Improved Visualization of Small Bowel Lesions by Capsule Endoscopy Using Flexible Spectral Imaging Color Enhancement (FICE) System Yasushi Sato*, Masahiro Hirakawa, Hiroyuki Ohnuma, Kohichi Takada, Tsutomu Sato, Koji Miyanishi, Rishu Takimoto, Masayoshi Kobune, Junji Kato Sapporo Medical University, School of Medicine, Sapporo, Japan Background and Aim: Computed virtual chromoendoscopy with flexible spectral imaging color enhancement (FICE) offers improved detection and characterization of the gastrointestinal tract lesions and are applied widely in clinical practice at gastroscopy and colonoscopy; however, its clinical usefulness in capsule endoscopy remain to be firmly established. The aim of this study was to evaluate the clinical usefulness of the FICE-enhanced capsule endoscopy system comparing with conventional, white light images. Methods: Three experienced endoscopists compared FICE images with corresponding conventional images of 232 lesions obtained from 151 patients who underwent video CE at our hospital between January 2009 and November 2011.The lesions were classified as angioectasia, erosion/ulceration, or tumor, and these images were viewed using white light and 3 different sets of FICE images (ie, setting 1: red 595 nm, green 540 nm, blue 535 nm; setting 2: red 420 nm, green 520 nm, blue 530 nm; setting 3: red 595 nm, green 570 nm, blue 415 nm). Endoscopists rated the visibility of the lesions on FICE images as follows: 2 (marked improvement), 1 (modest improvement), 0 (remain the same as conventional images), 1 (slight decrease), and 2 (marked decrease). Scores for each lesion were totaled per FICE setting and evaluated. Inter-observer agreement was also examined. The time taken to interpret the capsule videos was also determined. Results: With FICE setting 1, the mean visibility score was 4.7 0.4 for angioectasia images, 2.7 0.4 for erosion/ulceration images, and 0.8 0.2 for tumor images. With setting 2, the mean visibility scores were 4.3 0.4, 3.0 0.9, and 0.4 0.4, respectively. With setting 3, the mean visibility scores were 0.8 0.2, 0.3 0.4, and 2.8 0.4, respectively. The inter-observer agreement was good (mean weighted kappa 0.79). Interpretation times were 36 6.9 min, 33 5.4 min, 35 2.8, and 36 5.2 with conventional CE, CE-FICE setting 1, setting 2, and setting 3, respectively, and there was no significant difference among the 4 groups (P 0.05). Conclusions: FICE imaging adds valuable information to conventional CE imaging and enables better diagnostic utility for small-bowel lesions of angioectasia or erosion/ulceration, especially with the use of FICE setting 1 or 2.