August 11, 2022
Cancer in Israel: Capsule Endoscopy

This week, we continue our series on selected topics regarding cancer in Israel. In recent years, Israel has become a major leader in the technology and startup arena in health products. A leading example of the success in this arena has been the work of Gavriel Iddan.

One of the great technological advances that has made major contributions to medicine is fiber optic technology. The ability to transmit light along thin, flexible fibers and cables has had many applications in industry and elsewhere, especially telecommunications. One of the key individuals responsible for its development was awarded the Nobel Prize in Physics in 2009.

Fiber optics had its main applications in medicine in the creation of various flexible scopes. These have become a mainstay of otolaryngology, as well as pulmonary medicine with bronchoscopy, and the use of arthroscopy for inspection of joints by orthopedists. But perhaps the best known use of endoscopy has been in the alimentary tract. Esophagogastroduodenoscopy (EGD) is a commonly used tool for diagnostic evaluation of the upper GI tract (esophagus, stomach, duodenum) while colonoscopy is widely used for screening and diagnosis of the lower GI tract.

Between the 1.2 meters of the upper gastrointestinal tract and the 1.8 meters of the large intestine, however, is a large organ, the small bowel or small intestine, comprising an additional 6 meters, which is mostly inaccessible to either of these instruments. In truth, it was previously difficult to undertake diagnostic studies of conditions which involved the small intestine—tumors of one type or another, Crohn’s disease, celiac disease, etc.

Gavriel Iddan, born in Haifa in 1941, was an electro-optical engineer (whatever that is) and a graduate of the Technion in Haifa. He worked for the Rafael Armament Development Authority in Israel, working on guided missile technology, part of the research and development branch of the Israeli Ministry of Defense. In 1981, he was on a sabbatical leave in Boston and living next door to an Israeli gastroenterologist, Eitan Scappa. Iddan was working at Elscint, a company specializing in medical imaging. His neighbor, Dr. Scappa, developed some type of stomach ailment and Iddan became aware that there was no technology available for investigating his neighbor’s small bowel. This began his 20-year quest to solve the problem.

Iddan realized that the solution to the problem could lie with small charged coupled device imaging chips which had just been developed. (I have no clue what they are.)

By 1998, he had developed a prototype for an ingestible wireless capsule that contained a battery-powered camera and transmitter. This device would traverse the entire gastrointestinal tract and transmit images of the small bowel to a receiver held on the patient’s abdomen. Ultimately the device, capsule endoscopy, was created under the aegis of a new biotechnology company, Given Imaging, with a patent in 1999. The first patient underwent examination with this device in Dr. Scappa’s office in Ramat Hasharon near Tel Aviv. In this first trial, the capsule became stuck in the duodenum (the first part of the small intestine) and had to be pushed along by an endoscope.

In its current usage, it takes about an hour for the capsule endoscope to pass through the stomach. To get through the small intestine can take approximately another six hours. Passage through the large bowel is variable and can take hours or days. When the procedure is done, the recorder and patches are returned to the physician. The capsule itself is disposable and can be flushed down the toilet.

The procedure costs between $1,000 and $2,000. Once in about 1,000 procedures the capsule gets stuck and has to be retrieved in some fashion.

Given Imaging is headquartered in Yokneam, which seems to be the Israeli equivalent of Silicon Valley. It is a poster child for Israel’s hugely successful technology industries, with 140 scientists and technicians per 10,000 employees versus 85 in the U.S.

At this time, efforts are ongoing to expand the use of capsule endoscopy to investigate the large intestine and stomach. The same technology and video camera can be utilized to image those organs. In particular, it could hypothetically substitute for colonoscopy for those unwilling or unable to undergo that procedure. At this time, over 2 million capsule endoscopies are performed annually worldwide. One limitation is that additional procedures are limited, such as biopsies, but research groups are currently working to expand the ability of the capsule to be able to perform such procedures as well.