Emerging Technologies, Preparing Endoscopes For The Next Decade

Future work in the field of endoscopy will concentrate on creating a seamless integration of AI systems with current endoscopy platforms and robotic forms of capsule endoscope.

Over the years, medicines and the way physicians approach the patient have evolved from the basic clinical situations and the way they interpret signs and symptoms, to imaging technologies that help them provide a faster and more reliable diagnosis. Nonetheless, along with endoscopy appearance in daily practice, patient’s survival rate and treatment have improved, and have gradually become the mainstream use by introducing screening programs as in colorectal cancer. Based on the perceived balance between the necessity and benefits of endoscopy, this technique has prompted its need to be kept in current practice and has become a benchmark for human organs or cavity exploration. The use of endoscopy within the gastrointestinal tract has been embedded as a welcome development for both diagnosis and therapeutic paths. Continuous research of available technologies has led to a groundbreaking promising foundation to explore new options for the patient’s condition.

Endoscopy screening and treatment of pre-cancerous lesions is part of a growing trend and has been increasing exponentially in many specific lesions due to new technology embedment or transposing current surgical procedures. Thus, a shift has taken place and the use of endoscopic systems has allowed technology to become part of both the physician and patient’s life. Technological development is a continuous process in our day-to-day life and has been gradually inserted into endoscopy advances along with high-resolution endoscopes, devices, or accessories. The fact that some organs could have only been accessed by surgical procedures has promoted endoscopy to a level worthy of further appraisal. Among the different steps in endoscopy, the ones that surely changed the way physicians tend to diagnose or treat patients in daily practice are endoscopic retrograde cholangiopancreatography, capsule endoscopy, and endoscopic ultrasound. Thus, a new window was opened for both patients and physicians and allowed the concept of evidence-based medicine to be used in daily practice.

Flexible endoscopes continue to evolve along multiple vectors in order to meet the simultaneous needs of doctors for better access to hard-to-reach parts of the anatomy, better image quality and advanced modes of visualization, more ergonomic handling, and durability that holds up under heavy daily use. Highly advanced technologies like dual focus (for on-demand close examination of the tissue), responsive insertion technology (for faster access to the cecum and more precise handling during therapeutic maneuvers), and technologies that create a 3D image of the shape and position of the scope inside the patient have added new clinical and economic value to endoscopes, even as the complexity of the endoscopes’ internal design and manufacturing has increased accordingly. In addition, endoscope manufacturers continue to pay close attention to the cleaning and reprocessing of each endoscope model, ensuring that users have access to validated methods of disinfection for peace of mind.

Technological trends
The technology in the endoscopic systems has reached milestones over the past few years, opening a new era in endoscopic diagnosis. Manufacturers focusing on the development of miniaturized, enhanced resolution (high definition) systems with increased maneuverability have extended the realm of applicability of these systems.

High-definition endoscopy imaging. Substantial innovations in endoscopy imaging have occurred in the last 30 years, allowing physicians to perform a more personalized therapy for patients. With an increasingly technology-driven field, the current focus is to use high-definition (HD) and ultra-high-definition technologies in a platform that eliminate all disadvantages and enhance the gastroenterologist’s ability to provide a better diagnosis or therapeutic management. Endoscopy has taken an important leap from basic imaging to digital, HD white-light resolution which detects and highlights mucosal changes that were not perceived by the previous technologies. The use of HD endoscopes and monitors allows substantial image improvements by producing fewer artifacts on rapid movement and when combined with the corresponding processors may reach an image quality of over 2 million pixels. HD magnification endoscopes have the ability of enlarging the image up to 150x with an adjustable focus and to discriminate between lesion’s characteristics from 10 to 71 microns in diameter.

Confocal laser endomicroscopy. Confocal laser endomicroscopy (CLE) is a cutting edge technology based on real-time image reconstruction on a subcellular level, in any endoluminal cavity by using flexible endoscopy. This ability to see the microarchitecture in vivo in a non-invasive setting has opened up new windows of opportunity for a faster diagnosis. Thus, providing images of the mucosal layer not only ensures a rapid assessment of the lesions but also have a role in choosing the right therapeutic management. CLE is available either in an integrated conventional endoscope or on a probe-based system which is connected to a laser unit. Endoscope-based CLE (eCLE) systems can be used for both upper and lower gastrointestinal tract examinations with depth scan images from 0 to 250 microns and scan rate of 1.6 frames/second. The advantages of CLE have been recognized by the US Federal Drug Administration and it is being currently used in some clinical settings and settled by insurance policies. Thus, the field of endomicroscopy, a rather challenging one due to long learning curve and high costs, is on a continuous expansion with multiple methods being tested.

Capsule endoscopy. Video capsule endoscopy (VCE) has revolutionized the way physicians explore bowel disease and has become the reference method for small bowel imaging diagnosis. From its commercial release in 2001, VCE surfaced as the most challenging alternative for upper endoscopy or colonoscopy. However, as it turned out, its full potential is directed toward the small bowel, which until then represented an area difficult to explore. Over the years, as technology evolved, the optical lenses and image resolution have laid grounds for new improved VCE, now reaching an image resolution of 512×512 pixels. Moreover, the use of dedicated analysis software enhances the picture quality and provides more details that might suggest a more accurate diagnosis. This facilitates new ways to analyze patterns and lesions, decreasing inter-observer variability. Several robotic forms of CE are being developed. The future of VCE is directed to remote-controlled tools for both diagnosis and therapy as in drug delivery systems. This will provide non-invasive and easier management for the patient with potentially less side effects and stress than ordinary procedures.

Single-use endoscopes. Traditional, re-useable endoscopes are expensive pieces of equipment, dictating a massive capital outlay just to have access to the scope. Furthermore, it is impractical to fully sterilize these re-useable scopes, and as such, they require a robust cleaning process between patients to limit the risk of cross infection. There are therefore many failings associated with the use of re-useable scopes, with them potentially causing delays in patient diagnosis and treatment, not to mention the risks of infection due to a less than failsafe cleaning process. Single-use endoscopes, however, negate the need for cleaning machines, minimize the risk of infection, and are significantly cheaper than traditional scopes. All of these benefits make it impossible to deny their place in modern healthcare, considering their positive impact on patient safety, and the time and financial efficiencies that can be achieved through their use.

Artificial Intelligence. Applications of Artificial Intelligence (AI) techniques, specifically machine learning and more recently deep learning, are beginning to emerge in endoscopy. The most promising of these efforts have been in computer-aided detection and computer-aided diagnosis of colorectal polyps, with recent systems demonstrating high sensitivity and accuracy even when compared to expert human endoscopists. AI is also being utilized to identify gastrointestinal bleeding, to detect areas of inflammation, and even to diagnose certain gastrointestinal infections. Future work in the field will concentrate on creating a seamless integration of AI systems with current endoscopy platforms and electronic medical records, developing training modules to teach clinicians how to use AI tools, and determining the best means for regulation and approval of new AI technology.

Road ahead
Endoscopes have helped to revolutionize the way medical procedures are performed and allow physicians to operate in a less invasive manner. A large array of therapeutic alternatives has positioned endoscopy as the cornerstone for most of the diseases of the gastrointestinal tract and gradually has become a technique that may obviate surgery in some situations. From basic tissue harvesting to real-time confocal microscopic assessment or from palliative therapeutic armamentarium to procedures closely tied to surgery procedures, endoscopy has become more and more popular and along with its advantages or challenges has penetrated the gastroenterology community, becoming the touchstone for a medical specialty. Advances in technology over the past several decades have redefined endoscopy. These advancements will only accelerate over the next decade allowing for expanded indications, techniques, and technologies in the practice of endoscopy. These changes will all be encapsulated in the day-to-day operations of endoscopy practice.