In most medical facilities, fewer than 10 percent of procedures performed are endoscopies, as compared to before the pandemic. And access to negative pressure rooms either within or outside the usual endoscopy suite is scarce.
The COVID-19 pandemic has had a vast impact and necessitated a worldwide response. However, getting things back to normal is likely to come on a country-by-country, state-by-state and in some cases, city-by-city basis.
Endoscopy falls squarely into that reality. Non-emergent, endoscopic procedures were among the many elective procedures suspended when the pandemic reached full fervor in mid-March and continued well into the next 2 months. That meant the endoscopist’s bread and butter procedures, the screening colonoscopy, had to be put on the shelf until officials had a better grasp on the coronavirus disease and the outlook for society improved.
Although the pandemic is still ongoing, endoscopists are already beginning to resume the urgent and elective procedures that had to be postponed during the worst of COVID-19. To get back to the point of treating their patients, gastroenterologists have had to navigate a network of society guidelines, as well as governmental directives.
Indian market dynamics
The Indian endoscopes market in 2019 was dominated by the rigid models, with a 76 percent share by volume and a 67 percent share by value. The three leading players in the rigid endoscopes segment, Karl Storz, Olympus, and Stryker constitute 90 percent of the market combined. The local players continue to have a 10 percent market share. While the imported segment commands a unit price in the range of `12-15 lakhs, the local players have to make do with `7.5 lakhs.
The flexible endoscopes segment is dominated by Olympus with an estimated 24 percent share by volume and a 32 percent share by volume in 2019. The other players in the reckoning are Fujinon and Pentax, neck-to-neck, scrambling for a 10 percent share each. The refurbished market has its niche customers, while Karl Storz has some loyal customers in Gujarat and North-East, with a handful of Chinese players also striving to keep their presence intact. Pentax has lost some of its senior executives recently, and are in the process of appointing a distributor.
“The ability to perform ultrasound examination with an endoscope provides the needed third eye to look beyond visible lumen. This has made possible tissue availability from any structure in the vicinity of gut without surgery. EUS guided pseudocyst drainage, gallbladder drainage, choledochoduodenostomy, pancreaticogastrostomy and gastrojejunostomy have made surgery for these indications redundant. These advances have however come at a prohibitive cost both for the doctors and for the patients. A healthy collaboration between us professionals and innovators to develop dedicated and affordable instruments at affordable cost can bring these advances to the common man.”
The author is Consultant Gastroenterologist & Endosonologist, SIDS Hospital & Research Centre
Endoscopy devices are constantly undergoing improvements due to the innovation and technological advancement continuously. Apart from the technology, other major growth driver that has led to the development of endoscopy devices market is a natural preference for less and non-invasive methods of treatment. Technological advancements offer low morbidity and mortality associated in the advanced therapeutic procedures unlike the conventional gastro surgical procedures.
Gastrointestinal malignancies continue to be the second leading cause of cancer–related deaths in the developed world. The early detection and treatment of gastrointestinal pre-neoplasms has been demonstrated to significantly improve patient survival.
Unfortunately, the poor sensitivity associated with WLE is a significant limitation. In this regard, development of alternative diagnostic techniques like real-time optical chromoendoscopy offer significant improvements in the diagnosis of early lesions by allowing real time optical diagnosis targeted mucosal excisional biopsies.
The optical magnification capacity of specialized endoscopes is increased up to 520x and may provide optical biopsies of equivalent histological accuracy. This ability to detect subtle pre-neoplastic changes in the gastrointestinal mucosa in real time and improved staging of lesions could lead to curative endoscopic treatment of these lesions and, in the long-term, improve patient survival rates and quality of life.
Endoscopy market steadily increases its reach into therapeutic field, such as POEM/ESD and endoscopic bariatric procedures that previously were only performed through more invasive methods and now are treated through-the-scope.
Duodenoscopes with single use, disposable distal attachments are introduced recently, which elevate the standard of cleaning and care. Endoscopic ultrasound (EUS) has made many hepatobiliary procedures possible with echoendoscopes.
Disruptive technologies like motorized spiral enteroscope made the enteroscopy procedures easy, less time consuming, and complete with more therapeutic options. This led to more gastroenterologists opting to perform enteroscopy, which was earlier a time consuming and often incomplete procedure with the conventional balloon enteroscope.
In bronchoscopy, new technologies and innovations revolutionize the way pulmonologist were doing bronchoscopy. Modalities like radial EBUS, Cryo, BT, pleuroscopy open new avenues in respiratory field as well.
The promising future technologies for endoscopes are 4K imaging, bleeding detection technology, and Artificial Intelligence (AI) for detection and diagnosis. These are expected to be available in near future.
The coronavirus pandemic has significantly impacted endoscopic practice in India, as it has in the rest of the world. International guidelines are hard to follow in a country like India with limited resources, including limited PPE, lack of negative pressure units, overcrowding of centers, and limited resources in privately owned or smaller endoscopy units. Current recommendations to avoid endoscopy in elective cases are being followed by endoscopists. Adoption of international guidelines to tailor to the specific practice environment in India is desirable, especially when endoscopy units are reopened or should we have another surge in the SARS-CoV-2 infection.