Review Article

Split Viewer

J Innov Med Technol 2023; 1(1): 10-14

Published online November 30, 2023

https://doi.org/10.61940/jimt.230008

© Korean Innovative Medical Technology Society

Advances and challenges in gastrointestinal endoscopy: a comprehensive review

Sun Gyo Lim

Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea

Correspondence to : Sun Gyo Lim
Department of Gastroenterology, Ajou University School of Medicine, 164 WorldCup-ro, Yeongtong-gu, Suwon 16499, Korea
e-mail mdlsk75@ajou.ac.kr
https://orcid.org/0000-0003-2045-5099

Received: November 21, 2023; Accepted: November 21, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gastrointestinal endoscopy has become a very important platform in the diagnosis and treatment of various gastrointestinal diseases, propelled by application of innovative technological advancements. This review paper explores the current landscape, limitations, and ongoing developments in gastrointestinal endoscopy devices. This comprehensive review emphasizes persistent challenges and unmet needs. The prioritized quest for higher resolution, improved image quality, enhanced maneuverability, and user-friendliness presents a roadmap for future innovations. The integration of artificial intelligence emerges as a groundbreaking advancement, promising safer and more accessible endoscopic procedures for patients and practitioners. As the field continues to evolve, collaboration between clinicians, engineers, and researchers will be pivotal in shaping a more effective and patient-centric future for gastrointestinal endoscopy.

Keywords Medical devices; Endoscopes, gastrointestinal; Artificial intelligence; Engineering

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 introduced1-6 and improved diagnostic rates for abnormalities at the microscopic tissue and cellular levels. Additionally, analyzes of tissue structures at cellular levels have also become possible7,8. In the future, with the development of Raman spectroscopy, it is expected that the distinction between normal/precancerous lesions/cancerous lesions will become clearer9,10.

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 disorders11-14. 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 sideRight side
FingersThumb: 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
WristFlexion, extension or twisting to adjust right positioning of endoscope inside of lumenKeeping the angle of holding endoscope
forearmPronation or extroversionTwisting of flexible body of endoscope
Upper arm and shoulderWeight-bearing of endoscopeRotation, flexion, or extension of elbow
LegKeeping balance of body and position consistentlyKeeping 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 endoscope18-23. The second type is Robotic flexible endoscopy with therapeutic functions24-29.

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.

  1. Teh JL, Shabbir A, Yuen S, So JB. Recent advances in diagnostic upper endoscopy. World J Gastroenterol 2020;26:433-447. https://doi.org/10.3748/wjg.v26.i4.433.
    Pubmed KoreaMed CrossRef
  2. Dutta AK, Sajith KG, Pulimood AB, Chacko A. Narrow band imaging versus white light gastroscopy in detecting potentially premalignant gastric lesions: a randomized prospective crossover study. Indian J Gastroenterol 2013;32:37-42. https://doi.org/10.1007/s12664-012-0246-5.
    Pubmed CrossRef
  3. Dohi O, Yagi N, Majima A, et al. Diagnostic ability of magnifying endoscopy with blue laser imaging for early gastric cancer: a prospective study. Gastric Cancer 2017;20:297-303. https://doi.org/10.1007/s10120-016-0620-6.
    Pubmed CrossRef
  4. Dohi O, Yagi N, Naito Y, et al. Blue laser imaging-bright improves the real-time detection rate of early gastric cancer: a randomized controlled study. Gastrointest Endosc 2019;89:47-57. https://doi.org/10.1016/j.gie.2018.08.049.
    Pubmed CrossRef
  5. Fukuda H, Miura Y, Hayashi Y, et al. Linked color imaging technology facilitates early detection of flat gastric cancers. Clin J Gastroenterol 2015;8:385-389. https://doi.org/10.1007/s12328-015-0612-9.
    Pubmed CrossRef
  6. Dohi O, Yagi N, Onozawa Y, et al. Linked color imaging improves endoscopic diagnosis of active Helicobacter pylori infection. Endosc Int Open 2016;4:E800-E805. https://doi.org/10.1055/s-0042-109049.
    Pubmed KoreaMed CrossRef
  7. Misawa M, Kudo SE, Takashina Y, et al. Clinical efficacy of endocytoscopy for gastrointestinal endoscopy. Clin Endosc 2021;54:455-463. https://doi.org/10.5946/ce.2021.165.
    Pubmed KoreaMed CrossRef
  8. Wang WL, Wang HP, Han ML, Lee CT. New-generation endocytoscopy for optical characterization of elevated-type early gastric cancer. Endoscopy 2022;54:E472-E473. https://doi.org/10.1055/a-1625-5320.
    Pubmed CrossRef
  9. Lin K, Wang J, Zheng W, et al. Rapid fiber-optic Raman spectroscopy for real-time in vivo detection of gastric intestinal metaplasia during clinical gastroscopy. Cancer Prev Res (Phila) 2016;9:476-483. https://doi.org/10.1158/1940-6207.CAPR-15-0213.
    Pubmed CrossRef
  10. Sato H, Inoue H, Hayee B, et al. In vivo histopathology using endocytoscopy for non-neoplastic changes in the gastric mucosa: a prospective pilot study (with video). Gastrointest Endosc 2015;81:875-881. https://doi.org/10.1016/j.gie.2014.08.019.
    Pubmed CrossRef
  11. Rempel D, Lee D, Shergill A. Distal upper extremity musculoskeletal risk factors associated with colonoscopy. Work 2012;41 Suppl 1:4680-4682. https://doi.org/10.3233/WOR-2012-0109-4680.
    Pubmed CrossRef
  12. van Tulder M, Malmivaara A, Koes B. Repetitive strain injury. Lancet 2007;369:1815-1822. https://doi.org/10.1016/S0140-6736(07)60820-4.
    Pubmed CrossRef
  13. Shergill AK, McQuaid KR, Rempel D. Ergonomics and GI endoscopy. Gastrointest Endosc 2009;70:145-153. https://doi.org/10.1016/j.gie.2008.12.235.
    Pubmed CrossRef
  14. Harvin G. Review of musculoskeletal injuries and prevention in the endoscopy practitioner. J Clin Gastroenterol 2014;48:590-594. https://doi.org/10.1097/MCG.0000000000000134.
    Pubmed KoreaMed CrossRef
  15. Shergill AK, McQuaid KR. Ergonomic endoscopy: an oxymoron or realistic goal? Gastrointest Endosc 2019;90:966-970. https://doi.org/10.1016/j.gie.2019.08.023.
    Pubmed CrossRef
  16. Pawa S, Banerjee P, Kothari S, et al. Are all endoscopy-related musculoskeletal injuries created equal? Results of a national gender-based survey. Am J Gastroenterol 2021;116:530-538. https://doi.org/10.14309/ajg.0000000000001136.
    Pubmed CrossRef
  17. Shergill AK, Asundi KR, Barr A, et al. Pinch force and forearm-muscle load during routine colonoscopy: a pilot study. Gastrointest Endosc 2009;69:142-146. https://doi.org/10.1016/j.gie.2008.09.030.
    Pubmed CrossRef
  18. ECE Medical Products. EndoDrive [Internet]. ECE; 2020 [cited 2020 Jan 7].
    Available from: http://www.endodrive.de/flyer-endodrive-engl.pdf.
  19. Rösch T, Adler A, Pohl H, et al. A motor-driven single-use colonoscope controlled with a hand-held device: a feasibility study in volunteers. Gastrointest Endosc 2008;67:1139-1146. https://doi.org/10.1016/j.gie.2007.10.065.
    Pubmed CrossRef
  20. Groth S, Rex DK, Rösch T, Hoepffner N. High cecal intubation rates with a new computer-assisted colonoscope: a feasibility study. Am J Gastroenterol 2011;106:1075-1080. https://doi.org/10.1038/ajg.2011.52.
    Pubmed KoreaMed CrossRef
  21. Pullens HJ, van der Stap N, Rozeboom ED, et al. Colonoscopy with robotic steering and automated lumen centralization: a feasibility study in a colon model. Endoscopy 2016;48:286-290. https://doi.org/10.1055/s-0034-1392550.
    Pubmed CrossRef
  22. Kume K, Kuroki T, Sugihara T, Shinngai M. Development of a novel endoscopic manipulation system: the endoscopic operation robot. World J Gastrointest Endosc 2011;3:145-150. https://doi.org/10.4253/wjge.v3.i7.145.
    Pubmed KoreaMed CrossRef
  23. Woo J, Choi JH, Seo JT, Kim TI, Yi BJ. Development of a robotic colonoscopic manipulation system, using haptic feedback algorithm. Yonsei Med J 2017;58:139-143. https://doi.org/10.3349/ymj.2017.58.1.139.
    Pubmed KoreaMed CrossRef
  24. De Donno A, Zorn L, Zanne P, Nageotte F, de Mathelin M. Introducing STRAS: a new flexible robotic system for minimally invasive surgery. Proceedings of 2013 IEEE International Conference on Robotics and Automation, 2013 May 6-10; Karlsruhe, Germany. p. 1213-1220.
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  25. Zorn L, Nageotte F, Zanne P, et al. A novel telemanipulated robotic assistant for surgical endoscopy: preclinical application to ESD. IEEE Trans Biomed Eng 2018;65:797-808. https://doi.org/10.1109/TBME.2017.2720739.
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  26. Hwang M, Kwon DS. K-FLEX: a flexible robotic platform for scar-free endoscopic surgery. Int J Med Robot 2020;16:e2078. https://doi.org/10.1002/rcs.2078.
    Pubmed CrossRef
  27. Ho KY, Phee SJ, Shabbir A, et al. Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER). Gastrointest Endosc 2010;72:593-599. https://doi.org/10.1016/j.gie.2010.04.009.
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  28. Lomanto D, Wijerathne S, Ho LK, Phee LS. Flexible endoscopic robot. Minim Invasive Ther Allied Technol 2015;24:37-44. https://doi.org/10.3109/13645706.2014.996163.
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  29. Cauche N, Hiernaux M, Chau A, et al. Sa1435 Endomina: the endoluminal universal robotized triangulation system: description and preliminary results in isolated pig stomach. Gastrointest Endosc 2013;77(5 Suppl):204-205. https://doi.org/10.1016/j.gie.2013.03.486.
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  30. Al-Elq AH. Simulation-based medical teaching and learning. J Family Community Med 2010;17:35-40.
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  31. Narayan R, Rodriguez C, Araujo J, Shaqlaih A, Moss G. Constructivism—constructivist learning theory. In: Irby BJ, Brown G, Lara-Alecio R, Jackson S, ed. The handbook of educational theories. IAP Information Age Publishing, 2013:169-183.

Article

Review Article

J Innov Med Technol 2023; 1(1): 10-14

Published online November 30, 2023 https://doi.org/10.61940/jimt.230008

Copyright © Korean Innovative Medical Technology Society.

Advances and challenges in gastrointestinal endoscopy: a comprehensive review

Sun Gyo Lim

Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea

Correspondence to:Sun Gyo Lim
Department of Gastroenterology, Ajou University School of Medicine, 164 WorldCup-ro, Yeongtong-gu, Suwon 16499, Korea
e-mail mdlsk75@ajou.ac.kr
https://orcid.org/0000-0003-2045-5099

Received: November 21, 2023; Accepted: November 21, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Gastrointestinal endoscopy has become a very important platform in the diagnosis and treatment of various gastrointestinal diseases, propelled by application of innovative technological advancements. This review paper explores the current landscape, limitations, and ongoing developments in gastrointestinal endoscopy devices. This comprehensive review emphasizes persistent challenges and unmet needs. The prioritized quest for higher resolution, improved image quality, enhanced maneuverability, and user-friendliness presents a roadmap for future innovations. The integration of artificial intelligence emerges as a groundbreaking advancement, promising safer and more accessible endoscopic procedures for patients and practitioners. As the field continues to evolve, collaboration between clinicians, engineers, and researchers will be pivotal in shaping a more effective and patient-centric future for gastrointestinal endoscopy.

Keywords: Medical devices, Endoscopes, gastrointestinal, Artificial intelligence, Engineering

Introduction

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.

Resolution and Image Quality Improvement

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 introduced1-6 and improved diagnostic rates for abnormalities at the microscopic tissue and cellular levels. Additionally, analyzes of tissue structures at cellular levels have also become possible7,8. In the future, with the development of Raman spectroscopy, it is expected that the distinction between normal/precancerous lesions/cancerous lesions will become clearer9,10.

Improvement in Endoscope Maneuverability and User-Friendliness

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 disorders11-14. 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 sideRight side
FingersThumb: 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
WristFlexion, extension or twisting to adjust right positioning of endoscope inside of lumenKeeping the angle of holding endoscope
forearmPronation or extroversionTwisting of flexible body of endoscope
Upper arm and shoulderWeight-bearing of endoscopeRotation, flexion, or extension of elbow
LegKeeping balance of body and position consistentlyKeeping 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 endoscope18-23. The second type is Robotic flexible endoscopy with therapeutic functions24-29.

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.

Improvement of Endoscopic Training Systems

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.

Artificial Intelligence-Based Real-Time Video Diagnosis

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).

Conclusion

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.

Conflict of Interest

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

Funding

None.

Acknowledgments

None.

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

Left sideRight side
FingersThumb: 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
WristFlexion, extension or twisting to adjust right positioning of endoscope inside of lumenKeeping the angle of holding endoscope
forearmPronation or extroversionTwisting of flexible body of endoscope
Upper arm and shoulderWeight-bearing of endoscopeRotation, flexion, or extension of elbow
LegKeeping balance of body and position consistentlyKeeping balance of body and position consistently

References

  1. Teh JL, Shabbir A, Yuen S, So JB. Recent advances in diagnostic upper endoscopy. World J Gastroenterol 2020;26:433-447. https://doi.org/10.3748/wjg.v26.i4.433.
    Pubmed KoreaMed CrossRef
  2. Dutta AK, Sajith KG, Pulimood AB, Chacko A. Narrow band imaging versus white light gastroscopy in detecting potentially premalignant gastric lesions: a randomized prospective crossover study. Indian J Gastroenterol 2013;32:37-42. https://doi.org/10.1007/s12664-012-0246-5.
    Pubmed CrossRef
  3. Dohi O, Yagi N, Majima A, et al. Diagnostic ability of magnifying endoscopy with blue laser imaging for early gastric cancer: a prospective study. Gastric Cancer 2017;20:297-303. https://doi.org/10.1007/s10120-016-0620-6.
    Pubmed CrossRef
  4. Dohi O, Yagi N, Naito Y, et al. Blue laser imaging-bright improves the real-time detection rate of early gastric cancer: a randomized controlled study. Gastrointest Endosc 2019;89:47-57. https://doi.org/10.1016/j.gie.2018.08.049.
    Pubmed CrossRef
  5. Fukuda H, Miura Y, Hayashi Y, et al. Linked color imaging technology facilitates early detection of flat gastric cancers. Clin J Gastroenterol 2015;8:385-389. https://doi.org/10.1007/s12328-015-0612-9.
    Pubmed CrossRef
  6. Dohi O, Yagi N, Onozawa Y, et al. Linked color imaging improves endoscopic diagnosis of active Helicobacter pylori infection. Endosc Int Open 2016;4:E800-E805. https://doi.org/10.1055/s-0042-109049.
    Pubmed KoreaMed CrossRef
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Journal of Innovative Medical Technology
Nov 30, 2023 Vol.1 No.1, pp. 1~9

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