Upload
gianfranco-tammaro
View
1.728
Download
15
Embed Size (px)
Citation preview
C. HassanC. Hassan
La capsula endoscopicaLa capsula endoscopica
((CCECCE))
Why Why
do we need do we need
a a new screening test? screening test?
Winawer SJ, Zauber AG, Ho MN, et al. N Engl J Med 1993;329:1977-81.Segnan N, Senore C, Andreoni B, et al. Gastroenterology 2007;132:2304-12.Lisi D, Hassan C, Crespi M. Dig Liver Dis. 2009; PMID: 19747888
Efficacy Adherence
Colonoscopy screening
Can colon capsuleCan colon capsule
meetmeet
people people expectationsexpectations??
New PillCam Design 2-sided video cameras; 4 images per second, 2 fps
per camera Dimensions:
• Diameter: Same as PillCam SB• Length: 5mm longer than PCSB
Ø11
mm
31 mm
PillCamPillCam®® COLON Capsule COLON Capsule
No tube = No painNo tube = No pain No complicationNo complication Home-deliveredHome-delivered
No embarassmentNo embarassment No inconvenienceNo inconvenience Per os Per os
administeredadministered
Advantages of colon capsule
TOLERABLE (bowel preparation)TOLERABLE (bowel preparation)
TECHNICALLY SUCCESSFULTECHNICALLY SUCCESSFUL
ACCURATE FOR ADVANCED ACCURATE FOR ADVANCED
NEOPLASIANEOPLASIA
EFFICIENT IN INDICATING EFFICIENT IN INDICATING
ENDOSCOPYENDOSCOPY
Ideal colon capsule
IsIs
bowel preparation bowel preparation
for CCE for CCE
tolerable and effectivetolerable and effective ? ?
Day before examination
Day ofexamination
5-6 Liters !
PEG 3 LITERSTo clean the colon
PEG 1 LITERTo clean the colonSubmarine view
1-2 NaP booster+1-2 LITERTo propel the capsule
18-2100
6-700
10-1400
800
Bowel preparation
7.4500 Domperidone 20 mg
Bowel preparation
Good-excellent
Fair-poor
MEDIAN (range) of the mean values of 8 studies
Is CCE Is CCE
technicallytechnically successful? successful?
~2.4 hours (+2 h)
Technical failure
XX
No CCE colonoscopy
CCE incompletecolonoscopy
~2.2 hours(+1.5 h)
What isWhat is
CCE CCE accuracyaccuracy
for polyp?for polyp?
SYSTEMATIC REVIEW: 2006-2009
Significant polyp
(>6 mm/>3)
16
13
87
0
64
6
13
22
199
Full/abstr.
Eliakim et al. (2006) full
Schoofs et al. (2006) full
Van Gossum et al. (2009) full
Sieg et al. (2009) full
Gay et al. (2009) full
Pilz et al. (2008) Abstr.
Spada et al. (2009) Abstr.
Sacher-Huvelin et al. (2009) Abstr.
Total
Patients included
84
36
320
36
126
59
40
105
806
Polyp any size
36
25
212
11
67
28
20
-
399
Multi-centre
Yes
No
Yes
No
No
No
No
Yes
l
CCE: POLYP ANY SIZE
71% (61-76%)I2: 12.9%
Sensitivity
75% (66-83%)I2: 53%
Specificity
CCE: >6 mm polyp or >3 polyp
68% (56-79%)I2: 60%
Sensitivity
82% (77-85%)I2: 9%
Specificity
Sensitivity for >6 mm polyps
Level bowel prep
Good-excellent
Poor-fair
What isWhat is
CCE CCE sensitivitysensitivity
for cancer?for cancer?
CCE: CANCER
Van Gossum et al. (2009)
Sieg et al. (2009)
Spada et al. (2009)
Total
CancerCCE
19
1
1
21
CancerCapsule
14
1
1
16
Pooled sensitivity (95% CI)
76%(58-94%)
Colonoscopy
Additional Information on Misses of Adenocarcinoma by PillCam
Site Referral AdenoK by OCCapsule finding
PillCam
cleansing
Comments
Italy Hematochezia 40 mm, left< 6mm, right
< 6mm, sigm. Fair “Inadequate preparation precluding the visualization of colonic mucosa”
ItalyHematochezia
> 10 mm, left No finding Poor “Inadequate preparation precluding the visualization of colonic mucosa”
ItalyHematochezia
> 10 mm, left No finding Poor No comments
Spain CRC 40 mm, rectum2 x < 6mm, sigm
GoodK was located in rectum. Capsule stopped working at the sigmoid (at 07.52h)
Lyon CRC
Pedunculated 8-9 mm, sigm.
6 x < 6mm:
1-right
2-left
2-sigmoid
1-rectum
Good No comments
Lieberman DA, NEJM 2009
76% 68%
=
Sensitivity Cancer
Advanced Adenoma
How efficient isHow efficient is
colon capsule in selecting subjects for colon capsule in selecting subjects for
colonoscopy colonoscopy
in ain a screening setting? screening setting?
Lieberman D, Moravec M, Holub J, et al. Gastroenterology 2008;135:1100-5. Rex DK, Overhiser AJ, Chen SC, et al. Am J Gastroenterol 2009;104:149-53.Pickhardt PJ, Choi JR, Hwang I, et al. N Engl J Med 2003; 349: 2191-2200. Kim DH, Pickhardt PJ, Taylor AJ, et al. N Engl J Med 2007;357:1403-12.
No threshold
COLON CAPSULE EFFICIENCYCOLON CAPSULE EFFICIENCY
Post-capsuleOC referral rate
PPV for polyp
>6 mm
What are
the main risks of bias
in the available studies?
DistortionDistortion bias (enriched-disease bias (enriched-disease
pop.)pop.)
Withdrawal Withdrawal bias (no consecutive bias (no consecutive
enrolm.)enrolm.)
ClassificationClassification bias bias
No unblinding at colonoscopyNo unblinding at colonoscopy
Polyp-matching algorithm Polyp-matching algorithm
imperfectimperfect
RISK OF BIAS
ConclusionsConclusions
CCE may potentially meet people CCE may potentially meet people expectationsexpectations
Technology is expected to reach a 100% Technology is expected to reach a 100% technical success of CCE, and a very high technical success of CCE, and a very high accuracy in pts. with good-excellent bowel accuracy in pts. with good-excellent bowel preparationpreparation
GI-field need to focus on tolerability and GI-field need to focus on tolerability and efficacy of bowel prepefficacy of bowel prep
ConclusionsConclusions Future research:Future research:
CC1 to CC2CC1 to CC2 Consecutive enrollmentConsecutive enrollment Screening settingScreening setting Unblinding at colonoscopyUnblinding at colonoscopy Sensitivity for cancerSensitivity for cancer Specificity for polypsSpecificity for polyps Bowel preparationBowel preparation AcceptabilityAcceptability Endoscopist capacityEndoscopist capacity