Carolyn Davison

Tracheal Aspiration of a Capsule Endoscope: Not Always a Benign Event

To the Editor, We read with great interest the report and compilation of cases of capsule endoscope (CE) aspiration by Lucendo et al. [1] and also the correspondence from Koulaouzidis et al. [2] reporting a further 2 cases of aspiration and recommending use of real time viewer (RTV) in the immediate post-ingestion period. We would like to add a further case to complete the compilation. The case occurred in a 77 year-old-lady with a history of iron deficiency, abdominal pain and weight loss. The only past medical history was a hysterectomy. She had previously been investigated with an oesophagoduodenoscopy (OGD) and duodenal biopsies and a colonoscopy, which other than the presence of a small hiatus hernia were all normal. There was no history of dysphagia or pharyngeal disorder. Ingestion of the capsule was attempted but caused a choking episode, resulting in the capsule being coughed up. Endoscopic placement of the capsule was then arranged using the advanCE device. This was carried out unsedated and without incident; there were no significant haemodynamic changes or changes in oxygenation noted during the procedure. On return to the ward, the patient was noted to have developed slurred speech which gradually progressed with right-sided limb and facial weakness. An urgent CT head was performed which showed extensive haemorrhage into the right frontal and parietal lobes, with marked associated mass effect and midline shift. The case was discussed with the regional neurosurgical team at the tertiary referral centre and the patient was intubated for transfer. She was assessed by the neurosurgical team on arrival and it was felt that intervention was not in the patient’s best interests; she died soon after. This case adds to the growing recognition that capsule aspiration is a potential hazard. There have been multiple previously published cases of CE aspiration [3–14]. A recent case compilation and literature review by Lucendo et al. [1] looked at documented cases and concluded that aspiration could occur in at least 1 in 800 cases, especially in elderly patients, and is usually considered a benign event. In this case, we presume the mechanism of intracerebral haemorrhage (ICH) to be related to rupture of a cerebral aneurysm as a result of increased intracranial pressure, either as a result of the coughing bout due to aspiration of the CE or related to the endoscopy used to place the capsule, demonstrating that these aspirations are not always benign. Previous cases of capsule aspiration have noted that aspirations are more frequent in patients with a weak or absent cough. This patient had no obvious reason to be at risk of aspiration, and we would agree with Koulaouzidis et al. [2] in their suggestion for confirmation of CE position with RTV shortly after ingestion. We would take this further and suggest that, in high risk patients, the safest approach may be to directly place the capsule into the duodenum. This is the first case to document fatality due to ICH following possible capsule aspiration and endoscopic capsule placement, questioning the assumption that CE aspiration is a benign event.

Tracheal Aspiration of Capsule Endoscopes: Detection, Management, and Susceptibility

Dear Editors, We read with interest the article by Lucendo et al. [1] and subsequent correspondence from Koulaouzidis et al. [2] and wish to include a further three cases (two from the United Kingdom and one from Australia) of tracheal aspiration of capsule endoscopes, bringing the total number of worldwide cases reported to date to 18. Our first case involved a 65-year-old man with suspected obscure gastrointestinal bleeding, history of ethanol induced cirrhosis, chronic pancreatitis and chronic obstructive pulmonary disease (COPD). Other than demonstrating small non-bleeding gastric varices, several upper GI endoscopies (EGD) and colonoscopies were unhelpful. At the time of capsule endoscopy (CE), although the patient appeared frail and undernourished there was no history of dysphagia. Following capsule ingestion (in the upright position), the patient remained asymptomatic but the ‘‘real-time viewer’’ (RTV) showed immediate aspiration of the capsule into the bronchial tree. A chest X-ray identified the capsule to the right of the midline below the bifurcation of the trachea (Fig. 1). Rigid bronchoscopy under general anesthesia (GA) was urgently performed with the capsule found deep in the right main bronchus (Fig. 2). Initial retrieval efforts using a Roth Net (US Endoscopy, USA) were unsuccessful—full deployment of the net was impossible within the narrow bronchial confines; further attempts at extraction using a Cryo-probe (ERBE Elektromedizin GmbH, Germany) and balloon traction with a Fogarty endovascular catheter also failed. Successful retrieval was ultimately achieved with large ‘‘crocodile’’ grasping forceps. A second capsule was then placed without incident into the duodenum using an AdvanCE device (Given imaging, Israel) while the patient remained under GA. The second case involved a 73-year-old man with COPD and persistent iron deficiency anemia (IDA). EGD, colonoscopy and abdominal CT scan were unremarkable. Capsule ingestion resulted in brief coughing and RTV images confirmed aspiration (Fig. 3). Retrieval of the capsule from the left main bronchus at bronchoscopy under conscious sedation using a snare was unsuccessful. The patient was then asked to cough, which led to disimpaction and successful capsule capture using a Roth Net . Another capsule was then deployed into the duodenum using an AdvanCE device. Our final case involved an 81-year-old man with recurrent IDA and negative EGD and colonoscopy. He described a fleeting choking sensation during ingestion of the capsule but otherwise remained asymptomatic. RTV images confirmed capsule aspiration and rigid bronchoscopy was performed with removal of the capsule from the right main bronchus using large crocodile grasping forceps. We agree with our colleagues’ view that CE is associated with a small but definite risk of capsule aspiration [1] in a subset of patients who undergo CE and that this deserves greater clinical recognition. E. J. Despott A. O’Rourke C. Fraser (&) Wolfson Unit for Endoscopy, St Mark’s Hospital and Academic Institute, Imperial College London, Northwick Park Campus, London, UK e-mail: chris.fraser@imperial.ac.uk

Capsule endoscopy--not just for the small bowel: a review.

Video capsule endoscopy is being increasingly used to investigate the esophagus and colon as well as the small bowel. With the advancement of technology used in capsule endoscopy there have been marked improvements in diagnostic rates for colon capsule endoscopy in the detection of colonic polyps and colorectal cancer. It is also being increasingly used in the field if inflammatory bowel disease to investigate for mucosal inflammation and could potentially be used to assess mucosal healing. It also has role in completing the evaluation of colonic pathology in those in whom colonoscopy is incomplete. Esophageal capsule is preferred by patients over esophagogastroduodenoscopy (EGD) but as yet does not rival EGD in terms of diagnostic accuracy however the advent of magnetically steerable capsules may improve this. This review covers advances in the field of colon and esophageal capsule endoscopy; it covers diagnostic capabilities of these 2 tools as well as technical aspects of both procedures and preparation.

Provision of service and training for small bowel endoscopy in the UK

Objective To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery. Design Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training. Results 45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohns disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses. Conclusions Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.

Training in Capsule Endoscopy: Are We Lagging behind?

Capsule endoscopy (CE) is a new modality to investigate the small bowel. Since it was invented in 1999, CE has been adopted in the algorithm of small bowel investigations worldwide. Reporting a CE video requires identification of landmarks and interpretation of pathology to formulate a management plan. There is established training infrastructure in place for most endoscopic procedures in Europe; however despite its wide use, there is a lack of structured training for CE. This paper focuses on the current available evidence and makes recommendations to standardise training in CE.

Small Bowel Capsule Endoscopy

Although optical technology in the gastrointestinal tract has much improved in the last decade, image quality is only as good as the preparation achieved. As current capsule technology does not allow suctioning or flushing of fluid from the surface of the small bowel mucosa, there is consequently a greater imperative for adequate preparation to optimise detection of any potential lesion by the capsule endoscope.

International core curriculum for capsule endoscopy training courses

Capsule endoscopy (CE) has become a first-line noninvasive tool for visualisation of the small bowel (SB) and is being increasingly used for investigation of the colon. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines have specified requirements for the clinical applications of CE. However, there are no standardized recommendations yet for CE training courses in Europe. The following suggestions in this curriculum are based on the experience of European CE training courses directors. It is suggested that 12 hours be dedicated for either a small bowel capsule endoscopy (SBCE) or a colon capsule endoscopy (CCE) course with 4 hours for an introductory CCE course delivered in conjunction with SBCE courses. SBCE courses should include state-of-the-art lectures on indications, contraindications, complications, patient management and hardware and software use. Procedural issues require approximately 2 hours. For CCE courses 2.5 hours for theoretical lessons and 3.5 hours for procedural issued are considered appropriate. Hands-on training on reading and interpretation of CE cases using a personal computer (PC) for 1 or 2 delegates is recommended for both SBCE and CCE courses. A total of 6 hours hands-on session- time should be allocated. Cases in a SBCE course should cover SB bleeding, inflammatory bowel diseases (IBD), tumors and variants of normal and cases with various types of polyps covered in CCE courses. Standardization of the description of findings and generation of high-quality reports should be essential parts of the training. Courses should be followed by an assessment of traineesʼ skills in order to certify readers’ competency.

PTH-031 Pillcam sb2 and sb3 small bowel capsule endoscopy – comparisons and implications for practice

Introduction South Tyneside Hospital has been a referral centre for capsule endoscopy since 2005, performing over 1000 studies. We have previously shown that the diagnostic yield (DY) of the PillCam SB3 capsule (Given Imaging, Israel) is significantly higher than that of the PillCam SB2.1Here we present additional data on “learning curve” and offer suggestions for practice. Method Previous work compared the DY of the last 100 SB2 capsules with the first 100 SB3s. To assess for a “learning curve” effect we reviewed our first 100 SB2 capsules (Oct 2007–Aug 2008). Indications, completion rates, small bowel recording times and pathology were recorded. Pathology was classed as significant if it related directly to indication. Results 46 of the first 100 SB2 capsules were abnormal, of which 31 had significant pathology; almost identical to the last 100 SB2s (45 abnormal, 30 significant). Most tests (255/300, 85%) were for unexplained anaemia or Crohn’s disease assessment. More capsules are now done for acute GI bleeding; 4 of the first 100 SB2 capsules, 12 of the last 100 SB2s and 15 of the first 100 SB3s. There were 23 incomplete SB2 capsules (11.5%) of which 18 (9%) were in small bowel at the end of recording and 5 were held up by pathology (2.5%). Only 5 SB3 studies (5%) were incomplete, with 4 (4%) not entering the colon and 1 (1%) held up by pathology. On average SB3 capsules had a longer recording time of 9 h and 24 min compared to 8 h and 2 min for the SB2s. Conclusion 219 capsules were reported before the SB2 was introduced. Between the first hundred and last hundred SB2 capsules there were 1003 SB2 studies. This suggests that the increased DY is not due to a “learning curve”, supporting our finding of increased DY with the SB3. Any “learning curve” is likely to be from the first 200 studies. Most studies are for iron deficiency anaemia and Crohn’s disease assessment but there is a trend towards using capsules as a diagnostic tool in overt GI bleeds. Fewer SB3 studies were incomplete compared to SB2s. Our unit is now more proactive in monitoring gastric transit and colonic entry using the real time viewer and this change in practice may have helped with this. Longer recording times due to increased battery life may also play a part. We recommend monitoring capsules in real time and leaving the recorder on for longer if gastric transit is delayed or colonic entry is not clear.Abstract PTH-031 Table 1 Pathology by capsule group Capsule Type First 100 SB2 Last 100 SB2 First 100 SB3 Angioectasia 7 6 18 Blood 4 3 4 Coeliac changes 2 3 1 Polyp/Mass 1 1 4 Stricture 1 3 1 Ulcers/erosions 16 14 20 Other 0 0 1 Total 31 30 49 Disclosure of interest None Declared. Reference Dunn, S. et al. PTU-053 Is It Worth Repeating Previous Unremarkable Sb2 Capsules With The New Sb3? Gut 63 Suppl 1(2014):A61–A62

Practical aspects of delivering a small bowel endoscopy service in the UK

Capsule endoscopy remains at the forefront of small bowel investigation, offering the only non-invasive means of directly imaging the mucosa of the small bowel. Recommended for the investigation of obscure gastrointestinal bleeding, Crohns disease, coeliac disease, small bowel tumours and hereditary polyposis syndromes, the uptake of small bowel capsule endoscopy has been widespread in the UK. However, despite a wealth of published literature supporting the utility of capsule endoscopy in clinical practice, there are limited data regarding the actual practical aspects of service delivery, training and quality assurance. In this article, we attempt to address this by considering specific factors that contribute to provision of a high-quality capsule service. The role of formal training, accreditation and quality assurance measures is also discussed.

Education and Training in Video Capsule Endoscopy

In most countries around the world, structured training is in place for standard gastrointestinal (GI) endoscopic procedures. Despite an exponential growth worldwide in the use of video capsule endoscopy (VCE), a standardised infrastructure for training in VCE and accepted credentials for physicians who provide this service are yet to be established. With such rapid expansion in uptake of this modality comes the inherent need to develop diagnostic knowledge, skill and competence assessments [1]. In Europe, training in VCE is not a mandatory requirement of specialist training; many trainees receive no training at all in this field, and access to services and in-house training is not universal [2]. This chapter provides an overview of training issues for both the trainer and trainee, with consideration of what we need to train, how to train, whom to train and how to assess competence.