Colon capsule endoscopy (CCE) is a minimally invasive alternative to colonoscopy that offers a patient-friendly method of evaluating the colon. While its diagnostic yield is well established and shown to be comparable to conventional colonoscopy, far less is known about the downstream workload generated by CCE—particularly the need for subsequent colonoscopy, additional imaging, or repeat CCE examinations. Understanding these follow-up requirements is crucial for assessing service efficiency, planning resource allocation, and evaluating cost-effectiveness. As CCE becomes increasingly integrated into colorectal pathways, quantifying the procedural load it generates is essential for informed decision-making. This study aims to characterize the downstream workload associated with our CCE service over the past decade, with a specific focus on the frequency and drivers of follow-up procedures, including colonoscopy, imaging, and repeat CCE.

We conducted a retrospective analysis of all colon capsule endoscopy (CCE) studies performed at our centre over the past 10 years. Case lists were generated from the local PillCam™ database, and patient identifiers were cross-referenced with the hospital Endoscopy database to identify subsequent procedures. Individual CCE reports were reviewed to assess study completeness and to document any downstream investigations, including colonoscopy, radiological imaging, or repeat capsule examinations. The primary outcomes were the frequency and type of follow-up procedures following CCE, with secondary outcomes capturing repeat CCE rates and indications for additional investigations

Over the 10-year period, 1,302 CCE examinations were performed. Repeat CCE was recommended in 268 cases (21%). The annual repeat CCE rate showed substantial variability, ranging from 4.8% to 26.6%, with a mean of 17.7% and a median of 17.9%, indicating a consistently moderate downstream capsule workload. Surveillance was the predominant indication with 209 procedures (78%), with a progressive rise over time, increasing more than 30-fold between 2015 (1 case) and 2023 (52 cases). Symptomatic indications accounted for 24 cases (10%) and repeats due to failed or inadequate bowel preparation occurred in 32 cases (11%). Follow-up endoscopy was recommended in 440 cases (34%). Annual endoscopic workload ranged from 14.3% to 41.6%, with a mean of 29.1% and median of 28.3%, demonstrating greater yearly fluctuation than repeat CCE. Peaks in 2019 and 2023 (both 87 cases) reflected high-volume years with increased diagnostic yield or completion requirements. Indications included polypectomy (224; 51%), completion colonoscopy (95; 21%), and other therapeutic or diagnostic interventions (102; 23%). CT colonography was recommended in only four cases (0.3%), all following failed CCE studies. Across the dataset, a substantial proportion of patients did not require further investigation, 586 cases (45%).

Overall, 45% of CCE examinations required no further follow-up and a further 21% were suitable for capsule-based surveillance—patients who historically would have undergone colonoscopy. This represents a potential 66% reduction in index colonoscopy demand (859 cases). Repeat CCE was required in 21% of examinations, with an average annual repeat rate of 18%, a factor that will need to be considered in future service planning should national adoption of CCE expand. Our follow-up endoscopy rate of 34% (mean annual rate 29%) compares favourably with the ~42% pooled rate reported by Lei et al. (2025). These findings indicate that CCE can operate effectively alongside colonoscopy, reducing the overall burden on endoscopy services. Appropriate patient triage will be essential to further minimise downstream workload, consistent with broader use of non-invasive testing pathways such as the Faecal Immunochemical Test (FIT). In the context of a growing population and increasing colonoscopy waiting lists, expanding CCE capacity offers a practical strategy to enhance access and efficiency within colorectal diagnostics. Additionally, by reducing procedure-related resource use, CCE may contribute to lower carbon emissions in endoscopy units and support the goals of Green Endoscopy