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Endoscopic Innovations: Improved Imaging, Techniques, Quality Metrics
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With advances in technology and technique, endoscopy has begun to play an ever-increasing role in the detection and treatment of gastrointestinal cancers, esophageal cancers, and other GI conditions. For patients, endoscopic procedures represent a less invasive option with no need for general anesthesia, reduced hospital time, and a faster return to normal daily life.
Through improved endoscopic imaging, clinicians can improve adenoma detection rates (ADRs) and prevent interval cancers. Improvements in endoscopic tools for mucosal resection and submucosal dissection have enabled physicians to remove, stage and treat mucosal cancers. Quality performance metrics have encouraged gastroenterologists to document and report their performance data not only for insurance purposes, but also to hold gastroenterology to the highest standard of patient care.
“We have now started looking not only at how many of these procedures we can do, and not only that we can do these novel techniques, but that we can do it by improving patient quality and outcomes,” Prateek Sharma, MD, a professor of medicine at the University of Kansas in Kansas City, said in an interview.
Sharma spoke with Healio Gastroenterology and Liver Disease about what he considers the most important new developments in endoscopy, as well as the top new tools in the field of GI endoscopy.
Healio: In what areas has endoscopy improved recently?
Sharma: In general, there have been improvements in both diagnostic endoscopy and therapeutic endoscopy.
In terms of diagnostics, we have improved our ability to see more, to see better, and to see even smaller things than in the past. The endoscopes have gotten more high definition. The images have become clearer, the contrast has improved. This has all led to improved diagnostic tools. Along with that, we have developed quality measures in endoscopy, which forces us to be better at diagnosis. So, whether it is picking up more polyps during colonoscopy or diagnosing more dysplasia in Barrett’s or inflammatory bowel disease diagnostic endoscopy has really become an important part of diagnosis.
On the therapeutic side, we have both new techniques, as well as new accessories and tools to help us treat these areas that we are now diagnosing more of. So, for example, if we are diagnosing more flat polyps in the colon, we now have the ability to demarcate the polyps better by diagnostic endoscopy. We have the ability to inject colored solutions underneath the polyp to raise the polyp well, so that it is not only better seen, but also can be better demarcated. We also have better accessories by which these flat polyps can be resected, so that we are actually treating the disease.
Additionally, we have the ability now to not only treat the mucosal disease, but also the submucosal disease. We have the advent of submucosal endoscopy, in which we can create a space below the mucosa into the submucosa and we can advance our endoscopes into the submucosa and treat diseases there as well. That’s sort of an overall outline of the recent advances.
Healio: What do you consider to be the top new tools in diagnostic endoscopy?
Sharma: I think the number one recent tool would be high-definition endoscopy and chromoendoscopy. HD endoscopy and virtual chromoendoscopy. With HD endoscopy, it’s allowed us to have a high definition TV along with a high definition camera, so that we can take better pictures and look at them on a bigger and better screen.
Virtual chromoendoscopy is almost like a “smart TV” and a smart camera, in which with a switch of a button, you can change the contrast, which gives you a better definition of the blood levels, of the surface patterns, as well as help demarcate the lesions better. So that would be one advance.
Healio: What are the top tools as far as technique?
Sharma: The second top advance is in technique: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Those are ways of removing the mucosa, and if there is mucosal cancer, removing that and staging it and also treating and curing it by removing the smaller lesions. ESD is a way of going even further — getting into the submucosa, dissecting it and getting an en bloc resection. Early esophageal cancers, gastric cancers and colon cancers can now be treated endoscopically.
I would say a third advance would be what’s called POEM, which stands for peroral endoscopic myotomy. That is now an endoscopic way of treating diseases like achalasia. The surgical approach to that would be laparoscopic myotomy, and now we’re to the point where we can actually treat that with an endoscopic myotomy. You can create a myotomy through the esophagus with the help of your endoscope, and then dissect into the mucosa, and create a myotomy by cutting the muscle fibers of the esophagus up to the gastroesophogeal junction and thus, treat achalasia and other esophageal motor disorders with the help of the POEM technique.
Another innovation along these lines would be endoscopic suturing and clipping techniques. Not only can we create these so-called acrogenic tears in the mucosa, submucosa and the muscle wall of the GI tract, but now we also have the ability to close it shut with the help of clips, with the help of suturing devices. This is also an advance in devices and tools. It’s almost as though you’re creating a defect in a hole and then shutting it closed.
Healio: You also mentioned the importance of quality metrics in improving care and advancing en d oscopy. How have these quality measures helped?
Sharma: The GIQuIC is a registry that we can use toward quality but we have developed different metrics, such as the ADR. That is a quality metric that looks at not only whether you can do screenings for colon cancer, but how good you are at diagnosing polyps and things like that.
There have been new data that show that improving the ADR will decrease the risk for interval colon cancers. That link between ADR and interval cancers is a new link, and it’s a good one. Understanding these associations, and tracking ADR is a way of taking the various advances we’ve made and tying them all together. Not only are we getting better at diagnostic endoscopy and detecting more polyps, but we have better tools and techniques to remove large polyps, flat polyps, and flat cancer, and all of this has been shown to reduce interval cancers. So that is definitely another major advance, the fact that we’re now focusing our attention on this whole concept of quality – providing quality care and improving outcomes in our patients. – by Jennifer Byrne
For more information:
Prateek Sharma, MD, can be reached at 3901 Rainbow Blvd., Kansas City, KS 66103; email: PSHARMA@kumc.edu.
Disclosure: Sharma reports receiving grant funding from Boston Scientific and Olympus.