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Wireless capsule endoscopy: where and how to learn?
THE FELLOWS’ CORNER
Wireless capsule endoscopy: where and how to learn? Since the initial reports in 2000, the indications and use of capsule endoscopy have rapidly expanded in clinical gastroenterology. This month in the Fellows’ Corner, Dr Jonathan Erber provides us with a general overview of this endoscopic technique and then delves into some of the more complex issues surrounding the training and credentialing for both fellows and practicing physicians. Jonathan M. Buscaglia, MD Fellows’ Corner Editor Therapeutic Endoscopy Fellow Johns Hopkins Hospital Baltimore, Maryland, USA Wireless capsule endoscopy (WCE) provides visualization of the small intestine by transmitting images wirelessly from a disposable capsule to a data recorder worn by the patient.1 The Given Diagnostic Imaging System (Given Imaging, Yoqneam, Israel, and Duluth, Ga) first received Food and Drug Administration clearance in 2001 to evaluate the small bowel for the indication of obscure GI bleeding.2 Since then, the indications for its use have expanded, and to date more than 500,000 capsules have been ingested worldwide.3 Despite this tremendous growth, there is a paucity of data regarding the training and credentialing of physicians who use WCE in their practices. To provide some form of standardization, the American Society for Gastrointestinal Endoscopy (ASGE) submitted its guidelines in 2005 on credentialing and granting privileges in capsule endoscopy.4 However, most gastroenterology training programs do not have a formal curriculum for teaching the interpretation and operation of the capsule system. In this review, I will briefly discuss the technology and indications for WCE and suggest where and how to best learn this tool of our trade.
computer (PC) workstation (Fig. 1). A complete overview of the technical aspects and performance of WCE has been extensively reviewed elsewhere.5 WCE is generally performed in the ambulatory setting, but it may be used for inpatients as well. Fasting for 12 hours before ingestion is standard practice. Some recommend the use of a bowel preparation such as a polyethylene glycol– based electrolyte solution to improve visualization of the small intestine and ensure complete passage. Sensor pads are placed on the abdominal wall and connected to the portable hard drive. The disposable capsule is designed to be excreted. Imaging occurs for a total of 8 hours, after
Key points d
d
d
d
WCE is an exciting field and has emerged as an important tool for GI specialists There is a paucity of data regarding the training and credentialing of physicians who use WCE Most GI training programs do not have a formal curriculum Evidence-based training guidelines should be developed to enhance the quality of education in WCE
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2008.01.029
which the data recorder is connected to a PC workstation to download and review the images. Proprietary software (RAPID 4 Application, Given Imaging, Duluth, Ga) is used to process and display the images for review in single, double, or quad views at rates of 5 to 40 images per second. Images and video clips can be annotated and saved into an integrated reporting application. The ‘‘‘suspected blood indicator’’ feature facilitates detection of bleeding lesions by identifying red pixels. The software automatically annotates the scroll bar with a red hash mark, indicating to the reader that potential bleeding lesions or other sites of pathologic features may be present. Localization software estimates the capsule location within the abdomen and graphically displays its path of transit. The average reading time varies between 30 to 120 minutes, depending on small bowel transit time and reader experience. The indications for WCE include obscure GI bleeding,
www.giejournal.org
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 115
GENERAL OVERVIEW The Given Diagnostic Imaging system consists of 3 components: (1) a capsule endoscope, or pill-like video camera (PillCam), (2) a sensing system composed of sensing pads, a data recorder, and a battery pack, and (3) a personal
Wireless capsule endoscopy
Erber
in WCE. The RAPID Application also comes integrated with an atlas to reference and aid in the interpretation of images. Given Imaging’s sponsored Web site (www.capsuleendoscopy.org) and the DAVE project (www.dave1.mgh) are both excellent Web resources that provide case summaries and video clips archived with references. The ASGE has a special interest group for WCE that meets biannually at both the American College of Gastroenterology meeting and during Digestive Disease Week. In 2002, Given Imaging established the International Conference on Capsule Endoscopy (ICCE), an annual meeting dedicated to the research, practice, and advancement of capsule endoscopy. In 2005 a set of baseline consensus guidelines were developed for WCE11 and then updated at the fifth ICCE meeting in 2006. These guidelines can be found online at http://www.icce.info/consensus.html. The next consensus meeting is planned for later this year.
CONCLUSION
Figure 1. Capsule endoscope, PillCam, sensing system with sensing pads and data recorder/battery pack, PC workstation.
suspected and known Crohn’s disease, surveillance in patients with polyposis syndromes, evaluation for occult small bowel malignancies, and the evaluation for suspected and refractory celiac disease.6-8
WHERE AND HOW TO LEARN Most gastroenterology training programs do not have a structured curriculum for teaching WCE. The 2007 GI core curriculum9 recommends reading a minimum of 25 cases to achieve competency, and it suggests that ‘‘most experienced endoscopists who have completed a formal GI fellowship can readily master this technique.’’ However, it goes on to state that the minimum training requirements needed to competently perform WCE have not been evaluated.9 ASGE guidelines recommend that training within GI fellowship must include didactic tutoring and an adequate case volume so the trainee attains a level of competence similar to that of the mentor.4 The necessary case volume may vary among trainees and may also depend on when during the fellowship the training is undertaken. The ASGE recommends that training performed outside a GI fellowship should include the completion of a hands-on course with a minimum of 8 hours of continuing medical education, followed by review of the first 10 complete cases by a credentialed capsule endoscopist. Both Given Imaging and the ASGE hold several courses throughout the year for beginners and advanced users. The Atlas of Video Capsule Endoscopy10 provides an excellent overview of the technology, indications, and images 116 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
WCE is an exciting new field that has emerged as an important tool for gastroenterologists. As the technology advances and its indications continue to expand, it should soon share an equal branch along with EGD and colonoscopy in standard endoscopic education. Evidence-based training guidelines should be developed to enhance the quality of education and to ensure that WCE is practiced according to established standards. In the absence of such guidelines, gastroenterology trainees should take every opportunity to learn from those experts within their own program, read as many cases as possible, and attend an ASGE-sponsored course on capsule endoscopy. DISCLOSURE The authors report that there are no disclosures relevant to this publication. Jonathan A. Erber, MD Clinical Assistant Instructor, Senior Fellow Division of Gastroenterology and Hepatology S.U.N.Y. Downstate Medical Center Brooklyn, New York, USA This month’s Fellows’ Corner marks my last month as editor of this section of GIE. It has truly been a wonderful opportunity to be a part of this journal. I would like to thank all the authors that so graciously contributed upon my request over the past 2 years, as well as the terrific group of associate editors at GIE who have helped me along the way. Finally, I would like give special thanks to Dr. George Triadofilopoulos, Dr. Steven Edmundowicz, and Deborah Bowman, who allowed me the opportunity to be a part of their team, and who have guided me through the process. Thank you. Jonathan M. Buscaglia, MD www.giejournal.org
Erber
Abbreviations: ASGE, American Society for Gastrointestinal Endoscopy; ICCE, International Conference on Capsule Endoscopy; PC, personal computer; WCE, wireless capsule endoscopy.
REFERENCES 1. Iddan G, Meron G, Glukhovsky A, et al. Wireless capsule endoscopy. Nature 2000;405:417. 2. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med 2001;344: 232-3. 3. Given Imaging: http://www.givenimaging.com. Accessed August 31, 2007. 4. Faigel DO, Baron TH, Adler DG, et al. ASGE guideline: guidelines for credentialing and granting privileges for capsule endoscopy. Gastrointest Endosc 2005;61:503-5. 5. Mishkin DS, Chuttani R, Croffie J, et al. ASGE technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc 2006; 63:539-45.
www.giejournal.org
Wireless capsule endoscopy 6. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100:2407-18. 7. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn’s disease. Am J Gastroenterol 2006;101:954-64. 8. Lewis BS, Eisen GM, Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy 2005;37:960-5. 9. Gastroenterology core curriculum. 3rd ed. American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy; 2007: http://www.asge.org/TrainingEducationIndex. aspx?idZ502#curriculum. Accessed October 14, 2007. 10. Keuchel M, Friedrich H, Fleisher DE. Atlas of video capsule endoscopy. New York: Springer Link Publishing; 2007. 11. Lewis BS, Rey JF, Seidman EG. Capsule endoscopy 2005: results of the 2005 International Consensus Conference, introduction. Endoscopy 2005;37:1038-9.
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 117
Wireless capsule endoscopy: where and how to learn? Since the initial reports in 2000, the indications and use of capsule endoscopy have rapidly expanded in clinical gastroenterology. This month in the Fellows’ Corner, Dr Jonathan Erber provides us with a general overview of this endoscopic technique and then delves into some of the more complex issues surrounding the training and credentialing for both fellows and practicing physicians. Jonathan M. Buscaglia, MD Fellows’ Corner Editor Therapeutic Endoscopy Fellow Johns Hopkins Hospital Baltimore, Maryland, USA Wireless capsule endoscopy (WCE) provides visualization of the small intestine by transmitting images wirelessly from a disposable capsule to a data recorder worn by the patient.1 The Given Diagnostic Imaging System (Given Imaging, Yoqneam, Israel, and Duluth, Ga) first received Food and Drug Administration clearance in 2001 to evaluate the small bowel for the indication of obscure GI bleeding.2 Since then, the indications for its use have expanded, and to date more than 500,000 capsules have been ingested worldwide.3 Despite this tremendous growth, there is a paucity of data regarding the training and credentialing of physicians who use WCE in their practices. To provide some form of standardization, the American Society for Gastrointestinal Endoscopy (ASGE) submitted its guidelines in 2005 on credentialing and granting privileges in capsule endoscopy.4 However, most gastroenterology training programs do not have a formal curriculum for teaching the interpretation and operation of the capsule system. In this review, I will briefly discuss the technology and indications for WCE and suggest where and how to best learn this tool of our trade.
computer (PC) workstation (Fig. 1). A complete overview of the technical aspects and performance of WCE has been extensively reviewed elsewhere.5 WCE is generally performed in the ambulatory setting, but it may be used for inpatients as well. Fasting for 12 hours before ingestion is standard practice. Some recommend the use of a bowel preparation such as a polyethylene glycol– based electrolyte solution to improve visualization of the small intestine and ensure complete passage. Sensor pads are placed on the abdominal wall and connected to the portable hard drive. The disposable capsule is designed to be excreted. Imaging occurs for a total of 8 hours, after
Key points d
d
d
d
WCE is an exciting field and has emerged as an important tool for GI specialists There is a paucity of data regarding the training and credentialing of physicians who use WCE Most GI training programs do not have a formal curriculum Evidence-based training guidelines should be developed to enhance the quality of education in WCE
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2008.01.029
which the data recorder is connected to a PC workstation to download and review the images. Proprietary software (RAPID 4 Application, Given Imaging, Duluth, Ga) is used to process and display the images for review in single, double, or quad views at rates of 5 to 40 images per second. Images and video clips can be annotated and saved into an integrated reporting application. The ‘‘‘suspected blood indicator’’ feature facilitates detection of bleeding lesions by identifying red pixels. The software automatically annotates the scroll bar with a red hash mark, indicating to the reader that potential bleeding lesions or other sites of pathologic features may be present. Localization software estimates the capsule location within the abdomen and graphically displays its path of transit. The average reading time varies between 30 to 120 minutes, depending on small bowel transit time and reader experience. The indications for WCE include obscure GI bleeding,
www.giejournal.org
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 115
GENERAL OVERVIEW The Given Diagnostic Imaging system consists of 3 components: (1) a capsule endoscope, or pill-like video camera (PillCam), (2) a sensing system composed of sensing pads, a data recorder, and a battery pack, and (3) a personal
Wireless capsule endoscopy
Erber
in WCE. The RAPID Application also comes integrated with an atlas to reference and aid in the interpretation of images. Given Imaging’s sponsored Web site (www.capsuleendoscopy.org) and the DAVE project (www.dave1.mgh) are both excellent Web resources that provide case summaries and video clips archived with references. The ASGE has a special interest group for WCE that meets biannually at both the American College of Gastroenterology meeting and during Digestive Disease Week. In 2002, Given Imaging established the International Conference on Capsule Endoscopy (ICCE), an annual meeting dedicated to the research, practice, and advancement of capsule endoscopy. In 2005 a set of baseline consensus guidelines were developed for WCE11 and then updated at the fifth ICCE meeting in 2006. These guidelines can be found online at http://www.icce.info/consensus.html. The next consensus meeting is planned for later this year.
CONCLUSION
Figure 1. Capsule endoscope, PillCam, sensing system with sensing pads and data recorder/battery pack, PC workstation.
suspected and known Crohn’s disease, surveillance in patients with polyposis syndromes, evaluation for occult small bowel malignancies, and the evaluation for suspected and refractory celiac disease.6-8
WHERE AND HOW TO LEARN Most gastroenterology training programs do not have a structured curriculum for teaching WCE. The 2007 GI core curriculum9 recommends reading a minimum of 25 cases to achieve competency, and it suggests that ‘‘most experienced endoscopists who have completed a formal GI fellowship can readily master this technique.’’ However, it goes on to state that the minimum training requirements needed to competently perform WCE have not been evaluated.9 ASGE guidelines recommend that training within GI fellowship must include didactic tutoring and an adequate case volume so the trainee attains a level of competence similar to that of the mentor.4 The necessary case volume may vary among trainees and may also depend on when during the fellowship the training is undertaken. The ASGE recommends that training performed outside a GI fellowship should include the completion of a hands-on course with a minimum of 8 hours of continuing medical education, followed by review of the first 10 complete cases by a credentialed capsule endoscopist. Both Given Imaging and the ASGE hold several courses throughout the year for beginners and advanced users. The Atlas of Video Capsule Endoscopy10 provides an excellent overview of the technology, indications, and images 116 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
WCE is an exciting new field that has emerged as an important tool for gastroenterologists. As the technology advances and its indications continue to expand, it should soon share an equal branch along with EGD and colonoscopy in standard endoscopic education. Evidence-based training guidelines should be developed to enhance the quality of education and to ensure that WCE is practiced according to established standards. In the absence of such guidelines, gastroenterology trainees should take every opportunity to learn from those experts within their own program, read as many cases as possible, and attend an ASGE-sponsored course on capsule endoscopy. DISCLOSURE The authors report that there are no disclosures relevant to this publication. Jonathan A. Erber, MD Clinical Assistant Instructor, Senior Fellow Division of Gastroenterology and Hepatology S.U.N.Y. Downstate Medical Center Brooklyn, New York, USA This month’s Fellows’ Corner marks my last month as editor of this section of GIE. It has truly been a wonderful opportunity to be a part of this journal. I would like to thank all the authors that so graciously contributed upon my request over the past 2 years, as well as the terrific group of associate editors at GIE who have helped me along the way. Finally, I would like give special thanks to Dr. George Triadofilopoulos, Dr. Steven Edmundowicz, and Deborah Bowman, who allowed me the opportunity to be a part of their team, and who have guided me through the process. Thank you. Jonathan M. Buscaglia, MD www.giejournal.org
Erber
Abbreviations: ASGE, American Society for Gastrointestinal Endoscopy; ICCE, International Conference on Capsule Endoscopy; PC, personal computer; WCE, wireless capsule endoscopy.
REFERENCES 1. Iddan G, Meron G, Glukhovsky A, et al. Wireless capsule endoscopy. Nature 2000;405:417. 2. Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med 2001;344: 232-3. 3. Given Imaging: http://www.givenimaging.com. Accessed August 31, 2007. 4. Faigel DO, Baron TH, Adler DG, et al. ASGE guideline: guidelines for credentialing and granting privileges for capsule endoscopy. Gastrointest Endosc 2005;61:503-5. 5. Mishkin DS, Chuttani R, Croffie J, et al. ASGE technology status evaluation report: wireless capsule endoscopy. Gastrointest Endosc 2006; 63:539-45.
www.giejournal.org
Wireless capsule endoscopy 6. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100:2407-18. 7. Triester SL, Leighton JA, Leontiadis GI, et al. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn’s disease. Am J Gastroenterol 2006;101:954-64. 8. Lewis BS, Eisen GM, Friedman S. A pooled analysis to evaluate results of capsule endoscopy trials. Endoscopy 2005;37:960-5. 9. Gastroenterology core curriculum. 3rd ed. American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy; 2007: http://www.asge.org/TrainingEducationIndex. aspx?idZ502#curriculum. Accessed October 14, 2007. 10. Keuchel M, Friedrich H, Fleisher DE. Atlas of video capsule endoscopy. New York: Springer Link Publishing; 2007. 11. Lewis BS, Rey JF, Seidman EG. Capsule endoscopy 2005: results of the 2005 International Consensus Conference, introduction. Endoscopy 2005;37:1038-9.
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 117