Endoscopy imaging: Fusion of two clinical specialties

If someone were to ask you to encapsulate perhaps the most intriguing trend in high-end surgery within the first two decades of the 21st century, you might likely respond with “convergence.”

And like what’s happening in high-end surgery today, regardless of specialty, you’d be spot-on.

What surgeons have witnessed within the last 20 years is the remarkable convergence of computerization and imaging in the surgical theater to enable more precise treatment and excision of organs and tissue.

Twenty years ago, surgeons might have marveled at learning about computer-directed/sensor-guided arthroscopic, hip-replacement and knee-replacement surgeries, computer-directed, image-guided radiation therapy, interventional radiology, as well as flexible endoscopes equipped with tiny cameras. And the cherry on top of this surgical technology? None other than Given Imaging’s legendary “Pill Cam,” which ushered in the concept of so-called capsule endoscopy. Basically, the patient swallows a tiny camera that takes pictures as it traverses the digestive tract. Call it the peristaltic paparazzi.

Today, this all encompasses standard operating procedure. No surgeons would bat an eye of surprise. But some worry that endoscopic imaging devices will mimic the technological and marketing development of popular smart phones.

“The further into the body we can go with minimally invasive equipment, the more power we will have to diagnose disease earlier and more accurately,” said Kurt Heine, Group Vice President, Endoscopy Division, Olympus America, Inc. “This can lead to combined benefits of reduced cost and improved patient outcomes and satisfaction, of which the endoscopic surgeons and interventional radiologists ultimately benefit.”

Heine points to the importance of improved visualization, particularly in “highly effective cancer-curbing procedures” such as colonoscopy.

“Olympus America’s Endocuff Vision, which is placed on the distal tip of a colonoscope, has hinged arms that fall flat against the shaft of the scope to reduce slippage during forward advancement,” Heine explained. “During withdrawal, the arms flare out and stabilize the tip, gently stretching the mucosal surface to allow the physician thorough inspection of the anatomy during the search for polyps. Endocuff Vision has been shown to improve adenoma detection rates which, at times, can be precursors to cancer. For each 1 percent increase in adenoma detection, there is a 3 percent reduction in the risk of interval cancer and a 5 percent decrease in the risk of a fatal interval colorectal cancer.”

Heine cited a multi-center randomized study on emerging colonoscopy technologies, published in the August 2018 edition of the “GIE Journal of the American Society of Gastroenterologists” (https://www.giejournal.org/article/S0016-5107(18)30192-5/abstract) that revealed using Endocuff Vision “produced gains in adenoma detection, even in the hands of physicians who are very skilled with standard instruments lacking adjunctive devices and with a high adenoma detection rate (ADR).” ADR was 14 percent higher compared to HD colonoscopy without an adjunctive device. “Considering that colon cancer remains the second highest most common cause of cancer-related mortality, these percentages can be very meaningful in terms of lives impacted,” he added.

KARL STORZ’s Quigley stresses surgeon zeal for improved visualization, too, as being high on their product wish lists going forward.

“Some of the key product features and benefits will be focused on new visualization modes that help surgeons see things they’ve never seen before,” Quigley noted. These include “4K and Beyond” capabilities.

For example, 4K technology “gives surgeons the advantages of enhanced brightness and billions of colors to help differentiate the various tissue planes,” Quigley said. Meanwhile, fluorescence imaging — both NIR/ICG and PDD — help surgeons identify key structures in the common bile duct, identifying potentially necrotic tissue (perfusion assessment), or identifying clear margins for bladder cancer, he added.

Endoscopic surgeons are welcoming advanced imaging modalities, too, according to Quigley. For example, “CLARA” helps surgeons benefit from having a greater working distance by brightening up the dark space in the back of the image without oversaturating areas at the front of the image. “CHROMA” helps surgeons identify key vascular parts of the anatomy by enhancing the reds in the image, Quigley indicated.

Endoscopic imaging offers valuable assistance in lung sampling and diagnosis, Olympus America’s Heine stresses.

“Lung cancer is the leading cause of cancer-related deaths in the U.S., according to the Centers for Disease Control, with more than 400 Americans each day dying from the disease,” he said. “About 70 percent to 80 percent of cancers are diagnosed at the advanced stage when the survival rate is only 5 percent — defined as surviving for five or more years from diagnosis. Only 15 percent of patients are diagnosed in the early stage when the survival rate is much more promising, at 55 percent. Accessing smaller and more distal airways is a critical component when pulmonologists are accessing, sampling and diagnosing lung cancer. Olympus’ BF-MP190F provides expanded reach, when used with radial EBUS probes, and allows for real-time confirmation of the lesion location, which can assist in targeted sampling.”

Endoscopic ultrasound can offer better visualization, too, according to Heine. “While conventional endoscopy only provides a view of the innermost lining of the digestive tract, or its wall, the addition of ultrasound allows the physician to see beyond that wall to visualize all five layers of the GI tract as well as surrounding tissue and organs,” Heine said. “Endoscopic ultrasound also provides a minimally invasive means for biopsy…allowing for more detailed observation.”