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J Gastroint Dig Syst Gastrointestinal Endoscopy ISSN: 2161-069X
JGDS, an open access journal
Journal of Gastrointestinal & Digestive System
Pérez Roldán et al. J Gastroint Dig Syst 2011, S:2 DOI: 10.4172/
.S2-002
Research Article Open Access
Usefulness of Capsule Endoscopy for Full Examination of the
Colon in Patients with Large Bowel Cancer Treated Using
Self-Expanding Metal Stents Pérez Roldán F
Francisco Pérez Roldán, Pedro González Carro, María Concepción
Villafáñez García y Natividad Sánchez-Manjavacas Muñoz
Abstract Since the discovery of capsule endoscopy, have been
introduced in different indications. It is used mainly to
examine the small intestine. Newly Introduced Improvements
include the technical design of specific capsules for the esophagus
and colon. We must not forget that colon capsule preparation needed
before the colon, like a colonoscopy. The most common indications
are screening for colorectal cancer when colonoscopy is incomplete
and when the patient refuses to undergo colonoscopy.
This article aims to describe a possible indication of colon
capsule endoscopy and the experience gained in our hospital. The
indication would be in patients with stenosing left colon tumors
treated using self-expanding metal stents. This technique would be
an alternative to colonoscopy colon through the colon prostheses as
a bridge to surgery.
In our experience, we must be modified the colon preparation
adding lactulose, and we waiting that the colon diameter at ends of
the stent both is similar. We have obtained promising results with
a diagnosed case of synchronous cancer, and we have not had any
cases of impaction of the capsule.
Keywords: Colon capsule endoscopy; Stenosing Colorectal
Cancer;Self-expanding metal stent
Introduction Capsule endoscopy is a relatively new diagnostic
technique that
was first investigated in Israel in the 1980s by a mechanical
and optical engineer, Dr. G. Iddan. It is used mainly to examine
the small intestine [1,2]. Visualization of the colon is usually
hampered by intestinal fecal content, and visualization of the
stomach is incomplete because of the lack of distension and the
fact that some areas remain outside the field of vision. The
capsule measures 26 × 11 mm, and this is of particular relevance
when evaluating its usefulness in specific conditions affecting the
colon. Since its introduction at the end of 2001, the capsule has
been widely used, thanks to its high diagnostic efficacy.
The main indications for capsule endoscopy are as follows:
Visible or occult hemorrhage of unknown origin (iron deficiency
anemia)
• Suspected Crohn disease
• Suspicion of intestinal tumors and follow-up of intestinal
polyposissyndromes
• Study of malabsorption disorders such as celiac disease
This technique is contraindicated in pregnancy, patients
withswallowing disorders, and patients with small bowel stricture,
such as that caused by inflammation, cancer, or extrinsic
compression, as is the case in postsurgical adhesions [1,2].
The complications of this technique are uncommon and include
inability to swallow, impaction of the pyriform sinus, impaction of
the esophagus or bronchus, delayed evacuation of the stomach,
retention in an afferent loop or in lesions of the small intestine,
impaction in the small intestine (including perforation), and
retention in the colon (eg. diverticula) [1-3].
Newly introduced technical improvements include the design of
specific capsules for the esophagus and colon. The endoscopic
PillCamTM ESO capsule was approved by the United States Food and
Drug Administration in October 2004 for visualization of the
esophagus. The device was modified to include cameras on each
end that enable it to acquire 7 images per second as it passes
through the esophagus. In addition, the batteries last 20-30
minutes, which is sufficient time to explore the esophagus and part
of the stomach. The main indications are examination of the
esophagus, esophageal varices, or suspected Barrett esophagus
[4,5]. The advantage of the technique is that the patient does not
have to be sedated and can return to normal daily activities after
the procedure. Capsule endoscopy is indicated in patients who
refuse to undergo conventional endoscopy, which continues to be the
diagnostic method of choice.
Colon Capsule Colonoscopy is the gold standard when screening
for diseases of
the large intestine, including colorectal cancer. This invasive
approach requires the colon to be intubated and insufflated. It is
operator-dependent and requires extensive training. In addition,
the technique carries a 0.3% risk of complications in diagnostic
uses, and this could increase to 2% in polypectomy.
A new application of the endoscopic capsule, the PillCamTM Colon
Capsule, has recently been developed. This capsule is different
from that used to examine the small intestine. First, it is 31 mm
long (4 mm longer than other types), although the diameter remains
unchanged. The camera at each end can acquire 4 images per second
[6,7]. Its battery lasts longer (9-10 hours) and can be
disconnected for several
*Corresponding author: Pérez Roldán F, Gastroenterology
Department, Emergency Department, Hospital General La
Mancha-Centro, Alcázar de San Juan, Spain, E-mail:
[email protected]
Received October 29, 2011; Accepted December 16, 2011; Published
December 18, 2011
Citation: Pérez Roldán F (2011) Usefulness of Capsule Endoscopy
for Full Examination of the Colon in Patients with Large Bowel
Cancer Treated Using Self-Expanding Metal Stents. 2161-069XS2:002.
doi:10.4172/ .S2002
Copyright: © 2011 Pérez Roldán F. This is an open-access article
distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source
are credited.
mailto:[email protected]
-
Citation: Pérez Roldán F (2011) Usefulness of Capsule Endoscopy
for Full Examination of the Colon in Patients with Large Bowel
Cancer Treated Using Self-Expanding Metal Stents. J Gastroint Dig
Syst S2:002. doi:10.4172/2161-069X.S2-002
hours after ingestion in order to conserve power in the colon.
The second-generation PillCamTM Colon Capsule is slightly larger
(31.5 mm × 11.6 mm) than its predecessor. In addition, the angle of
vision at each end has been increased, enabling 35 images per
second to be acquired when the capsule is moving. These
improvements have enhanced visualization of the colon [8,9].
Preparation
The colon should be carefully prepared. Cleansing before
ingestion is similar to that used for traditional colonoscopy
[6-10]. The patient should begin a low-fiber diet 2 days before the
procedure. The day before the examination, the patient should
receive a laxative (eg. 4 liters of polyethylene glycol taken in 2
doses), with or without prokinetic drugs before ingestion,
depending on the protocol. After ingestion, the patient should take
another laxative (eg. 30-45 ml of sodium phosphate) and a
prokinetic agent (tegaserod 6 mg) in order to maintain the colon
clean and promote propulsion of the capsule to ensure that it is
excreted 9-10 hours after ingestion.
Indications
Studies have shown that the capsule has 69-76% sensitivity, a
7483% positive predictive value, and a 54-78% negative predictive
value in the diagnosis of polyps (any size) [6-10]. These values
are lower than those of colonoscopy [11]. The technique has also
been used for the diagnosis of inflammatory lesions such as
diverticulitis and ulcerous colitis. The most common indications,
however, are screening for colorectal cancer when colonoscopy is
incomplete and when the patient refuses to undergo colonoscopy.
Safety and cost-effectiveness
Capsule endoscopy is a safe technique with few side effects,
which do not usually last longer than 24-48 hours. The most common
complications include those arising during preparation, namely,
laxative-induced abdominal pain, nausea, and vomiting. In addition,
1.6% of patients find it impossible to swallow the capsule
[10,11].
Capsule endoscopy is an attractive noninvasive method that can
be used to screen for colorectal cancer, especially in patients who
cannot undergo currently available screening procedures. If
screening for colorectal cancer increased by more than 30%, this
technique could prove more cost-effective than colonoscopy.
Colon Capsule in Stenosing Colorectal Cancer
One of the manifestations of stenosing tumors is obstruction of
the intestinal lumen, defined as an interruption of the course of
intestinal contents (feces, gas, enteral content) through the
intestine as a result of functional or organic conditions (eg.
colon tumors). Currently available therapeutic approaches aim to
relieve or eliminate the obstruction and correct water electrolyte
imbalance. Obstructions can be relieved or eliminated using
surgery, or, where possible and the patient’s condition permitting
(i.e absence of perforation or colonic ischemia), a self-expanding
metal stent can be fitted using endoscopy or radiological
techniques. In addition to relieving or eliminating the symptoms,
this palliative approach allows more time for the tumor to be
properly assessed and has lower morbidity and mortality than
emergency surgery. In patients with obstruction, the colon should
be examined as far as the stricture; other techniques have been
proposed, including virtual colonoscopy (computed tomography),
opaque enema, stent-based colonoscopy, and even capsule endoscopy
(Figures 1 and 2).
Capsule endoscopy is contraindicated in cases of suspected
Page 2 of 3
Figure 1: Prestenotic bowel and edge of the open stent
(arrowhead) seen from inside the stent.
Figure 2: Image of the tumor as the endoscopy capsule passes
through the metallic stent towards the poststenotic area.
obstruction of the small or large intestine. However, this
contraindication would theoretically no longer be valid if it was
possible to prevent the stricture and if the capsule could improve
diagnosis and treatment. Consequently, the group of patients that
would most benefit from the technique would be operable patients
with nonmetastasizing stenosing cancer of the left colon. Given
that obstructed colon is an emergency indication for self-expanding
metal stents, a device measuring 25 mm in diameter and 6-9 cm in
length can be fitted and an extension study can be performed to
rule out metastasis.
These patients can be offered capsule endoscopy for
compassionate use instead of colonoscopy after stenting (greater
risk of perforation) or virtual colonoscopy (poor definition due to
poor preparation). Initially, standard preparation was insufficient
in patients undergoing this technique, for reasons such as dilation
of the colon as far as the stricture, poorer motility of the
dilated colon, and extensive accumulation of feces [12].
Therefore, in order to improve cleansing, we recommend the
following modifications to standard preparation:
• Perform capsule endoscopy 7-8 days after stenting.
• From day 4 after stenting (and ensuring that that the stent
works), the patient should receive lactulose 15 ml every 8 hours
and abundant water. In addition, the patient should get up and walk
around, if possible.
J Gastroint Dig Syst Gastrointestinal Endoscopy ISSN: 2161-069X
JGDS, an open access journal
-
Citation: Pérez Roldán F (2011) Usefulness of Capsule Endoscopy
for Full Examination of the Colon in Patients with Large Bowel
Cancer Treated Using Self-Expanding Metal Stents. J Gastroint Dig
Syst S2:002. doi:10.4172/2161-069X.S2-002
Page 3 of 3
J Gastroint Dig Syst Gastrointestinal Endoscopy ISSN: 2161-069X
JGDS, an open access journal
Abdominal radiographs should be taken on day 6-7 to ensure that
the diameter at both ends of the stent is similar and that patency
is maintained. If this is the case, standard preparation for the
colon capsule should be undertaken.
These modifications make it possible to cleanse the colon more
efficiently; however, they should be verified in further studies.
Imaging by capsule has enabled us to diagnose the presence of
synchronous cancer (1 patient) and polyps and thus modify surgical
treatment and plan endoscopic polypectomy before or after surgery
depending on the size of the polyp [12].
Even though the stent is open, the capsule could become stuck
(although we have had no cases to date). However, if this did
occur, the capsule could be extracted using colonoscopy. In the
presence of a stenosing synchronous tumor, another metal stent
could be fitted and the capsule withdrawn or the stent could be
removed by surgical resection (treatment of localized colon
tumors).
In summary, capsule endoscopy of the colon would be indicated in
patients with stenosing left colon tumors treated using
self-expanding metal stents. This approach entails few risks and
provides huge benefits in the extension study.
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This article was originally published in a special issue,
Gastrointestinal Endoscopy handled by Editor(s). Dr. Rohan R.
Walvekar, LSU Health Sciences Center, New Orleans, USA
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TitleCorresponding authorAbstractKeywordsIntroductionColon
Capsule PreparationIndicationsSafety and cost-effectiveness Colon
Capsule in Stenosing Colorectal Cancer
Figure 1Figure 2References
