JIMT

Gastrointestinal endoscopy devices have undergone significant advancements with the introduction of innovative technologies, playing a crucial role as a platform for treating various gastrointestinal disorders. The prominence of gastrointestinal endoscopy in the field is expected to persist and further evolve in the future. However, improvements and developments in gastrointestinal endoscopy devices are still ongoing. This paper aims to discuss the current limitations of gastrointestinal endoscopy devices and the unmet needs that persist in the field, highlighting areas that require further development.

While the current resolution of gastrointestinal endoscopy is already quite high, there is a need for even higher resolution and image quality. Although resolution may vary depending on the specific model or manufacturer, gastrointestinal endoscopy devices generally offer resolutions in the range of hundreds to thousands of pixels, enabling visualization of details at the level of small tissues or cells. However, enhanced image quality could better visualize subtle lesions or differentiate poorly visualized abnormalities. Research is ongoing to develop high-resolution sensors and optical lens systems to achieve this goal. The application of various digital image processing technologies, such as image-enhanced endoscopy using techniques like narrow-band imaging, blue laser imaging, and linked color imaging, has been introduced^1-6 and improved diagnostic rates for abnormalities at the microscopic tissue and cellular levels. Additionally, analyzes of tissue structures at cellular levels have also become possible^7,8. In the future, with the development of Raman spectroscopy, it is expected that the distinction between normal/precancerous lesions/cancerous lesions will become clearer^9,10.

Technical advancements are needed to enhance the maneuverability and user-friendliness of endoscopy devices. Smaller and more flexible endoscope cameras and control devices, as well as automated systems, can enhance both patient comfort and the efficiency of medical staff during procedures.

Difficulty in endoscopic manipulation

The current endoscopy systems can be relatively complex to operate. Particularly, when precise movement or manipulation is required for specific areas, medical staff must manipulate it in real-time, and this is a task that requires learning and experience. To adjust the directionality of the endoscope tip, the left finger, typically the thumb, needs to move the greater and lesser knobs. Becoming proficient in this requires a considerable amount of practice. Another challenge is determining the direction of the endoscope with the left hand while simultaneously pushing the endoscope in with the right hand. This process needs to happen very smoothly and organically, requiring numerous practices. If innovations occur to make the manipulation of the current endoscopy system more seamless through easier techniques, the barriers to performing gastrointestinal endoscopy would significantly decrease. This could lead to an earlier focus on the process for diagnosis and procedural training for therapeutic endoscopy, as the learning curve for endoscopy procedures could be reduced.

Lack of convenience of manipulation

To operate an endoscope skillfully, not only both arms but also many parts of the examiner's body are utilized (Table 1). Because such examinations or procedures need to be repeated, a significant burden is placed on various body parts, leading examiners to be susceptible to various musculoskeletal disorders^11-14. According to research based on surveys, 39% to 89% of endoscopists report experiencing WRMD (work-related musculoskeletal disorders)^15,16.

Table 1 . The required movements of each part of endoscopists body.

	Left side	Right side
Fingers	Thumb: rotation of knobs Index finger: press of buttons on control part Mid finger: press of buttons on control part or rotation of knobs 4th and 5th finger: holding of control part	Thumb, index finger, and mid finger: holding of flexible body of endoscope, pushing or retraction of endoscope
Wrist	Flexion, extension or twisting to adjust right positioning of endoscope inside of lumen	Keeping the angle of holding endoscope
forearm	Pronation or extroversion	Twisting of flexible body of endoscope
Upper arm and shoulder	Weight-bearing of endoscope	Rotation, flexion, or extension of elbow
Leg	Keeping balance of body and position consistently	Keeping balance of body and position consistently

A study monitoring individual muscles of endoscopists using tactile pads and surface electromyography during endoscopy procedures revealed that the right thumb and elbow exceeded injury limits. The left transverse lower limb, left long wrist extensor, and right long wrist extensor showed activities surpassing the American Industrial Hygiene Association hand activity levels¹⁷. The ergonomic stress imposed on these endoscopists should no longer be taken for granted or ignored, and it should be addressed through the introduction of new technological solutions.

Challenging blind spots in access

Although there have been significant improvements compared to early models, evolving to be more suitable for observing various parts of the gastrointestinal tract, there are still blind spots that are difficult to properly observe with current endoscopic systems. This may be due to issues with the structure of the organs themselves, but it is also influenced by the limitations of the operating range of existing endoscopic systems. Typically, endoscopes have a long cylindrical structure with numerous fibers inside, including light fibers that drive the system. Consequently, the range of bending angles is inherently limited, and in positions where direct viewing is not possible, a certain length of rotational radius is required during bending. Therefore, in narrow or highly curved sections of the intestines, difficulties in observation can frequently arise, even for experienced endoscopists. Moreover, if therapeutic intervention is required rather than simple observation, there are situations where endoscopic procedures may have to be abandoned. Two-bending endoscopes are used to reduce the bending radius and increase the degree of reflection, but they are primarily designed for upper gastrointestinal use and have a larger diameter, posing challenges for use in all diagnostic endoscopic examinations.

Robot-assisted endoscopic systems

To overcome the difficulties in endoscopic manipulation mentioned above, robot-assisted endoscopic systems are currently under development. There are two main types: the first is a system called robot-assisted flexible endoscopy for maneuvering, which involves electromechanically adjusting a conventional endoscope^18-23. The second type is Robotic flexible endoscopy with therapeutic functions^24-29.

Although several systems to assist the maneuvering of endoscope were already commercialized, any of flexible robotic endoscopic platform for advanced endoscopic procedures has not been conformité européene (CE) or FDA marked yet. Some platforms for improving advanced endoscopic procedures equipped almost functions enough to be applied to real clinical fields, which are heightening our expectations. In near future, some of these platforms are expected that they are proved to be effective and safe in ongoing or awaiting clinical trials.

Learning gastrointestinal endoscopy is a process that demands a significant amount of time, learning, and experience from medical professionals. This places a burden not only on the endoscopist learning the procedure but also on the master instructor. Currently, most medical institutions follow an apprenticeship model for endoscopic training. This traditional educational model starts with observation, moves on to imitation, and progresses to autonomy through practicing techniques and guidance from skilled mentors, eventually reaching the master level, adapting to new challenges along the way³⁰.

The drawback of this education model is the high risk of adverse events for patients, the substantial burden on teaching masters, and the potential for confusion when trainees receive feedback from different instructors. Realistically, receiving continuous training from a single teaching staff member is challenging for many medical institutions. According to the constructivist learning theory, learning is constructed by the learner rather than transferred to the learner³¹.

Overcoming these limitations and creating a more efficient and safe endoscopic training system is a significant issue. Recently, education using simulation models has gained popularity in early-stage training. While most training is currently done with physical simulation models, some countries are developing virtual reality simulation models. The GI Mentor II simulator (Simbionix Corporation, Cleveland, OH, USA) is the most representative system, offering hands-on simulation for endoscopic ultrasound training. It has been evaluated as the most realistic virtual reality simulation available, validated in over 40 studies, and deemed to have reliable educational effectiveness. The system is continuously being improved, and scenarios, including emergencies and various therapeutic endoscopy situations, are gradually being developed. Although there is a need for further improvement in realistic scenarios and the system’s high cost makes it challenging for real-world application, it represents a futuristic area of technology. The advantages include the freedom from various ethical issues, the ability to provide diverse simulation training beyond endoscopic techniques, and the collection of performance-related data at each stage of training. Thus, it is a technology that could be applied in the near future.

The field of real-time endoscopic diagnosis has rapidly advanced in recent years through the application of real-time image processing technology and artificial intelligence. One of the most pioneering areas is the technology for detecting colorectal polyps. There are already models that have obtained CE certification and been commercialized in Europe, with commercialized models also available domestically. Furthermore, there is active development of models for the detection and diagnosis of early-stage cancers, such as early-stage colon cancer and esophageal cancer. Research on artificial intelligence-based analysis of small bowel capsule endoscopy images is also underway. In addition, there are efforts to develop systems for automated endoscopy report writing.

This field has tremendously progressed within the last decade, and it would have been impossible without the development of deep learning systems based on Convolutional Neural Networks (CNN).

In conclusion, the landscape of gastrointestinal endoscopy has witnessed remarkable progress fueled by innovative technologies. As a cornerstone in the diagnosis and treatment of gastrointestinal disorders, endoscopy continues to evolve, with a promising future ahead.

This comprehensive exploration of current challenges and emerging technologies underscores the dynamic nature of gastrointestinal endoscopy. Collaboration between clinicians, engineers, and researchers will be pivotal in shaping a future where endoscopic procedures are not only more effective but also safer and more accessible for both patients and medical practitioners.

No potential conflict of interest relevant to this article was reported.

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