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Tsuboi et al. Mini-invasive Surg 2024;8:26 https://dx.doi.org/10.20517/2574-1225.2023.94 Page 9 of 21

to 4 L of liquid laxatives such as PEG solution. In a recent meta-analysis, PEG laxative and sodium
phosphate (NaP) boosters were the most commonly used regimens. However, this regimen was not
[100]
associated with a higher complete examination rate or bowel cleansing level . Another meta-analysis
reported that routine prokinetics specifications and split-dose PEG were associated with complete
examinations . Ohmiya et al. reported the effectiveness of castor oil as a booster of CCE . They reported
[102]
[101]
that the capsule excretion rate of castor oil was significantly higher than that without castor oil (97% and
81%, respectively; P < 0.0001). In a recent meta-analysis, the castor oil has the potential for improvement of
excretion rates in CCE . To address these issues, the Japanese Association for Capsule Endoscopy (JACE)
[103]
recommends castor oil as the standard preparation regimen for CCE. Mizukami et al. reported that
encapsulation of castor oil increased patient tolerability while maintaining the capsule excretion rate .
[104]
However, patient acceptance is poor because of the unpleasant flavor of castor oil. On the other hand, for
patients with ulcerative colitis, the same rigorous preparation required for colorectal tumors is not necessary
[88]
to observe mucosal inflammation. Okabayashi et al. reported that a reduced dose of laxatives is possible .
In fact, in JACE, the recommended regimens are separated for patients with ulcerative colitis and colorectal
tumors.

We summarized the current issues for SBCE and CCE in Table 1.

CURRENT STATUS OF ECE
ECE was developed as a non-invasive diagnostic tool based on SBCE technology, aimed at visualizing the
esophagus without the need for sedation or invasive procedures associated with traditional endoscopy. The
first generation of esophageal capsules, such as the PillCam ESO (Given Imaging Ltd., Yoqneam, Israel),
was approved in 2004. The second generation of ECE, which has been improved and available since 2007,
TM
shares a similar size, shape, and weight with the small-bowel capsule (PillCam SB2), measuring 26 mm ×
11 mm. It is equipped with cameras on both ends that capture images at 18 FPS, compared to the 2-3 FPS of
TM
small-bowel capsules, providing a wider 169° angle of view. The third-generation ECE, PillCam ESO3,
features an even wider 174° angle of view and a higher recording rate of 35 FPS.

ECE was designed specifically to evaluate esophageal conditions, including gastroesophageal reflux disease
(GERD), Barrett’s esophagus (BE), and esophageal varices. ECE operates by capturing high-speed images of
the esophagus as the capsule travels through the gastrointestinal tract, offering a patient-friendly alternative
to standard endoscopic examinations. Currently, ECE is primarily used for screening and monitoring
esophageal varices, BE, and detecting other esophageal lesions in patients who are at high risk or unwilling
to undergo conventional endoscopy. A meta-analysis conducted by Bhardwaj et al. revealed that the pooled
sensitivity and specificity for the diagnosis of BE for all studies were 77% and 86%, respectively .
[105]
According to a recent meta-analysis by McCarty et al., the diagnostic pooled sensitivity and specificity for
esophageal varices were 83% and 85%, respectively . In a multicenter prospective ECE study for pediatric
[106]
patients by Cardey et al., the sensitivity, specificity, and accuracy for esophageal varices using a modified
classification were 100 %, 93 %, and 97 %, respectively . ECE is a well-tolerated and safe procedure,
[107]
making it a viable alternative to EGD in infants suspected of having esophageal varices or in cases where
EGD is declined, such as pediatric patients.

Recent improvements, such as the ability to transmit images in real-time, have enabled more immediate
interpretation, facilitating quicker clinical decision-making. Despite its advantages, ECE faces challenges,
including limited maneuverability compared to conventional endoscopes, the potential for incomplete
examinations due to rapid transit times, and the need for further validation in detecting early-stage
neoplasms. Additionally, image interpretation requires significant expertise, highlighting the need for