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Tsuboi et al. Mini-invasive Surg 2024;8:26 https://dx.doi.org/10.20517/2574-1225.2023.94 Page 3 of 21

While SBCE is minimally invasive and highly accurate in detecting small-bowel lesions, it does not allow for
pathological diagnosis through tissue sampling. In contrast, DAE is invasive but enables both pathological
diagnosis via tissue sampling and endoscopic treatments, such as endoscopic hemostasis, endoscopic
balloon dilation, and endoscopic resection. SBCE is recommended as the first-line modality for suspected
small-bowel bleeding in the guidelines of the U.S, Europe, and Japan . Further examination with DAE is
[2-4]
recommended depending on the findings of SBCE. In patients with overt small-bowel bleeding, early
examinations of SBCE following a bleeding episode yield higher diagnostic outcomes . Uchida et al.
[14]
conducted a meta-analysis and found that performing SBCE within two days of bleeding leads to elevated
diagnostic and therapeutic yields (55.9% and 65.2%, respectively) . Consequently, ESGE guidelines
[3]
[14]
recommend SBCE examination within 48 h of suspected small-bowel bleeding.

[15]
In terms of total enteroscopy rates, double-balloon endoscopy has been reported at 44% , single-balloon
enteroscopy at 17% , and motorized spiral enteroscopy at 61%-70% [17,18] . On the other hand, the total
[16]
[19]
enteroscopy rate of SBCE is reported to be 85% . Thus, SBCE has a higher exploration rate of the entire
small-bowel compared to other enteroscopy methods.
The total enteroscopy rate of DAE via the anterograde route was reported to be 1.6% for double-balloon
enteroscopy and 16.7% for motorized spiral enteroscopy . Thus, physicians typically select the insertion
[15]
[17]
route for DAE - antegrade or retrograde - based on physical findings and cross-sectional imaging in clinical
practice. The usefulness of SBCE for selecting the DAE route has been reported [20-26] . In a recent meta-
analysis, the localization of small-bowel lesions by SBCE was found to be useful; however, 3D localization
[27]
technologies and tracking systems need to be developed to further improve accuracy .
The indications, contraindications, preparation, completeness, and safety profiles of SBCE
The indications and contraindications for SBCE vary among devices. Generally, the indication for SBCE is
diagnosis and surveillance of small-bowel disease, including suspected small-bowel bleeding, chronic
diarrhea, chronic abdominal pain, the detection and surveillance of small-bowel lesions associated Crohn’s
disease, celiac disease, graft versus host disease, collagen disease, and vasculitis. It is also indicated for
detecting small-bowel lesions in polyposis syndromes, such as familial adenomatous polyposis and Peutz-
Jeghers syndrome. An absolute contraindication, regardless of the model, is known or suspected
gastrointestinal obstructions, strictures, or fistulas. SBCE devices that require radiofrequency for image
transfer are contraindicated for patients with implanted cardiac devices, such as pacemakers or implantable
cardioverter defibrillators (ICD). Although the manufacturer advises against using SBCE for patients with
implanted cardiac devices, a meta-analysis showed that the examination in these patients was safe, and
SBCE did not affect the devices . Artifacts in SBCE images occurred in 5.8% of patients with left
[28]
[28]
ventricular assist devices (LVAD) . Although these artifacts did not affect the diagnostic yield, the number
of patients with LVADs and ICDs is small. Thus, SBCE is not recommended for these patients. In fact, while
the guidelines do not restrict the use of CE in patients with implanted pacemakers, they do not mention
patients with LVADs or ICDs [29,30] . Patients with dysphagia are considered to have relative contraindications
due to the risk of aspiration. However, endoscopic placement is effective for these patients to avoid
aspiration, and the effectiveness of AdvanCE delivery device (US Endoscopy Inc., Mentor, OH, USA), a
dedicated device that can be used for PillCam, has recently been reported . SBCE during pregnancy is not
[31]
recommended due to limited data.

The preparation for SBCE remains controversial. Initially, preparation was not recommended when SBCE
was first developed. However, as SBCE moves through the gastrointestinal tract and captures images
automatically, the visibility of the mucosa can be reduced by residual material and air bubbles.