Screening value for gastrointestinal lesions of magnetic-controlled capsule endoscopy in asymptomatic individuals.

BACKGROUND AND AIM: Most patients with gastric tumors and precancerous lesions are asymptomatic, which often results in delayed diagnosis and treatment. Compared with conventional gastroscopy and capsule endoscopy, magnetic-controlled capsule endoscopy is a non-invasive, effective, and cost-efficient diagnostic modality for gastric examination. We retrospectively investigated magnetic-controlled capsule endoscopy as a screening tool for gastrointestinal lesions (particularly gastric tumors and precancerous lesions) in asymptomatic individuals. METHODS: In this retrospective study, 1757 patients who voluntarily underwent magnetic-controlled capsule endoscopy between January and December 2019 at nine medical centers across Shaanxi province based on strict inclusion and exclusion criteria were enrolled. The primary outcomes were gastric tumor and precancerous lesion detection rates and procedural safety. RESULTS: The upper and lower gastrointestinal lesion detection rates were 98.35% (1728/1757) and 21.61% (78/361), respectively; 2.28% of patients were diagnosed with gastric tumors including gastric cancer (4/1757) and submucosal tumors (36/1757). Three types of precancerous lesions were found in 591 patients (33.64%), including chronic atrophic gastritis (23.16%), gastric polyp (10.98%), and gastric ulcer (2.96%). For patients aged over 40 years, the detection rate of precancerous lesions was higher (14.36% vs 42.58%, P < 0.001). No patient was diagnosed with small intestinal cancer. No adverse events occurred. CONCLUSIONS: Magnetic-controlled capsule endoscopy could be used as a promising novel screening modality for diagnosis of gastrointestinal lesions in asymptomatic individuals, specifically gastric tumors and precancerous lesions, with the advantages of safety, non-invasiveness, effectiveness, and cost-efficiency.

Colon capsule endoscopy in colorectal cancer screening: a randomised controlled trial.

INTRODUCTION: The use of capsule endoscopy has become an approved method in small bowel diagnostics, but the same level of integration is not seen in large bowel diagnostics. We will use colon capsule endoscopy (CCE) as a filter test in colorectal cancer (CRC) screening between the faecal immunochemical test (FIT) and colonoscopy. We aim to investigate the clinical performance, population acceptability, and economic implications of the procedure in a large-scale clinical trial. METHODS AND ANALYSIS: We will randomly allocate 124 214 Danish citizens eligible for participation in the national CRC screening programme within the Region of Southern Denmark to either an intervention group or a control group. Prior to submitting a FIT, citizens randomised to the intervention group will be informed about their opportunity to undergo CCE, instead of colonoscopy, if the FIT is positive. Suspected cancers; >3 adenomas <10 mm in size, 1 adenoma >10 mm in size or >4 adenomas regardless of size, detected during CCE will generate an invitation to colonoscopy as per regular screening guidelines, whereas citizens with suspected low risk polyps will re-enter the biennial screening programme. Citizens with no CCE findings will be excluded from screening for 8 years. In the control group, citizens will follow standard screening procedures. ETHICS AND DISSEMINATION: All participants must consent prior to capsule ingestion. All collected data will be handled and stored in accordance with current data protection legislation. Approvals from the regional ethics committee (ref. S-20190100) and the Danish data protection agency have been obtained (ref. 19/29858). TRIAL REGISTRATION DETAILS: The study has been registered with ClinicalTrials.gov under: NCT04049357.

Economic analysis of the adoption of capsule endoscopy within the British NHS.

OBJECTIVE: Identification of a cost-effective treatment strategy is an unmet need in Crohn's disease (CD). Here we consider the patient outcomes and cost impact of pan-intestinal video capsule endoscopy (PVCE) in the English National Health Service (NHS). DESIGN: An analysis of a protocolized CD care pathway, informed by guidelines and expert consensus, was performed in Microsoft Excel. Population, efficacy and safety data of treatments and monitoring modalities were identified using a structured PubMed review with English data prioritized. Costs were taken from the NHS and Payer Provided Services (PSS) 2016-17 tariffs for England and otherwise literature. Analysis was via a discrete-individual simulation with discounting at 3.5% per annum. SETTING: NHS provider and PSS perspective. PARTICIPANTS: 4000 simulated CD patients. INTERVENTIONS: PVCE versus colonoscopy ± magnetic resonance enterography (MRE). MAIN OUTCOME MEASURES: Costs in 2017 GBP and quality-adjusted life years (QALY). RESULTS: The mean, total 20-year cost per patient was £42 266 with colonoscopy ± MRE and £38 043 with PVCE. PVCE incurred higher costs during the first 2 years due to higher treatment uptake. From year 3 onwards, costs were reduced due to fewer surgeries. Patients accrued 10.67 QALY with colonoscopy ± MRE and 10.96 with PVCE. PVCE dominated (less cost and higher QALY) colonoscopy ± MRE and was likely (>74%) to be considered cost-effective by the NHS. Results were similar if a lifetime time horizon was used. CONCLUSIONS: PVCE is likely to be a cost-effective alternative to colonoscopy ± MRE for CD surveillance. Switching to PVCE resulted in lower treatment costs and gave patients better quality of life.

Prospective cost analysis of early video capsule endoscopy versus standard of care in non-hematemesis gastrointestinal bleeding: a non-inferiority study.

Background and aim: A non-inferiority cost analysis was performed to assess if the early capsule approach would incur higher costs than the standard of care approach in patients presenting with non-hematemesis gastrointestinal bleeding.Methods: A prospective non-inferiority cost analysis was performed on patients receiving either an early video capsule as the first diagnostic procedure or an endoscopic procedure as determined by gastroenterology staff that were not involved in the study. Primary outcome was total direct costs incurred in both groups.Results: Forty-five patients and 42 patients were enrolled into the early capsule and standard of care arms, respectively. There was no difference in total direct cost per inpatient case in both groups ($7,362 vs $7,148, p = 0.77 [CI = -2,285-2,315, equivalent margin = -$3,100]). Localization of a bleeding source after the first diagnostic procedure was identified more frequently in the early capsule group (69.2% vs 27.9%, p = 0.0003). If patients were discharged after their last non-diagnostic evaluation, then length of stay could be decreased by 50% in both groups (58.5 to 31.6 h, p = 0.02 in the early capsule group and 69.4 to 39.2 h in the standard of care group p = 0.001). Projections indicate the fastest a patient with non-diagnostic evaluations could be discharged is 0.88 days in the early capsule group vs 1.63 days in the standard of care group (p = 0.0005).Discussion: In patients with non-hematemesis bleeding, video capsule endoscopy may be a more efficient diagnostic approach than the standard of care approach, since it detects bleeding significantly more often without an increase in healthcare costs.

High concordance between trained nurses and gastroenterologists in evaluating recordings of small bowel video capsule endoscopy (VCE).

BACKGROUND AND AIMS: . The video capsule endoscopy (VCE) is an accurate and validated tool to investigate the entire small bowel mucosa, but VCE recordings interpretation by the gastroenterologist is time-consuming. A pre-reading of VCE recordings by an expert nurse could be accurate and cost saving. We assessed the concordance between nurses and gastroenterologists in detecting lesions on VCE examinations. METHODS: This was a prospective study enrolling consecutive patients who had undergone VCE in clinical practice. Two trained nurses and two expert gastroenterologists participated in the study. At VCE pre-reading the nurses selected any abnormalities, saved them as "thumbnails" and classified the detected lesions as a vascular abnormality, ulcerative lesion, polyp, tumor mass, and unclassified lesion. Then, the gastroenterologist evaluated and interpreted the selected lesions and, successively, reviewed the entire video for potential missed lesions. The time for VCE evaluation was recorded. RESULTS: A total of 95 VCE procedures performed on consecutive patients (M/F: 47/48; mean age: 63 +/- 12 years, range: 27-86 years) were evaluated. Overall, the nurses detected at least one lesion in 54 (56.8%) patients. There was total agreement between nurses and gastroenterologists, no missing lesions being discovered at a second look of the entire VCE recording by the physician. The pre-reading procedure by nurse allowed a time reduction of medical evaluation from 49 (33-69) to 10 (8-16) minutes (difference: -79.6%). CONCLUSIONS: Our data suggest that trained nurses can accurately identify and select relevant lesions in thumbnails that subsequently were faster reviewed by the gastroenterologist for a final diagnosis. This could significantly reduce the cost of VCE procedure.

Recent diagnostic procedures for colorectal cancer screening: Are they cost-effective?

Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most common cause of death. Reduction in mortality rates in some countries worldwide are most likely ascribed to CRC screening and/or improved treatments. We reviewed the most relevant articles which discuss the cost-effectiveness of colorectal cancer screening procedures, in particular, the recent ones through the last eight years. The effectiveness of screening estimated by discounted life years gained (LYGs) compared to no screening, differed considerably between the studies. Despite these differences, all studies consistently emphasized that screening for CRC was cost-effective compared with no screening for each of the recognized screening strategies. Newer technologies for colorectal cancer screening, including computed tomographic colonography (CTC), faecal DNA test, and Pillcam Colon are less invasive and accurate, however, they are not cost-effective, as their cost was higher than all other established screening strategies. When compliance and adherence to such new techniques are increased more than the established strategies they would be more cost-effective particularly CTC.

Colon Capsule Endoscopy for the Detection of Colorectal Polyps: An Economic Analysis.

BACKGROUND: Colorectal cancer is a leading cause of mortality and morbidity in Ontario. Most cases of colorectal cancer are preventable through early diagnosis and the removal of precancerous polyps. Colon capsule endoscopy is a non-invasive test for detecting colorectal polyps. OBJECTIVES: The objectives of this analysis were to evaluate the cost-effectiveness and the impact on the Ontario health budget of implementing colon capsule endoscopy for detecting advanced colorectal polyps among adult patients who have been referred for computed tomographic (CT) colonography. METHODS: We performed an original cost-effectiveness analysis to assess the additional cost of CT colonography and colon capsule endoscopy resulting from misdiagnoses. We generated diagnostic accuracy data from a clinical evidence-based analysis (reported separately), and we developed a deterministic Markov model to estimate the additional long-term costs and life-years lost due to false-negative results. We then also performed a budget impact analysis using data from Ontario administrative sources. One-year costs were estimated for CT colonography and colon capsule endoscopy (replacing all CT colonography procedures, and replacing only those CT colonography procedures in patients with an incomplete colonoscopy within the previous year). We conducted this analysis from the payer perspective. RESULTS: Using the point estimates of diagnostic accuracy from the head-to-head study between colon capsule endoscopy and CT colonography, we found the additional cost of false-positive results for colon capsule endoscopy to be $0.41 per patient, while additional false-negatives for the CT colonography arm generated an added cost of $116 per patient, with 0.0096 life-years lost per patient due to cancer. This results in an additional cost of $26,750 per life-year gained for colon capsule endoscopy compared with CT colonography. The total 1-year cost to replace all CT colonography procedures with colon capsule endoscopy in Ontario is about $2.72 million; replacing only those CT colonography procedures in patients with an incomplete colonoscopy in the previous year would cost about $740,600 in the first year. LIMITATIONS: The difference in accuracy between colon capsule endoscopy and CT colonography was not statistically significant for the detection of advanced adenomas (≥ 10 mm in diameter), according to the head-to-head clinical study from which the diagnostic accuracy was taken. This leads to uncertainty in the economic analysis, with results highly sensitive to changes in diagnostic accuracy. CONCLUSIONS: The cost-effectiveness of colon capsule endoscopy for use in patients referred for CT colonography is $26,750 per life-year, assuming an increased sensitivity of colon capsule endoscopy. Replacement of CT colonography with colon capsule endoscopy is associated with moderate costs to the health care system.

Capsule Endoscopy in the Assessment of Obscure Gastrointestinal Bleeding: An Economic Analysis.

BACKGROUND: Small-bowel capsule endoscopy is a tool used to visualize the small bowel to identify the location of bleeds in obscure gastrointestinal bleeding (OGIB). Capsule endoscopy is currently funded in Ontario in cases where there has been a failure to identify a source of bleeding via conventional diagnostic procedures. In Ontario, capsule endoscopy is a diagnostic option for patients whose findings on esophagogastroduodenoscopy, colonoscopy, and push enteroscopy have been negative (i.e., the source of bleeding was not found). OBJECTIVES: This economic analysis aims to estimate the budget impact of different rates of capsule endoscopy use as a complement to push enteroscopy procedures in patients aged 18 years and older. DATA SOURCES: Population-based administrative databases for Ontario were used to identify patients receiving push enteroscopy and small-bowel capsule endoscopy in the fiscal years 2008 to 2012. REVIEW METHODS: A systematic literature search was performed to identify economic evaluations of capsule endoscopy for the investigation of OGIB. Studies were assessed for their methodological quality and their applicability to the Ontarian setting. An original budget impact analysis was performed using data from Ontarian administrative sources and published literature. The budget impact was estimated for different levels of use of capsule endoscopy as a complement to push enteroscopy due to the uncertain clinical utility of the capsule based on current clinical evidence. The analysis was conducted from the provincial public payer perspective. RESULTS: With varying rates of capsule endoscopy use, the budgetary impact spans from savings of $510,000, when no (0%) push enteroscopy procedures are complemented with capsule endoscopy, to $2,036,000, when all (100%) push enteroscopy procedures are complemented with capsule endoscopy. A scenario where 50% of push enteroscopy procedures are complemented with capsule endoscopy (expected use based on expert opinion) would result in additional expenditure of about $763,000. LIMITATIONS: In the literature on OGIB, estimates of rebleeding rates after endoscopic procedures or spontaneous cessation rates are unreliable, with a lack of data. Rough estimates from expert consultation can provide an indication of expected additional use of capsule endoscopy; however, a wide range of capsule uses was explored. CONCLUSIONS: The budgetary impact in the first year in Ontario of capsule endoscopy use to complement push enteroscopy procedures ranges from $510,000 in savings to an additional expenditure of $2,036,000 (at 0% and 100% push enteroscopy procedures complemented, respectively). The expected scenario of 50% of push enteroscopy procedures likely to benefit from the use of capsule endoscopy, based on expert opinion, would result in additional expenditures of $763,000 in the first year.

[Diagnostic yield of video capsule endoscopy in premenopausal women with iron-deficiency anemia]. / Rentabilidad de la cápsula endoscópica en mujeres premenopáusicas con anemia ferropénica.

UNLABELLED: Clinical practice guidelines recommend video capsule endoscopy (VCE) studies in patients with iron-deficiency anemia (IDA) after conventional upper and lower endoscopies but there is a need for studies demonstrating the diagnostic yield, clinical impact, and cost in some patient subgroups. OBJECTIVES: 1.To determine the diagnostic yield of VCE in premenopausal women with IDA compared with that in men and postmenopausal women. 2. To identify the presence of VCE predictors in premenopausal women. 3. To estimate the cost-clinical impact relationship associated with VCE in this indication. MATERIAL AND METHOD: We retrospectively analyzed 408 patients who underwent VCE. Patients with IDA were enrolled (premenopausal, postmenopausal women, and men), with previous normal work-up by conventional endoscopies. RESULTS: A total of 249 patients were enrolled: 131 women (52.6%), of which 51 were premenopausal and 80 were post-menopausal, and 118 men. The mean age was 60.7±16 years. The diagnostic yield of VCE for the diagnosis of IDA was 44.6% (95% CI 39.9 - 50.8). Diagnostic yield was 50.8% vs 38.9% in men vs women (p=0.05) and was 55% vs 13.7% in postmenopausal vs premenopausal women (p<0.001). No predictors of small bowel lesions were found in premenopausal women. The most common findings in the postmenopausal group were angioectasias (70.5%) and erosions (57.1%) in the premenopausal group. The cost in premenopausal women was 44.727€ and 86.3% of the procedures had no clinical impact. CONCLUSIONS: The diagnostic yield of VCE is low in the etiological study of IDA in premenopausal women and there is no cost-effectiveness in relation to clinical impact. No predictors of small bowel lesions were found in this group.

A platform for gastric cancer screening in low- and middle-income countries.

Gastric cancer is the second leading cause of cancer death worldwide and screening programs have had a significant impact on reducing mortality. The majority of cases occur in low- and middle-income countries (LMIC), where endoscopy resources are traditionally limited. In this paper, we introduce a platform designed to enable inexpensive gastric screening to take place in remote areas of LMIC. The system consists of a swallowable endoscopic capsule connected to an external water distribution system by a multichannel soft tether. Pressurized water is ejected from the capsule to orient the view of the endoscopic camera. After completion of a cancer screening procedure, the outer shell of the capsule and the soft tether can be disposed, while the endoscopic camera is reclaimed without needing further reprocessing. The capsule, measuring 12 mm in diameter and 28 mm in length, is able to visualize the inside of the gastric cavity by combining waterjet actuation and the adjustment of the tether length. Experimental assessment was accomplished through a set of bench trials, ex vivo analysis, and in vivo feasibility validation. During the ex vivo trials, the platform was able to visualize the main landmarks that are typically observed during a gastric cancer screening procedure in less than 8 min. Given the compact footprint, the minimal cost of the disposable parts, and the possibility of running on relatively available and inexpensive resources, the proposed platform can potentially widen gastric cancer screening programs in LMIC.

The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the ED.

STUDY OBJECTIVE: Acute upper gastrointestinal (GI) hemorrhage is a common presentation in hospital-based emergency departments (EDs). A novel diagnostic approach is to use video capsule endoscopy to directly visualize the upper GI tract and identify bleeding. Our objective was to evaluate and compare the relative costs and benefits of video capsule endoscopy compared to other strategies in low- to moderate-risk ED patients with acute upper GI hemorrhage. METHODS: We constructed a model using standard decision analysis software to examine the cost-effectiveness of 4 available strategies for a base-case patient who presents to the ED with either mild- or moderate-risk scenarios (by Glasgow-Blatchford Score) for requiring invasive hemostatic intervention (ie, endoscopic, surgical, etc) The 4 available diagnostic strategies were (1) direct imaging with video capsule endoscopy performed in the ED; (2) risk stratification using the Glasgow-Blatchford score; (3) nasogastric tube placement; and, finally, (4) an admit-all strategy. RESULTS: In the low-risk scenario, video capsule endoscopy was the preferred strategy (cost $5691, 14.69 quality-adjusted life years [QALYs]) and was more cost-effective than the remaining strategies including nasogastric tube strategy (cost $8159, 14.69 QALYs), risk stratification strategy (cost $10,695, 14.69 QALYs), and admit-all strategy (cost $22,766, 14.68 QALYs). In the moderate-risk scenario, video capsule endoscopy continued to be the preferred strategy (cost $9190, 14.56 QALYs) compared to nasogastric tube (cost $9487, 14.58 QALYs, incremental cost-effectiveness ratio $15,891) and more cost effective than admit-all strategy (cost, $22,584, 14.54 QALYs.) CONCLUSION: Video capsule endoscopy may be cost-effective for low- and moderate-risk patients presenting to the ED with acute upper GI hemorrhage.

Capsule endoscopy in a network cooperation: assessment of the experience in 822 patients.

INTRODUCTION: Capsule endoscopy (CE) is firmly established as a standard procedure in the diagnostic algorithm of occult or obscure gastrointestinal bleeding and Crohn's disease. Despite its excellent diagnostic yield, missing expertise, reading time and financial expenditure limit an area-wide availability. A multicentric cooperation might compensate these disadvantages. METHODS: CE device was bought by a central hospital (CH). Requested equipment is transported to the network partner (NP) and the procedure performed at the spot in personal responsibility. Video reading is exclusively done in the CH. RESULTS: Within 10 years, 822 CE (438 m., 384 f.; 63 ± 17 (13-92) years) were performed by 18 cooperating gastroenterological departments. 587/822 (71%) CE were done at NP, 235/822 (29%) in the CH. Between 2002 (n = 39) and 2011 (n = 123) the annual number of CE increased threefold. 95% of the capital investment in each cooperating hospital could be avoided by sharing one workstation within the network. Leading indication for CE was suspected mid-GI-bleeding (80%). Mean latencies between requested date and actual examination were 0 and between equipment's return and report 2 days. 45/191(24%) flexible enteroscopies performed in the CH followed CE findings from NP. DISCUSSION: Our 10 years experience show that mobile use of CE is feasible providing quality parameters similar to a single center solution, increases the number of CE investigations, therefore, improves reading expertise and enables both an area-wide and economic offer for this technique. Additionally, patients with the need for invasive enteroscopy are identified and attracted to that NP who provides an invasive SB endocopy device.

[Utility and cost of the endoscopic capsule. Three years' experience in our center]. / Utilidad y coste de la cápsula endoscópica. Tres años de experiencia de nuestro centro.

INTRODUCTION: The aim of this study was to evaluate the safety, clinical impact and costs associated with capsule endoscopy (CE) in our center. RESULTS: We retrospectively analyzed the CE procedures carried out in our center from 2009 to 2012. The most frequent indications were investigation of anemia (39%), obscure gastrointestinal bleeding (OGIB) (19%) and inflammatory bowel disease (IBD)(18%). Findings were positive in 51% of the patients, which had a clinical impact in 36.5%. The indication in which CE had the greatest clinical impact was IBD (74.5%, p<0,001). The clinical impact of CE in OGIB and anemia was 41% and 26%, respectively. The procedures performed represented an investment of at least 132 600€; since 63.5% of the procedures had no clinical impact, an investment of 84 200€ had no effect on patient management. In patients who underwent CE for OGIB, early performance of the procedure (<7 days) was related to the presence of pathological findings and clinical impact. We found no other epidemiological, clinical or analytic factors able to predict the clinical impact of CE in the various indications. CONCLUSIONS: In our experience, CE had the greatest impact in the study of IBD and, if performed early, in OGIB. However, the indications for CE in the study of anemia should be most precisely defined to achieve a greater clinical impact in this disorder.

Small bowel endoscopy: cost-effectiveness of the different approaches.

Obscure gastrointestinal haemorrhage is defined the presence of overt or occult bleeding in the setting of a normal endoscopic examination of the upper and lower gastrointestinal tracts. While obscure bleeding is not common, the evaluation and management of these patients often incurs considerable expense. Potential options for small bowel evaluation include traditional radiographic studies, push enteroscopy, video capsule endoscopy, deep enteroscopy, tagged red blood cell scans, angiography, and enterography examinations with either computed tomography and/or magnetic resonance imaging. The decision regarding which modality to employ depends on the cost of the procedure, its effectiveness in rendering a diagnosis, and the potential for administration of therapy. This article will discuss determination of costs associated with technology for small bowel imaging, quality of life data associated with chronic GI haemorrhage, and available cost-effectiveness studies comparing the options for small bowel exploration.

Analysis of small-bowel capsule endoscopy reading by using Quickview mode: training assistants for reading may produce a high diagnostic yield and save time for physicians.

GOAL: The aim was to investigate the clinical utility of RAPID Access 6.5 Quickview software and to evaluate whether preview of the capsule endoscopy video by a trained nurse could detect significant lesions accurately compared with endoscopists. BACKGROUND: As reading capsule endoscopy is time consuming, one possible cost-effective strategy could be the use of trained nonphysicians or newly available software to preread and identify potentially important capsule images. STUDY: The 100 capsule images of a variety of significant lesions from 87 patients were investigated. The minimum percentages for settings of sensitivity that could pick up the selected images and the detection rate for significant lesions by a well-trained nurse, two endoscopists with limited experience in reading, and one well-trained physician were examined. RESULTS: The frequency of the selected lesions picked up by Quickview mode using percentages for sensitivity settings of 5%, 15%, 25%, and 35% were 61%, 74%, 93%, and 98%, respectively. The percentages for sensitivity significantly correlated (r=0.78, P<0.001) with the reading time. The detection rate by the nurse or the well-trained physician was significantly higher than that by the physician with limited capsule experience (87% and 84.1% vs. 62.7%; P<0.01). The clinical use of Quickview at 25% did not significantly improve the detection rate. CONCLUSIONS: Quickview mode can reduce reading time but has an unacceptably miss rate for potentially important lesions. Use of a trained nonphysician assistant can reduce physician's time and improve diagnostic yield.

Cost effectiveness and projected national impact of colorectal cancer screening in France.

BACKGROUND: Colorectal cancer (CRC) is a major cause of morbidity and mortality in France. Only scanty data on cost-effectiveness of CRC screening in Europe are available, generating uncertainty over its efficiency. Although immunochemical fecal tests (FIT) and guaiac-based fecal occult blood tests (g-FOBT) have been shown to be cost-effective in France, cost-effectiveness of endoscopic screening has not yet been addressed. METHODS: Cost-effectiveness of screening strategies using colonoscopy, flexible sigmoidoscopy, second-generation colon capsule endoscopy (CCE), FIT and g-FOBT were compared using a Markov model. A 40 % adherence rate was assumed for all strategies. Colonoscopy costs included anesthesiologist assistance. Incremental cost-effectiveness ratios (ICERs) were calculated. Probabilistic and value-of-information analyses were used to estimate the expected benefit of future research. A third-payer perspective was adopted. RESULTS: In the reference case analysis, FIT repeated every year was the most cost-effective strategy, with an ICER of €48165 per life-year gained vs. FIT every 2 years, which was the next most cost-effective strategy. Although CCE every 5 years was as effective as FIT 1-year, it was not a cost-effective alternative. Colonoscopy repeated every 10 years was substantially more costly, and slightly less effective than FIT 1-year. When projecting the model outputs onto the French population, the least (g-FOBT 2-years) and most (FIT 1-year) effective strategies reduced the absolute number of annual CRC deaths from 16037 to 12916 and 11217, respectively, resulting in an annual additional cost of €26 million and €347 million, respectively. Probabilistic sensitivity analysis demonstrated that FIT 1-year was the optimal choice in 20% of the simulated scenarios, whereas sigmoidoscopy 5-years, colonoscopy, and FIT 2-years were the optimal choices in 40%, 26%, and 14%, respectively. CONCLUSIONS: A screening program based on FIT 1-year appeared to be the most cost-effective approach for CRC screening in France. However, a substantial uncertainty over this choice is still present.

Colon capsule endoscopy compared with conventional colonoscopy for the detection of colorectal neoplasms.

Given the low compliance with screening colonoscopy in countries with a national colorectal cancer screening program, noninvasive methods with an acceptable high rate of sensitivity and specificity are welcome to enlarge the array of screening tools. Colon capsule endoscopy seems to be a safe and effective method of visualizing the colonic mucosa without the need for sedation or insufflation of air. Bowel cleansing for colon capsule endoscopy is more rigorous as only excellent or good results can be accepted in order to obtain an adequate sensitivity. This restricts its application on persons who are able to drink 4 l of polyethylene glycol plus laxatives. The sensitivity of colon capsule endoscopy to detect polyps, advanced adenomas and cancer is lower compared with optical colonoscopy. It still seems to be an adequate alternative for patients reluctant to undergo colonoscopy. Conventional colonoscopy is still established as the gold standard in colorectal cancer screening and is used to evaluate positive screening tests of all programs. It is the only method with the ability to remove detected polyps and obtain biopsy specimens.

Bleeding lesions within reach of conventional endoscopy in capsule endoscopy examinations for obscure gastrointestinal bleeding: is repeating endoscopy economically feasible?

BACKGROUND: Most tertiary gastroenterology centers currently offer an open-access capsule endoscopy (CE) service, including patients with obscure gastrointestinal bleeding. However, CE may identify lesions missed by conventional endoscopy. AIMS: To determine the incidence of bleeding lesions missed by the preceding gastroscopy/colonoscopy that were revealed by CE and compare potential differences in the rate of identifying such lesions in patients that we investigated as opposed to those investigated elsewhere. METHODS: We prospectively reviewed data from patients subjected to CE for obscure bleeding. We analyzed all cases where a source of bleeding was located in the stomach, duodenum, or colon. RESULTS: A total of 317 consecutive patients were subjected to CE for obscure gastrointestinal bleeding within 28 months. Prior to CE examination, 174 patients had gastroscopy and colonoscopy in our institutions and 143 were referrals, all with negative endoscopic investigation. We identified 11 (3.5%) cases where the source of bleeding was found in the stomach (n = 4) or the cecum (n = 7). There was a significant difference of extra small intestinal lesions diagnosed by CE between referrals (9/143, 6.3%) and endoscopic investigation performed in our institutions (2/174, 1.15%), (p = 0.026). The estimated cost of re-endoscoping in our institution all CE referrals would be 50,050 euro (143 patients × 350 euro), to avoid unnecessary CE examinations (9 patients × 600 euro = 5,400 euro). CONCLUSIONS: Reading the whole CE video is important, because small-bowel CE may identify lesions responsible for obscure bleeding missed by the preceding gastroscopy and colonoscopy. Repeating conventional endoscopy by experts before CE is not a cost-effective approach.