Associate Professor of Medicine and Director of Bariatric Endoscopy at Johns Hopkins Medicine

Vivek Kumbhari

In concordance with rapid advancements in non-invasive imaging technologies (computed tomography, magnetic resonance imaging, etc.), the future of endoscopy resides in its ability to treat pathology. Currently, however, endoscopy remains a critical diagnostic instrument frequently used to investigate for the presence of diseases such as gastroesophageal reflux and colonic polyps.

Innovation in endoscopy can be classified into three categories: a) technologies to enhance image interpretation, b) platforms to facilitate surgical maneuvers through a natural orifice, and c) wireless and/or single-use endoscopes. Put together, the overarching objective of these innovations is to support the clinician in performing cutting-edge value-based care.

Improvements in image quality, together with the addition of artificial intelligence (AI), will form the basis by which the clinician will have improved detection and characterization of pathology in the luminal gastrointestinal tract. Medtronic’s GI Genius^TM is a software that is an adjunct to the endoscopist as it highlights polyps in the colon to decrease the number of polyps being missed (colonoscopy traditionally has an approximately 10 percent polyp miss rate). Other AI-based technologies are being developed to aid in optimizing the quality of an endoscopic examination by providing real-time feedback on the percentage of surface area visualized. Once a lesion is detected, AI technologies will rapidly and precisely diagnose the lesion without interobserver variability. This will result in only pre-malignant lesions being resected and will decrease expenditure, as only indeterminate lesions will be sent for histopathological analysis. AI will initially serve to augment the clinician with the aim of improving the clinician’s quality metrics. These metrics will likely be made transparent to the clinician themselves, their practice setting, payers, litigators, and patients.

Endoscopic transoral and transanal platforms to facilitate similar maneuvers to what a laparoscopic or robotic surgeon can perform are in clinical trials. Commercially available endoscopes are limited as they do not allow for triangulation of accessories, and hence, the ability to manipulate tissue by fine dissection (requires adequate exposure and retraction) or refashioning the morphology of an organ (reducing the size of the stomach to confer weight loss) is limited. Platforms such as Colubris^TM and Medrobotics^TM have developed next-generation flexible robotic systems with superb imaging performance and large accessory channels, which will allow for endosurgical procedures to be performed without the need for a skin incision.

“In an era of value-based care, adoption of new technologies will lag until the clinicians and hospital systems can financially justify the capital outlay.”

The culmination of AI and robotic platforms has resulted in the creation of wireless capsule endoscopes with therapeutic capabilities. With reliable communication systems, refinements in design, and improved operative characteristics, the futuristic concept of a patient swallowing a capsule and a clinician remotely navigating the capsule throughout the gastrointestinal tract and providing critical care (e.g. treating a bleeding duodenal ulcer) is what we should expect within the next two decades. Furthermore, in the context of outbreaks of infection secondary to inadequate endoscope reprocessing, the notion of a single-use endoscope is appealing to both industry and patients. The Exalt^TM single-use duodenoscope was designed to negate concerns regarding pathological organisms being transferred from one patient to another.

Although there are many factors driving innovation in endoscopy, there are barriers, with concerns of suboptimal reimbursement for endoscopic procedures being at the forefront. In an era of value-based care, adoption of new technologies will lag until the clinicians and hospital systems can financially justify the capital outlay.