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Page 8 of 21 Tsuboi et al. Mini-invasive Surg 2024;8:26 https://dx.doi.org/10.20517/2574-1225.2023.94

Figure 3. Images of colon tumors by colon capsule endoscopy. (A): The endoscopic image of a 0-Is lesion located in the sigmoid
TM
colon using colon capsule endoscopy (PillCam CCE2); (B): A conventional colonoscopy image of the same lesion detected by
CCE2; (C): An endoscopic image of 0-IIa lesion located in transverse colon by CCE2; D: A conventional chromoendoscopy image of
the same lesion detected by CCE2. CCE: Colon capsule endoscopy.

MES and UCEIS are based on CS images and are not specific scoring systems for CCE. To address this,
Hosoe et al. developed Capsule Scoring of Ulcerative Colitis (CSUS), a scoring system based on CCE-2,
which they reported correlates with fecal calprotectin, the Lichtiger index, and UCEIS . Matsubayashi et
[91]
al. reported a higher relapse rate in patients with ulcerative colitis in remission who had a CSUC score
higher than 1 compared to those with a CSUC score of 0 . Based on the above, CCE-2 can serve as an
[93]
alternative examination to CS for disease assessment in ulcerative colitis. However, there are no reports on
the usefulness of CCE-2 regarding neoplasia associated with ulcerative colitis, and further case
accumulation will be needed.

Although CCE is a minimally invasive modality with a high diagnostic yield, it has several limitations. The
first problem is the detection rate of flat and diminutive lesions. It has been reported that lateral spreading
tumors and sessile serrated lesions in the right-sided colon are more likely to yield false negatives [96,97] . While
the diagnostic accuracy for polyps larger than 6 mm is adequate, there are insufficient studies on the
detection of smaller lesions. The second issue is the lengthy reading time; physicians need to examine
images captured by the two cameras separately, requiring 50 to 60 min of reading time [98,99] . Thus, compared
with the CS, CCE can be time-consuming and burdensome for physicians. Furthermore, CCE is expensive
compared to other modalities, such as CS and CTC, costing approximately 100,000 yen in Japan. Another
challenge is the extensive bowel preparation required for CCE, involving laxatives for both bowel cleansing
and promoting capsule excretion. To ensure the detection of colorectal polyps, CCE necessitates the use of 2