Sorry for the delay in answering, vitaminj.
There was a good article in a recent issue of Resident Physician from May, I think. I have the issue and will re-read it to post the major points. I'm in the middle of moving apartments, and my wife did a number on my desk where I had a bunch of journals stacked
but I know exactly where it is, just need to unpack it.
The long and short of it is that GI docs have been the biggest proponents of capsule endoscopy. To that end, don't worry about the capsule endoscope supplanting the fiberoptic endoscope. Most lesions of clinical significance are within the reach of the fiberoptic endoscope, therefore allowing for diagnostic and therapeutic manuevers that are the real art of endoscopy. So the vast majority of the time, a conventional endoscopic evaluation is all a patient needs. Capsule is employed when standard fiberoptic endoscopy has failed to find a lesion or source of the problem -- e.g. AVMs farther down the small bowel. So you've found AVMs at a point where standard endoscopes can't reach, therefore they're not amendable to heat therapy or whatever. You resign yourself to the fact that the patient has a slow chronic bleed from AVMs and you put the patient on iron. I suppose if the AVM bleeding is significant enough and is confined to a particular region, you could refer them for surgical resection, but that situation seems pretty silly and would likely never be the case clinically.
One of the major issues the article I quote above cites is the issue of localizing the lesion in the small bowel. Past the duodenum, most of the small bowel looks the same, so you have no real way (with current techology) of knowing exactly where a lesion is located, so even if you want to do something about it, where is it? If you worry about malignancy, that's pretty rare past the duodenum anyway. So what are you going to do with a lesion you've "found" but can't "find" again, if you catch my drift. Another issue is the type of images generated (not the greatest) but that's a technology issue that I'm sure will be resolved.
As for who reads the 2 hours or more of images generated by the capsule, I believe that will still be in the purview of GI docs. Sure, internists, radiologists, and surgeons can be trained to read the images, but it will be the GI doc who will more than likely have the most to gain from a time and reimbursement standpoint when the $$$ issue is worked out. Reimbursement schedules are optimized for each field -- so it pays for a radiologist to read films or do their procedures, an internist to see patients or admit pneumonia or CHF, or a surgeon to be in the OR, not reading capsule endoscopy films. The internist won't have the time to spend 2 hours reading a film just to refer a patient on for further therapy, and GI docs will have access to and control these patients before the surgeon or radiologist, so they'll order and interpret the procedure before those two fields will. Also, say you find a a confusing lesion -- a GI doc probably has the most experience in interpreting what the mucosa means clinically, and therefore recommending initial therapy. Bottom line, the ball stays firmly in their court.
In the end, capsule endoscopy will be an addition to the current endoscopic armamentarium. I suppose the situation might arise where everyone gets a capsule first, then if something is found where a standard endoscope can reach, the patient then undergoes a second procedure, but why have to pay for two procedures when the standard (fiberoptic endoscopy) is safe, time efficient and effective in trained hands anyway? IF you find something on capsule where a standard endoscope can reach, they'll need one anyway. For these reasons, I don't forsee capsule endoscopy in any way supplanting the need for standard endoscopic procedures. If anything, if ever used for screening, it will find more lesions to go after where and when they can be reached with standard endoscopy.
I'll be sure to find that article -- it is much more succinct and eloquent than my rambling above
