a systematic review and proportion meta-analysis

BACKGROUND

A full spectrum of video capsule endoscopy (VCE) adverse events over the past two decades has not been evaluated. We aimed to determine pooled rates, predictors and temporal-trend of VCE adverse events over the past two decades.

METHODS

Systematic search of PubMed and EMBASE for English-language publications reporting VCE adverse events (January 1, 2000 to March 31, 2019). Data were extracted independently by two investigators. Pooled VCE adverse event rates were calculated using the random or fixed model as appropriate. Predictors and temporal-trend of each adverse event were performed by meta-regression analyses.

RESULTS

In total, 402 studies were identified, including 108,079 VCE procedures. Rate of retention, swallow disorder, aspiration, technical failure, and procedural adverse events were 0.73% (95% confidence interval [CI] 0.59-0.89%), 0.75% (95% CI 0.43-1.13%), 0.00% (95% CI 0.00-0.00%), 0.94% (95% CI 0.65-1.28%), 0.67% (95% CI 0.32-1.10%), respectively; incomplete examination rate of esophagus, stomach, small bowel, and colon were 9.05%, 7.69%, 12.08%, 19.19%, respectively. Patency capsule reduced retention rate by 5.04%, whereas known inflammatory bowel disease increased retention rate by 4.29%. Elder was the risk and protective factor for small bowel incomplete examination (0.30%) and swallow disorder (- 0.72%), respectively. Rates of retention and small bowel incomplete examination significantly declined over time (P = .0006 and P < .0001)..

CONCLUSIONS

VCE adverse event rates were generally low, and retention and small bowel incomplete examination rates declined over the past two decades. Patients with known inflammatory bowel disease or elder should be alerted to high risk of retention or small bowel incomplete examination (PROSPERO: CRD42019139595).