Quality assurance in small-bowel endoscopy is essential to ensure diagnostic accuracy, therapeutic efficacy and patient safety. In this study we aimed to evaluate concordance of data from real-life practice in small bowel endoscopy across Gastroenterology Units in Emilia-Romagna, Italy, with the updated ESGE key performance indicators (KPIs) for device-assisted enteroscopy (DAE) and video capsule endoscopy (VCE). Secondary aims were to describe diagnostic yield, efficacy, safety and organizational factors influencing quality.

This prospective multicenter observational study included ten regional referral centres performing small bowel endoscopy with VCE and/or DAE. Consecutive procedures performed between 10 April and 20 August 2025 were collected. Demographic, clinical, and procedural data were recorded, including diagnostic yield, therapeutic success, complications and adherence to 2025 ESGE key performance indicators (KPIs).

A total of 258 VCE procedures were analysed. Indications included iron-deficiency anemia (29.5%), occult bleeding from small-bowel (25.2%), overt bleeding from small-bowel (19.3%) and Crohn disease (17%). Adequate bowel preparation was achieved in 89.8% of examinations with a completion rate of 96.5%. The overall detection rate was 52.7%, and the clinically significant detection rate was 41.1 %. Capsule retention occurred in three patients (1.16%) and only required endoscopic retrieval due to an underlying jejunal adenocarcinoma. A total of 65 DAE procedures were analysed. Procedures were anterograde in 77 % and retrograde in 23 %. Repeat procedures accounted for 32.3 %, mainly due to failure to visualize previously detected target lesions. Mean duration was 64 minutes and mean small bowel length explored was 147.7 cm. Technical success was 95.3 %, therapeutic success 72.3 %, and diagnostic yield 69.2 %. Only one complication occurred (1.6 %), consisting of intraprocedural bleeding resolved endoscopically. Indications included VCE-detected lesions (61.5 %), abnormalities on other imaging (15.4 %), polyposis surveillance (6.1 %), suspected Crohn disease (6.1 %), and overt or occult bleeding evaluated directly with DAE (7.7 %).  These data were compared to the most recent ESGE quality performance measures. Most key performance indicators were met. Specifically, for VCE, appropriate indication (97.3 %), adequate preparation (95.6 %), completeness (96.5 %), overall and clinically significant detection rates (52.7 % and 41.1 %), and low retention rate (1.16 %) all fulfilled ESGE minimum requirements. For DAE, appropriate indication (96.9 %), adequate preparation (95.2 %), procedural completeness (83.3 %), diagnostic yield (69.2 %), and low complication rate (1.54 %) met ESGE standards. Some KPIs  did not achieved the minimum standard, particularly patency capsule use in high-risk patients (90.1 % vs minimum 95 %), timing of VCE for overt bleeding (50% within 48 hours vs minimum 75 %), and performance of DAE after positive VCE when indicated (41% vs minimum 75 %). Particularly, even though the minimum ESGE standard was not fulfilled, we performed a subgroup analysis in patients undergoing VCE examination for suspected small bowel overt bleeding. Diagnostic yield in patients undergoing VCE within 48 hours from the last bleeding episode was 76% while it decreased to 47% in patients with VCE performed between 48 hours and 14 days and 40 % in the group where VCE was performed after 14 days after the bleeding episode. Although the overall comparison among the three groups showed only a trend toward significance (p=0.06), early VCE performed within 48 hours was significantly superior to delayed examinations (>48 hours), with a diagnostic yield of 76% versus 44% (p=0.04).

To our knowledge this is the first prospective study comparing real world-data of small bowel enteroscopy and the latest ESGE quality performance measure. In Emilia-Romagna the endoscopic approach to small bowel pathology demonstrates high diagnostic yield, excellent safety, and strong adherence to ESGE performance standards for both DAE and VCE. Strengths include appropriate indications, high completeness rates, adequate bowel preparation, and very low complication rates. The findings support the clinical value of early VCE in overt bleeding and emphasize the importance of optimized diagnostic pathways and closer coordination between VCE and DAE to strengthen consistency and quality.