Capsule endoscopy for treat-to-target monitoring in Crohn’s disease: a systematic review and meta-analysis

Background and Aims Achieving mucosal healing has become a central therapeutic objective in treat-to-target strategies for Crohn's disease (CD). Capsule endoscopy, including small-bowel capsule endoscopy (SBCE) and pan-enteric capsule endoscopy (PCE), enables comprehensive mucosal evaluation and supports treatment optimization. This systematic review and meta-analysis aimed to evaluate the role of SBCE and PCE within treat-to-target strategies in patients with small-bowel or ileocolonic CD. Methods A systematic search of PubMed/MEDLINE, CENTRAL, ClinicalTrials.gov, and Google Scholar was conducted from inception to November 2025. Randomized Clinical Trials and observational studies using capsule endoscopy to monitor mucosal activity and guide therapy were included. The primary outcome was the proportion of patients achieving mucosal healing after targeted medical therapy. Pooled proportions were estimated using random-effects models, and heterogeneity was assessed using the I 2 statistic. Results Nine studies comprising 321 patients were included. The weighted mean age was 31.3 years, and 46% of patients were male. Active disease was detected in 76.3% of patients at baseline, leading to treatment modification in 71% overall and 93% of those with active disease. After a weighted mean follow-up of 33.5 weeks, the pooled proportion of patients achieving mucosal healing was 27% (95% CI: 18–38%), with substantial heterogeneity (I 2 = 71%). Mucosal response was observed in 43%, while 34% showed no response. Capsule retention was observed in 1 case. Conclusions Capsule endoscopy enables comprehensive assessment of mucosal activity across the gastrointestinal tract and supports proactive, individualized treatment optimization within treat-to-target strategies. Further prospective studies are needed to standardize outcome definitions and to clarify its impact on long-term clinical outcomes.