In recent years, the field of endoscopy has experienced incredible advances thanks to new cutting-edge procedures and technologies. These innovative and sophisticated endoscopic surgical techniques are designed to provide better patient outcomes and improved quality of life for individuals with a wide range of diagnoses. Only a limited number of medical centers, however, currently offer these treatments.
Becker’s Hospital Review recently spoke with Christopher C. Thompson, MD, Director of Endoscopy and Co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston, about flexible endoscopy and its role in endoscopic surgery, as well as critical supporting technologies like systems integration, high-resolution endoscopes and image enhancement. In addition to his roles at Brigham and Women’s Hospital, Dr. Thompson is also Director of the Advanced Endoscopy Fellowship Program and a Professor at Harvard Medical School.
NOTES: the movement that launched flexible endoscopy and surgical advances
Many advanced endoscopic surgical procedures performed today originated from an innovation developed around 2005 called natural orifice transluminal endoscopic surgery, or NOTES. “It was an exciting time,” Dr. Thompson said. “It looked like we could actually do transluminal surgery, meaning we could remove a gallbladder or appendix out through the mouth.”
The possibility of performing surgery with an endoscope led to an explosion of technological development. “Before the NOTES movement, we didn’t have many accessories that went with an endoscope,” Dr. Thompson said. “We had snares, injection needles and some clips, but not much else. Then we started seeing multitasking platforms where you could triangulate and dissect tissue more effectively. We had vessel sealing graspers, all sorts of dissection knives and devices that could create anastomoses endoscopically.”
The NOTES movement then disappeared, due to a variety of hurdles. Some were reimbursement related, but others related to the specialists performing these complex procedures. “Most surgeons didn’t have the technical skill set to do complicated endoscopy and most endoscopists didn’t have a surgical mindset and the ability to deal with intra-abdominal complications,” Dr. Thompson said. “The technologies, however, have stayed around and found their way into a new type of endoscopic surgery that some people call flexible endoscopic surgery or natural orifice surgery.”
The endoscopic devices and technologies developed to support NOTES have made a whole new set of surgical procedures possible. These include peroral endoscopic myotomy, or POEM, procedures used to treat conditions like Zenker’s diverticula, achalasia and gastroparesis. In POEM procedures, which are also referred to as third space endoscopy, surgeons make tunnels in the wall of the bowel between the muscle and the mucosa.
“These procedures have largely replaced surgical diverticulectomy, Heller myotomy for achalasia and surgical pyloromyotomy for gastroparesis — and that’s just the tip of the iceberg,” Dr. Thompson said. “There are also several other procedures that we now perform to treat obesity with endoscopic suturing. We treat reflux with endoscopic anti-reflux procedures and the list goes on and on. As we look back, what really spurred these innovations nearly 15 years ago was the NOTES movement.”
Systems integration is the key to taking endoscopic surgery to the next level
To perform advanced endoscopic surgery well, system integration is essential, according to Dr. Thompson. This technology makes it easy to work with a large monitor and pull information seamlessly from several different imaging platforms.
“You see real-time fluoroscopy and endoscopy images next to one another,” Dr. Thompson said. “Systems integration has made traditional endoscopic procedures safer and easier to perform.”
For example, patients with a stone in their bile duct or with more serious conditions like a hilar tumor in their bile duct are often treated with an endoscopic retrograde cholangiopancreatography (ERCP) procedure. To access one branch of the biliary system, clinicians have traditionally injected contrast, found the dilated system and then attempted to drain it. Unfortunately, little islands of contrast remain that can cause bile duct infections, potentially leading to serious complications including death. Systems integration has revolutionized this procedure.
“With systems integration, you can pull up an MRCP; that is, an MRI that shows the bile duct. We can see that image right next to the ERCP image,” Dr. Thompson said. “Rather than injecting a large amount of contrast, we run a wire into the biliary system that’s dilated and insert a stent. We confirm that we’re in the right spot by injecting a focal amount of contrast once we’ve achieved target access.”
Systems integration also enables clinicians to take endoscopic surgery to the next level. For instance, a handful of hospitals now perform endoscopic gastro-enteral anastomosis procedures on a regular basis to palliate pancreatic cancer.
“We used to treat people with malignant gastric outlet obstruction with an enteral stent, but those often become blocked, and patients spend a lot of time back in the hospital getting their stents unclogged,” Dr. Thompson said. “That’s not the goal with palliation. You want patients to enjoy life more. Endoscopic gastro-enteral anastomosis allows them to do that, which is great.”
For this procedure to be successful, however, clinicians must see certain things next to each other in real time, like radiology imaging, endoscopic ultrasound, endoscopy and fluoroscopy. In addition, physicians must be able to change back and forth between those images in real time. “Systems integration is key for that,” Dr. Thompson said. “It really can be the difference between success and failure. Fujifilm has a major focus on this area and they’ve been able to work within our existing infrastructure to address our unique needs.”
Systems integration is also increasing patient access to advanced endoscopic procedures
Today, many advanced endoscopic surgeries are offered only by centers of excellence. “A very small number of hospitals do these procedures very well,” Dr. Thompson said. “We need systems integration for them to become more commonplace.”
With systems integration, experts can have a virtual presence when a physician performs a procedure for the first time or the first several times. An experienced physician is in the room, on a monitor, watching in real time and helping to proctor the procedure. Similarly, technology company reps can also be a virtual presence in the room.
“Systems integration allows more people to watch procedures. We have several residents and fellows that want to see procedures, but there are only so many people that will fit in the procedure room,” Dr. Thompson said. “Thanks to systems integration, they can watch from outside the room and still ask questions during the procedure. We also record all our cases. If something interesting develops, we catch it on video. Then we can share it and educate people about what can occur and how we dealt with it. It’s a great educational tool.”
Room cameras are also critically important for training, as ergonomic factors contribute to the success of endoscopic procedures. There are many subtleties to teaching endoscopic techniques, such as how clinicians hold the scope, how they position their body, and how they position the patient.
“With room cameras, we can demonstrate these points in real time during the procedure,” Dr. Thompson said. “It makes all the difference in the world. The Fujifilm system as well as others links the room camera and endoscopic images, so students see them at the same time. They translate the learning into something they can employ later and be more successful doing these procedures.”
High-resolution images and image enhancement may reduce bleeding and improve patient outcomes
With advanced endoscopic surgical procedures, imaging is an essential tool to minimize blood loss. “Any of our procedures, whether it’s an endoscopic submucosal dissection to remove an early cancer or a myotomy, are very surgical in nature,” Dr. Thompson said. “Seeing vessels ahead of time allows us to seal them, rather than cutting them inadvertently. If you accidentally cut a vessel, the bleeding slows the procedure and can negatively impact patient outcomes.”
Fujifilm’s proprietary Linked Color Imaging (LCI)® technology has significantly improved the clinician experience during third space procedures. “When we do tunneling procedures to perform myotomies, we’re in the chest and close to big blood vessels,” Dr. Thompson said. “Dissecting through cobwebs of submucosa can be like walking through a forest in a dense fog. We’ve found with LCI that the blood vessels pop out. You’ll see a vessel well in advance, prepare it, and seal it. I really enjoy using the LCI.”
Looking ahead, imaging and AI will transform GI procedures
In the future, AI has the potential to significantly improve many types of GI procedures. “Everything we do in endoscopy is image based, whether it’s an aggressive endosurgery or endoscopic ultrasound,” Dr. Thompson said. “It’s perfect for AI.”
AI in combination with less invasive imaging modalities, for example, has the potential to revolutionize colorectal cancer screenings. With these technologies, clinicians may be able to identify, characterize, and treat polyps more effectively, as well as more rapidly.
AI could also revolutionize the surgical experience for clinicians and patients alike. “Imagine AI analyzing LCI images — it will likely be better than the human eye at identifying blood vessels and navigating physicians through complex endoscopic surgical procedures. Fujifilm is doing some very interesting work utilizing LCI imaging in AI and I think it could help drive the field forward.”