The Future of Endolumenal Therapies

Artificial intelligence, nanotechnology and virtual reality can all play an important role in the future of endolumenal therapies.

Tom Cropper, Editor

Robotic surgery has many of the same benefits as laparoscopic surgery in that it can use smaller incisions to minimise blood loss. A doctor uses precise robotic arms which bend like wrists and are controlled by the doctor from a console next to the patient

DILUMEN™ PUSHROD CONTROL HANDLE

TECHNOLOGY WILL play a vital role in the future of healthcare. Much of it is untested and there is still a lot of work to ensure it can deliver everything that it needs to, but it has the potential to deliver benefits across the spectrum. By expanding the range of situations in which endoluminal therapies are appropriate, health services can improve outcomes, reduce costs and, most importantly, save lives.

Artificial Intelligence

Artificial intelligence (AI) attracts a huge amount of attention – some of it justified, some not. A study in Shanghai found that an AI system could improve adenoma and polyp detection rates in colonoscopy.

“The miss rate for colon polyps can be up to 27%,” said Tyler Berzin, MD, Co-Director, GI Endoscopy, and Director, Advanced Endoscopy Fellowship at BIDMC. “This limits the efficacy of screening colonoscopy, which is a critical tool for reducing the incidence and mortality of colorectal cancer by detecting and removing adenomatous polyps¹.”

The study used an automated polyp detection system developed by Wisconsin AI to investigate whether it could out-perform conventional colonoscopies. A total of 53 patients underwent a routine procedure while 522 underwent CAD colonoscopy.

The results indicated that the CAD system delivered superior results across a range of different metrics. The CAD group detected 0.97 polyps per colonoscopy compared with 0.51 for the control group and had a 1.89-fold increase in the mean number of polyps detected. The CAD group also has a slightly higher detection rate for adenomas and showed a significantly reduced procedure time compared to the conventional colonoscopy and there were no complications reported.

“The aim of a CAD system is not to show how smart the AI is, but to be useful in clinical settings, and this reflects our commitment to innovating AI-based diagnostics with proven clinical benefits,” said JingJia Liu, Chief Executive Officer at Wisconsin AI. “The study shows that use of our system did not increase procedure time, which is mainly because of the low false alarm rate. This demonstrates that the system can improve polyp and adenoma detection without negatively impacting physician and facility efficiency.”

HD Imaging

Effective lighting and imaging of affected areas is crucial for successful endoscopic treatment and there have been a number of advances in this area. Fibre bundle endoscopy has been replaced, by and large, by video endoscopy and, increasingly, high definition video. Lighting is improving and manual zoom controls help doctors to more thoroughly visualise the area. These help to improve identification and diagnosis as well as the removal of polyps.
Researchers from the University of Cambridge, for example, have developed a new imaging technique which offers what they call hyperspectral imaging. The technique, as Dr Sarah Bohndiek, from the University of Cambridge explains, dramatically increases the number of colour channels which can be detected.

“In traditional endoscopy, we use white light and detectors that replicate our eyes, which detect light in red, green and blue colour channels,” she explains. “We are now developing an approach called ‘hyperspectral imaging’, which will increase the number of colour channels that can be visualised from three to over 50.”²

Robots and Nanotech

Robotic surgery has many of the same benefits as laparoscopic surgery in that it can use smaller incisions to minimise blood loss. A doctor uses precise robotic arms which bend like wrists and are controlled by the doctor from a console next to the patient. All the details of the operation are displayed on a 3D screen next to the doctor.

Uptake has been slow thanks to high upfront costs. However, the technology is advancing. An overview of the current state of robotic colorectal surgery argued that the technology could advance to the point where many conventional surgical techniques are rendered obsolete³.

Moving into the realm of nanotechnology, meanwhile, offers the tantalising prospect of dramatically reducing the need for surgery. Researchers at UCSF and UC Berkeley have demonstrated a nanoscale polymeric drug delivery vehicle that can be loaded with a widely used anti-cancer agent that can cure colon cancer in mice in a single dose4.

This technique is also being used to improve the effectiveness of colonoscopies in the early identification of cancer. As things stand, the accuracy of colonoscopies is heavily dependent on the speed with which they are performed and how thoroughly doctors search for lesions. However, nanotechnology could potentially identify cancerous cells before they become visible via a colonoscopy. Researchers at the Center of Cancer Nanotechnology Excellence at Stanford University have developed a system in which gold nanoparticles can be used to seek out and bind to cancer cells. Light is shined from a device which can be inserted into a standard endoscope causing the cancer cells to stand out. They can then be removed relatively easily5.

Training and Development

As technologies expand the role of endoscopic techniques, the demands being placed on staff are evolving. Progress brings complexity. A gastroenterologist must develop a range of skills and expertise including experience in ultrasound, the macroscopic view of lesions of the gut as well as the ability and patience to follow up on thousands of images transmitted during capsule endoscopy. They will need knowledge of physics for autofluorescence imaging and much more. The idea of what an endoscopist is is evolving and one of the key challenges will be gaining the skillsets within teams to cater to heightened demands.

The way in which endoscopists are trained is also evolving with virtual reality adding enhanced realism into training scenarios. Rather than training in a clinical environment, students can use a simulator to create a 3D image with which they can interact as if it were real. It is a popular way to provide training in a risk-free environment. A study by Khan R, Plahouras et al into the use of virtual reality found that it did deliver improvements over no training, although they found no conclusive evidence that it improved results over traditional training techniques6. Virtual and augmented reality technology is, however, evolving at speed delivering enhanced levels of realism. The report suggested results could be improved by providing progressive learning strategies in which tasks become increasingly more difficult.

Another study into a technology using intuitive zoom in virtual reality showed that the technology could make it easier for operators to assess lesions7. By moving the head forwards, the image would expand providing a clearer view of a particular area. The endoscopist could then complete a successful biopsy of a polyp and shrink the image by moving his or her head backwards. Footage imported into VR and tracking devices in the corner of the room registered the position of the endoscopist.

Technology has an enormous role to play in the future of endoluminal therapies. It can reduce treatment times, lead to faster recoveries, improve accuracy of diagnosis and expand the use of non-invasive procedures which might previously have required surgery. By so doing, it allows many patients to avoid the stressful experience of surgery and return to their regular routines as quickly as possible.

  1. Wisconsin AI Announces Publication of Data from the First-Ever Prospective, Randomized Controlled Trial Evaluating the Use of Artificial Intelligence in Advanced Diagnostics: http://bit.ly/2HVN4tC
  2. New advances in Imaging to Improve the Detection of GI Cancer:https://www.ueg.eu/press/presssectioncards/ueg-press-release-nt/article/ueg-week-new-advances-in-imaging-to-enhance-the-detection-of-gi-cancers/
  3. Overview of Colorectal Surgery: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4770168/
  4. One Shot Nanotechnology ‘Cures’ Colon Cancer in Mice: https://foresight.org/one-shot-nanotechnology-treatment-cures-colon-cancer-in-mice/
  5. Nanotechnology to Improve the Early Detection and Treatment of Colorectal Cancer: https://www.nih.gov/research-training/nanotechnology-improve-early-detection-treatment-colorectal-cancer
  6. Virtual Reality Simulators for Training in Gastrointestinal endoscopy: https://www.cochrane.org/CD008237/COLOCA_virtual-reality-simulators-training-gastrointestinal-endoscopy
  7. Virtual Reality in GI Endoscopy: https://gut.bmj.com/content/early/2018/09/18/gutjnl-2018-317058
It’s the power of possibility. And it’s fueled by a fierce determination to find a better way—to elevate healthcare for everyone.