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

Abstract

Small-bowel capsule endoscopy (sbce): 1: ESGE recommends that prior to SBCE patients ingest a purgative (2 L of polyethylene glycol [PEG]) for better visualization.Strong recommendation, high quality evidence.However, the optimal timing for taking purgatives is yet to be established. 2: ESGE recommends that SBCE should be performed as an outpatient procedure if possible, since completion rates are higher in outpatients than in inpatients.Strong recommendation, moderate quality evidence. 3: ESGE recommends that patients with pacemakers can safely undergo SBCE without special precautions.Strong recommendation, low quality evidence. 4: ESGE suggests that SBCE can also be safely performed in patients with implantable cardioverter defibrillators and left ventricular assist devices.Weak recommendation, low quality evidence. 5: ESGE recommends the acceptance of qualified nurses and trained technicians as prereaders of capsule endoscopy studies as their competency in identifying pathology is similar to that of medically qualified readers. The responsibility of establishing a diagnosis must however remain with the attending physician.Strong recommendation, moderate quality evidence. 6: ESGE recommends observation in cases of asymptomatic capsule retention.Strong recommendation, moderate quality evidence.In cases where capsule retrieval is indicated, ESGE recommends the use of device-assisted enteroscopy as the method of choice.Strong recommendation, moderate quality evidence.

Device-assisted enteroscopy (dae): 1: ESGE recommends performing diagnostic DAE as a day-case procedure in patients without significant underlying co-morbidities; in patients with co-morbidities and/or those undergoing a therapeutic procedure, an inpatient stay is recommended.Strong recommendation, low quality evidenceThe choice between different settings also depends on sedation protocols.Strong recommendation, low quality evidence. 2: ESGE suggests that conscious sedation, deep sedation, and general anesthesia are all acceptable alternatives: the choice between them should be governed by procedure complexity, clinical factors, and local organizational protocols.Weak recommendation, low quality evidence. 3: ESGE recommends that the findings of previous diagnostic investigations should guide the choice of insertion route.Strong recommendation, moderate quality evidence.If the location of the small-bowel lesion is unknown or uncertain, ESGE recommends that the antegrade route should be generally preferred.Strong recommendation, low quality evidence.In the setting of massive overt bleeding, ESGE recommends an initial antegrade approach.Strong recommendation, low quality evidence. 4: ESGE recommends that, for balloon-assisted enteroscopy (i. e., single-balloon enteroscopy [SBE] and double-balloon enteroscopy [DBE]), small-bowel insertion depth should be estimated by counting net advancement of the enteroscope during the insertion phase, with confirmation of this estimate during withdrawal.Strong recommendation, low quality evidence.ESGE recommends that, for spiral enteroscopy, insertion depth should be estimated during withdrawal.Strong recommendation, moderate quality evidence. Since the calculated insertion depth is only a rough estimate, ESGE recommends placing a tattoo to mark the identified lesion and/or the deepest point of insertion.Strong recommendation, low quality evidence. 5: ESGE recommends that all endoscopic therapeutic procedures can be undertaken at the time of DAE.Strong recommendation, moderate quality evidence.Moreover, when therapeutic interventions are performed, additional specific safety measures are needed to prevent complications.Strong recommendation, high quality evidence.

Conflict of interest statement

S. Adler receives honoraria for giving seminars in capsule endoscopy, sponsored by Medtronic. E. J. Despott has received educational and travel grants and speaker’s honoraria from Fujifilm, Aquilant, Diagmed, and Medtronic (2007 to present); his department has received educational and travel grants and speaker’s honoraria from Olympus (2012 to present). I. Fernandez-Urien has received consultancy fees from Medtronic (2016 to 2017). A. Koulaouzidis is receiving material support for research from SynMed UK and IntroMedic (ongoing); his department is receiving material support from Aquilant/OMOM (ongoing); he received a research grant from Given Imaging (2011 to 2012). A. May receives speaker’s honoraria from FALK and Fujifilm; her department is receiving research support from Fujifilm (2014 to 2018), Olympus (2014 to 2018), and Interscope (2017 to 2019). S. Panter has received sponsorship support from Diagmed and Given to attend conferences and educational events (2005 to present); his department has received research fellowship funding from Aquilant and Fuji (2013 to 2015), and support for the delivery of capsule course infrastructure costs (2005 to present); he is currently the unpaid chair of the UK capsule endoscopy users’ group. G. Rahmi is giving training courses provided by Medtronic on the small-bowel capsule (2017 to 2018). C. Spada receives a consultancy fee from Medtronic. J. van Hooft’s department is currently receiving research grants from Cook Medical, Boston Scientific, Olympus, and Medtronic. D. Domagk, C. Hassan, M. Pennazio, M.E. Riccioni, and E. Rondonotti have no competing interests.

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