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Wireless Capsule Endoscopy P Swain iv48 PAPER Gut: first published as 10.1136/gut.52.suppl_4.iv48 on 1 June 2003. Downloaded from Wireless capsule endoscopy P Swain ............................................................................................................................. Gut 2003;52(Suppl IV):iv48–iv50 Gastroscopy, small bowel endoscopy, and colonoscopy was initially associated with CMOS image sen- are uncomfortable because they require comparatively sors. As a result it is now possible to design and build a CMOS imager that is comparable in image large diameter flexible cables to be pushed into the quality to the charge coupled device (CCD) image bowel, which carry light by fibreoptic bundles, power, sensors,7 but of extremely small size, and requir- and video signals. Small bowel endoscopy is currently ing significantly lower power than CCD sensors. Recent advances in ASIC design permitted the especially limited by problems of discomfort and failure integration of a colour video transmitter of suffi- to advance enteroscopes far into the small bowel. There cient power output, efficiency, and bandwidth of is a clinical need for better methods to examine the very small size into the capsule. Synchronous switching of the LED and the small bowel especially in patients with recurrent CMOS sensor was designed to minimise power gastrointestinal bleeding from this site. consumption. By careful design of the optics and .......................................................................... the transparent dome window it was possible to eliminate the stray light and reflections that are common problems when the illumination and isualisation of the whole stomach, upper imager are incorporated under the same dome. small bowel, and colon became possible The realisation of this technology has required 1 Vafter the invention of fibreoptic endoscopy. the conjunction of a series of advances in image Miniaturisation of electronic components has sensors, LED and ASIC design, the solution of allowed radical changes to the design of complex taxing optical, power and size problems, as well as structures using electrical power. The invention of the development of successful airless methods of the transistor in the 1950s by Bardeen, Brattain endoscopy. and Shockley (awarded the Nobel Prize in 1956 for work announced in 1949) was probably the Co-development single most important advance responsible for Two groups working independently on this the electronic revolution, which by miniaturising project in Israel and London joined forces in 1997 http://gut.bmj.com/ large electronic devices has permitted the devel- to complete the technical development of the opment of portable computers, telephones, and wireless capsule endoscope.8 The London group personal stereo systems. The newly invented published conceptual studies in 19949 and ac- transistor was quickly exploited for medical quired the first live pictures from the stomach of purposes with the development of electronic a pig with a miniature wireless camera using CCD radiotelemetry capsules, which were small technology, and a microwave transmitter in enough to swallow for the study of gastro- 10 1997, and performed the first feasibility studies on September 29, 2021 by guest. Protected copyright. intestinal physiological parameters. These cap- on airless endoscopy.11 Gavriel Iddan described a sules permitted measurements of temperature,2 34 34 video system for wireless endoscopy with an pressure, and pH. innovative lens system in 199712 and the Israeli team were the first to realise the value of CMOS TECHNOLOGICAL DEVELOPMENTS for this purpose and to make a device in The development and testing is described of a dimensions that could be readily swallowed by a new type of radiotelemetry capsule endoscope,56 human. With ethical committee approval the first which is small enough to be swallowed (11×27 human volunteer study was performed in August mm) and has no external wires, fibreoptic 1999. The author was privileged to swallow the bundles, or cables. first two wireless capsule endoscopes on consecu- The design of the video capsule was made pos- tive days. The capsule was easily swallowed and sible because of progress in the design and caused no discomfort. The capsule, propelled by performance of three technologies: complemen- peristalsis, successfully reached the caecum. The tary metal oxide silicon (CMOS) image sensors, image window remained clear throughout the application specific integrated circuit (ASIC) whole of the transmissions with transmission devices, and white light emitting diode (LED) times of up to seven hours. illumination. In addition novel optical design and The wireless capsule endoscope has received a ....................... better energy management and overall system CE mark and FDA approval in August 2001 for use in patients. Correspondence to: design were important in the capsule realisation. Professor C P Swain, During the past 10 years advances in CMOS Endoscopy Unit, Royal technology lead to a substantial reduction of ele- London Hospital, ment size below 1 micron. This size reduction in ................................................. Whitechapel, London turn made possible the inclusion of a buffer E1 1BB, UK; Abbreviations: CMOS, complementary metal oxide [email protected] amplifier on each pixel of the CMOS image silicon; ASIC, application specific intergrated circuit; LED, ....................... sensors thus reducing the output noise level that light emitting diode; CCD, charge coupled device www.gutjnl.com Wireless capsule endoscopy iv49 CURRENT TECHNOLOGY bleeding in 55% with the capsule and 30% with push enteros- A short focal length lens is used with a narrow aperture to copy. The capsule found the only malignancy in this series and Gut: first published as 10.1136/gut.52.suppl_4.iv48 on 1 June 2003. Downloaded from increase the depth of field. Images are obtained as the optical found a cause of bleeding beyond reach of the push window of the capsule sweeps past the gut wall, without enteroscope in 25%. There was good interobserver agreement requiring air inflation of the gut lumen. This optical arrange- between blind and unblinded observers. Wireless capsule ment allows the tissue to be in focus even if it is in contact endoscopy has been able to image abnormalities never seen with the optical dome window but also remain in focus over a before using flexible endoscopes. A report of the first few centimetres if the lumen is open with residual air or fluid. endoscopic diagnosis of a Meckel’s diverticulum made by The capsule endoscope is propelled by peristalsis though the wireless capsule has been reported.18 gastrointestinal tract and does not require a pushing force to Several clinical studies presented during Digestive Disease propel it through the stomach, small bowel, or colon. Because Week 2002 that are published in abstract form have confirmed the gut is a hollow tube it is comparatively unimportant that wireless capsule endoscopy is significantly superior to whether the capsule points forwards or backwards as it passes push enteroscopy in its ability to find bleeding abnormalities through. in the small intestine and that the examination is invariably The video images are transmitted using radiotelemetry preferred by patients undergoing both procedures.16–22 One (operating in UHF at 432 megahertz) to an array of eight aeri- study showed that wireless capsule endoscopy was signifi- als attached to the body, which permitted image capture but cantly superior to barium studies if small intestinal pathology which were also used to calculate and indicate the position of was suspected.23 the capsule in the body. The images are stored on a small port- The clinical indications for the use of wireless capsule able recorder carried on a belt. This aerial belt enables the endoscopy are becoming clearer in the light of recent studies. continuous triangulation of the capsule location in the abdo- Several studies have demonstrated that this investigation is men so that the whole trajectory can be shown on the work especially valuable in patients with difficult recurrent gastro- station monitor to help in locating abnormalities detected by intestinal bleeding when gastroscopy and colonoscopy are the capsule imager. This method, which uses signal strength negative. It is likely to have a role in the further investigation analysis of received signals from eight aerial antennae of patients found to have small intestinal abnormalities on attached to the patient’s abdomen, at present has an accuracy barium studies and may well become an adjunct to investiga- of about ±3 cm. The capsule transmits images at a rate of two tion of Crohn’s disease patients,24 or coeliac disease patients frames per second for over seven hours permitting the acqui- with weight loss. Its use in Crohn’s disease is likely to be tem- sition of over 50 000 images. This system permits more than pered by the fact that at present there is no non-surgical seven hours of continuous recording of images of the gastro- method for retrieval of capsules that become stuck in intestinal tract. The patient need not be confined to a hospital strictures in the small intestine and the problem that neither or clinic environment during the examination and is free to clinical history nor barium studies exclude the presence of a continue their daily routine. stricture. The images are subsequently downloaded from the portable Von Willebrand’s disease is the one condition for which recorder for analysis off line (software is also available for British
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