**6. Can colon capsule endoscopy play a role in clinical medicine today?**

**a.** Screening patients for presence of colonic polyps as primary colon cancer prevention.

Colonoscopy is the accepted gold standard and the most sensitive method to investigate pa‐ tients for the presence of colonic polyps. While colon cancer screening programs are availa‐ ble the participation rate of the general population has been disappointingly low. The reasons for the low adherence rate are multifactorial. Colonoscopy is associated with dis‐ comfort/pain, so there is a need for sedation, there are complications, albeit small, the proce‐ dure leads to loss of work and there is the issue of the invasion of one's privacy. Recently it has been reported that post procedural pain necessitating visits to the emergency room fol‐ lowing colonoscopy has been underestimated. While these reservations may appear trivial to gastroenterologists, this is perceived differently in the general public. Inadomi et al pub‐ lished the results of a prospective randomized trial [9]. In the office setting eligible patients were offered either colonoscopy or fecal occult blood testing (FOBT). 12 months thereafter 38% of patients offered colonoscopy had completed the procedure, while 31% more, a total of 69% of patients offered FOBT had done the test.

They concluded that our common practice of universally recommending only colonoscopy may actually reduce adherence to colorectal cancer screening.

In a prospective study performed in Germany to examine whether colon capsule endoscopy could increase adherence to screening colonoscopy in a healthy population Groth et al found that offering capsule endoscopy led to a fourfold increase of screening uptake com‐ pared to standard colonoscopy [10].

Rex and Lieberman published a survey study that colon capsule endoscopy could raise col‐ orectal cancer screening adherence rates among patients who decline screening colonosco‐ py. This was especially apparent when the participants in this survey were offered colon capsule endoscopy as an out of clinic test with no loss of work. We published a cohort study of 41 patients who underwent colon capsule endoscopy as an out of clinic study. Successful‐ ly completed colon capsule endoscopy examinations in this out-of-clinic trial, including cap‐ sule excretion rates and colon cleansing levels were similar to those of the two published inclinic trials. This study concluded that second generation colon capsule endoscopy may be offered as an out-of-clinic medically supervised procedure [11].

home procedure) and for all these reasons may increase adherence rates to participate in co‐ lon cancer screening. Therefore colon capsule endoscopy may become clinically important

Colon Capsule Endoscopy: Quo Vadis? http://dx.doi.org/10.5772/53055 251

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[6] Spada C, Hassan C, Munoz-Navas M, Neuhaus H, Deviere J, Fockens P, Coron E, Gay G, Toth E, Riccioni ME, Carretero C, Charton JP, Van Gossum A, Wientjes CA, Sacher-Huvelin S, Delvaux M, Nemeth A, Petruzziello L, de Frias CP, Mayershofer R, Aminejab L, Dekker E, Galmiche JP, Frederic M, Johansson GW, Cesaro P, Costama‐ gna G . Second-generation PillCam® Colon Capsule Compared with Colonoscopy.

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to practicing gastroenterologists.

and Cesare Hassan2

1 Division of Gastroenterology, BikurHolim Hospital, Jerusalem, Israel

2 Ospedale Nuovo Regina Margherita, Via Morosini, Roma, Italia

**Author details**

Samuel N. Adler1

**References**

2000;405. 417

NEMJoa0806347

349-53.

To summarize the above: offering colonoscopy only in colon cancer screening programs re‐ duces adherence. Loss of work and the need to have a person accompany the subject to be screened by colonoscopy are significant reasons for decreased adherence to undergo colono‐ scopy screening. Reduced adherence compromises the effectiveness of colonoscopy even if colonoscopy admittedly is the gold standard. Colon capsule endoscopy can offer itself as a non invasive test to identify patients with colonic polyps. In the future colon capsule endos‐ copy could be offered as an out of clinic test which potentially could further increase adher‐ ence rates for colon cancer screening programs. Modern technology has set the tone. Invasive diagnostic tests will be replaced with less or non invasive tests. Colon capsule en‐ doscopy may fit this paradigm.

**b.** Incomplete Colonoscopy.

For colonoscopy to reduce colon cancer rates certain criteria have to be met. Colonoscopy has to be carried out by competent endoscopists (operator dependent). Bowel cleansing has to be optimal. Cecal intubation has to be achieved (complete colonoscopy). Incomplete colo‐ noscopy, ie the failure to intubate the cecum with the colonoscope, in general practice is higher than expected [12]. Complete colonoscopy rates have been reported from 60% to over 90% [13],[14],[15]. If for whatever reason complete colonoscopy cannot be achieved then in‐ gestion of the colon capsule endoscope for visualization of the uninspected part of the colon is feasible. Colon capsule endoscopy in this setting may be especially attractive since it is the right colon which is usually not visualized in incomplete conventional colonoscopy whereas the right colon is routinely visualized by capsule endoscopy. A prospective multicenter Eu‐ ropean study demonstrated that colon capsule endoscopy in case of incomplete colonoscopy (74 cases) or contraindicated colonoscopy (26 cases) yields a high number of relevant diag‐ nostic findings (36 %) including one right sided colonic cancer. Furthermore, the authors re‐ port that during a one year follow up of this study no adenocarcinoma of the colon was missed by the colon capsule[16]. It should be emphasized that this study was performed with the inferior (today outdated) first generation colon capsule.
