Background Patency capsule (PC) is recommended before video capsule endoscopy (VCE) to prevent retention in high-risk patients, although PC testing has high failure rates (20-44% in high risk patients). Prior studies have identified predictors of failed PC expulsion under standard practice conditions, but predictors of failure despite standardized pro-motility preparation remain unclear. Objectives To evaluate baseline clinical factors associated with failed PC expulsion despite a standardized pro-motility preparation protocol. Design A retrospective analysis of a prospectively maintained database including all consecutive VCEs and PCs performed at a dedicated VCE service in our tertiary center between 01/2019-12/2023. Methods Multivariate logistic regression and classification tree (CRT) were used to identify predictive factors for failed expulsion. Results A total of 392 patients who underwent PC testing were included (median age 42 years; 47.4% males). Successful PC expulsion occurred in 323 patients (82.4%), while 69 failed (17.6%). Patients experiencing failed PC expulsion were significantly older, had higher body mass index (BMI), and fewer bowel movements per day (BPD). BPD<1 was twofold higher among patients with failed PC expulsion (20.3% vs. 9.6%; p=0.020). In multivariable logistic regression, higher BMI and BPD<1 were independently associated with failed PC expulsion. In exploratory CRT analysis, BPD<1 emerged as the primary splitting variable, while BMI and age provided additional subgroup stratification of observed failure rates. Conclusion Failed PC expulsion within the predefined 30-hour protocol window despite a standardized pro-motility preparation protocol was associated with higher BMI and lower BPD. These findings suggest that simple baseline factors related to gastrointestinal transit may retain predictive value even under protocolized preparation and may help support pre-test risk stratification.
Colon capsule endoscopy (CCE) is a patient-friendly, minimally invasive alternative to conventional colonoscopy, but its value depends on pathway performance rather than diagnostic accuracy alone. This narrative review examines the cost-effectiveness of CCE across colorectal cancer screening, symptomatic investigation, incomplete colonoscopy, post-polypectomy surveillance, inflammatory bowel disease monitoring, and AI-supported implementation. Targeted literature searches were performed in PubMed and official guidance sources through 6 July 2026. Across broad screening populations, CCE is not yet cost-effective compared with biennial faecal immunochemical testing (FIT) or 10-yearly colonoscopy; contemporary Dutch MISCAN modelling found all CCE screening strategies dominated at full adherence, largely because unit cost and follow-up colonoscopy burden remained high. The dominant economic problem is pathway duplication: a 2025 meta-analysis found a pooled follow-up endoscopy rate of 42%, and contemporary UK/Scottish service data showed that about half of patients required further optical endoscopy or sigmoidoscopy. CCE may offer conditional value after incomplete colonoscopy, in lower-risk symptomatic triage, and in carefully selected surveillance pathways where a negative or low-risk capsule result may avoid, defer, or focus colonoscopy. Evidence from Crohn’s disease and ulcerative colitis monitoring is encouraging but should not be extrapolated uncritically to colorectal cancer screening or dysplasia surveillance, where biopsy and therapy remain decisive. AI-assisted CCE may reduce reading time and improve polyp detection, but robust lifetime cost-effectiveness models are still needed. The current evidence supports CCE as a pathway-dependent filter, not a universal substitute for colonoscopy.
Background: Anorectal stricture is a challenging complication of Crohn’s disease (CD). Endoscopic needle-knife stricturotomy (NKSt) has emerged as a minimally invasive treatment option, but its long-term outcomes and factors influencing recurrence remain underexplored. Objectives: This study aimed to prospectively evaluate the long-term efficacy, safety, and risk factors for recurrence after NKSt for primary high-grade anorectal strictures in CD. Design: Single-center prospective cohort study. Methods: Between October 2020 and September 2023, 54 consecutive CD patients with primary high-grade anorectal strictures undergoing NKSt were enrolled. The primary endpoint was stricture recurrence requiring re-intervention. Risk factors were analyzed using univariable and multivariable Cox proportional hazards regression. Recurrence-free survival was estimated with the Kaplan-Meier method. A restricted cubic spline model within the Cox framework was employed to explore the nonlinear relationship between stricture length and recurrence. Results: The median follow-up was 24 months (interquartile range (IQR): 6–43). Immediate technical success was achieved in all patients (100%), and 38 patients (70.4%) reported symptomatic improvement at 3 months. Recurrence occurred in 20 patients (37.0%). Multivariable analysis identified stricture length (hazard ratio (HR) 1.184 per cm increase, 95% confidence interval (CI): 1.015–1.380; p = 0.032), the presence of an ostomy (HR 3.901, 95% CI: 1.406–10.823; p = 0.009), and concurrent biologic therapy (HR 0.177, 95% CI: 0.057–0.546; p = 0.003) as independent predictors of recurrence. In univariable analysis, NKSt combined with bleomycin injection was associated with a lower recurrence risk compared to NKSt alone ( p = 0.027). Conclusion: NKSt is an effective and safe treatment for primary high-grade anorectal strictures in CD, although recurrence is common. Stricture length, ostomy status, and the use of biologic agents are independent predictors of recurrence, while concomitant bleomycin injection may reduce recurrence risk. These findings can inform individualized treatment strategies and highlight the need for validation in larger, multicenter trials.
Background: Colon capsule endoscopy (CCE) is a minimally invasive alternative to colonoscopy, but its diagnostic performance depends entirely on adequate mucosal cleansing (adequate cleansing rate, ACR) and complete colonic transit (completion rate, CR). These requirements impose stringent preparation demands. Existing systematic reviews (SRs) show substantial heterogeneity in recommendations. Objectives: To identify optimal CCE preparation strategies. Design: Umbrella review (overview of SRs). Methods: A comprehensive literature search was conducted through November 2025 for SRs and meta-analyses (MAs) assessing CCE bowel preparation regimens. Methodological quality was assessed using AMSTAR2, and primary study overlap was quantified using the Corrected Covered Area (CCA). Outcomes included ACR and CR, stratified by preparation components. Results: Fourteen SRs (11 MAs) encompassing 102 primary studies (moderate overlap, CCA 8.59%) were included. Pooled ACR (72.5%–76.8%) and CR (79.8%–83.0%) remained below colonoscopy benchmarks. In inflammatory bowel disease, ACR varied widely (49%–98.5%) with no superior regimen. In the general population, low-volume polyethylene glycol (PEG <4 L) yielded higher ACR (77.5%) than high-volume PEG (72.9%). Sodium phosphate (NaP) boosters outperformed PEG specifically for CR, with NaP + Gastrografin achieving the highest CR (93.1%). Castor oil improved excretion (OR 0.17 of incomplete CCE transit, 95% CI 0.09–0.32), and routine prokinetics improved CR compared with no use (OR 1.86, 95% CI 1.13–3.05). Low-fiber diets provided better cleansing than clear liquids (ACR 78.5% vs 70.0%). Conclusion: Current CCE bowel preparation regimens demonstrate variable performance relative to targets, with no single intervention demonstrating unequivocal superiority over others in pairwise comparisons. Evidence supports optimizing performance via low-volume PEG, NaP or Gastrografin-based boosters, routine prokinetics, and a low-fiber diet. A universal regimen is unlikely to suit all patients, highlighting the need for personalized protocols. Standardized cleansing scores and AI-assisted assessment are critical to improving reproducibility and cost-effectiveness.
Background: There is no consensus on the optimal endoscopic drainage strategy for hilar malignant biliary obstruction (HMBO). Objectives: To compare transpapillary plastic stent (PS) plus endoscopic nasobiliary drainage (ENBD) with PSs alone for HMBO, and to evaluate risk factors for cholangitis in the combined strategy group. Design: Retrospective cohort study. Methods: A total of 175 consecutive patients with HMBO (Bismuth type II–IV) who underwent either PS plus ENBD or PSs alone were enrolled. Propensity score matching (1:1) was performed to reduce selection bias. The primary endpoint was successful drainage. Univariate analysis was used to identify risk factors for cholangitis in the PS plus ENBD group. Results: After matching, 74 patients remained in each group, with balanced baseline characteristics. Successful drainage rates were 77.0% in the PS plus ENBD group and 68.9% in the PSs alone group ( p = 0.267). The PSs alone group had significantly higher rates of cholangitis (23.0% vs 10.8%, p = 0.048) and overall adverse events (29.7% vs 12.2%, p = 0.009). No significant differences were observed in biliary patency, reintervention, or survival time between groups. In the PS plus ENBD group, initial drainage was associated with cholangitis (100.0% vs 59.3%, p = 0.011), and median drainage volume was lower in patients who developed cholangitis (85 mL vs 250 mL, p = 0.021). In 19 patients, the nasobiliary catheter was snipped to convert external to internal drainage. Conclusion: Endoscopic biliary stenting combined with ENBD followed by catheter snipping is a safe and effective approach for HMBO. The addition of ENBD was associated with reduced rates of cholangitis and overall adverse events. In this combined strategy, lack of initial drainage and low drainage volume were associated with cholangitis.
