Issue link: https://beckershealthcare.uberflip.com/i/493270
6 Gastroenterologist Thought Leadership There are a few specific technologies in imaging, such as narrow band imaging and chromoen- doscopy, which may ultimately play a significant role. The advent of high-definition imaging has been a significant advance and is the standard in most endoscopy suites. WP: The biggest technological advances involve im- proved visibility during a colonoscopy. Specifically, we have moved into high-definition visualization al- lowing for clearer images of the colon. The field of view has also widened, which has helped our ability to detect smaller polyps. Many of endoscopes now come with light filtering technology such as narrow band imaging which helps us discriminate the bor- ders of polyps from normal tissue. With the use of spraying certain dyes onto the co- lon tissue, we can also better discriminate small polyps and cancers in normal tissue (this tech- nique is referred to as chromoendoscopy). Finally, we have expanded our options for bowel prepara- tion as well as refined the protocols for taking it to improve the bowel cleansing process. This has made it easier for patients and allowed a better evaluation during colonoscopy. RZ: I can think of several. The visual field has improved, which plays a role in improving qual- ity. It has been incrementally helpful. I feel one of the greatest innovations has been jet wash. We can step on a pedal and flush out the colon. This can convert a colonoscopy that hasn't been prepped well into a clean exam. This dramatically impacts the quality of the exam. The argon laser for burning out very flat polyps, the advances in bicap therapy, clips and injection therapy to con- trol bleeding are also some of the more significant technical innovations over the past 10 to 15 years. Q: How do you think colonoscopy could still be improved? WC: The scopes are very good. I've done more than 10,000 colonoscopies and never had a per- foration. We are now focusing on increasing our polyp detection through improving our field of view. We are tweaking the procedure, but I don't think we will have a great jump in technology. DJ: The thing that needs the most improvement is universal quality. There is a tremendous amount of variation in the providers who perform colonosco- py. There need to be standard quality metrics, and all colonoscopists need to meet these benchmarks. Patients need to be able to depend on that qual- ity. This quality reporting should be available for review by peers, payers and patients. The collab- orative American College of Gastroenterology and American Society of Gastrointestinal Endoscopy national endoscopic benchmarking project GI Quality Improvement Consortium is an excellent example of such a benchmarking resource. My first plea for improvement is to get everyone to become better providers of standard colonoscopy, have more predictable ability to identify subtly lesions and expertly resect these lesions. This re- volves more around technique than technology! JK: One area that we can continue to improve on is our ability to visualize lesions in areas that are harder to appreciate, such as behind folds or in the cecum behind the ileo-cecal valve. Increasing the ability to evaluate these areas, as well as the colon as a whole, will increase adenoma detection rates. There have been some technological advances in this field such as the use of high definition wide angle views avail- able through Olympus or even wider angles of views with the FUSE system from EndoChoice. There also is the Third Eye Retroscope from Avantis, but as far as I am aware, these tools aren't available or used in the average endoscopy unit. WP: One of the biggest challenges has little to do with the actual procedure, but rather convincing pa- tients to get a colonoscopy. We can make even bigger strides in colon cancer incidence if we can improve patient compliance with getting a colonoscopy. As for the procedure itself, we still can miss rel- evant polyps and cancers. There are several thoughts as to why this may be including miss- ing polyps behind folds and inadequately remov- ing a polyp at the time of colonoscopy. There are evolving technologies focused on trying to solve the former. Finally, the physician community that performs colonoscopy also has to recognize this as a limited resource and minimize inappropriate use of colonoscopy, specifically bringing patients back for surveillance or screening too early. RZ: Right-sided lesions can hide behind folds. We need methods to improve evaluation of lesions in the right colon. Q: What role do colonoscopy alternatives play in the GI field? WC: I was involved in virtual colonoscopy stud- ies. That was promising, but you still need prep, something inserted in the patients anus and there is the issue of radiation. The radiation issue can't be overcome; I think that modality is dead. MRI was looked at as an alternative to virtual colonos- copy, but that is very expensive. Capsule endoscopy for screening is promising, but still requires a prep and good visualization of the en- tire colon. The capsule technology needs to improve. There are also noninvasive tests, such as Colo- guard and FIT. I don't think you gain much from Cologuard compared to FIT testing, yet you get a 10-fold increase in cost. If patients won't get a colonoscopy, FIT is still a good option. Flex- ible sigmoidoscopy is another option that some patients prefer, also. Flexible sigmoidoscopy re- quires no sedation and can be done every three to five years. Combine that with FIT testing and you have a good screening approach. DJ: The alternatives are very good for defining co- lon cancer, but not as effective for finding high-risk precancerous polyps. Cologuard has been the first test to suggest a fecal test can identify polyps, but colonoscopy remains the gold standard for preven- tion and early detection of colorectal cancer. There are other options such as colonography and capsule colonoscopy, but at present, these tests are best reserved for patients who cannot undergo colonoscopy. JK: Colonoscopy alternatives such as virtual colo- nography may help increase the rates of colon cancer screening in the general public which is a good thing but I do not think it will have a nega- tive impact on colonoscopy in general as there is still such a high demand for colon cancer screen- ing in the general population. Also, any colonos- copy alternative that is positive for a lesion will ultimately require a colonoscopy then for thera- peutic intervention to address the lesion. WK: Alternatives to colonoscopy, such as CT colo- nography, play a role in the overall strategy of screen- ing as many people as possible. However, that role is limited and has yet to be fully defined. The ability, with colonoscopy, to identify and remove even the smallest premalignant neoplasms maintains colo- noscopy in its primary screening and prevention roles. In certain patients with severe comorbidities, and in those with technically difficult exams, CT colonography plays an important role. WP: There are evolving technologies that may serve as alternatives to diagnosing colon polyps and cancers. This will primarily have the impact of reducing the number of colonoscopies strictly performed for screening. However, for many of these new types of tests, a positive test will STILL require a colonoscopy to investigate and remove the detected polyp or cancer. CR: There are approximately 23 million eligible patients who have not been screened for colorec- tal cancer. Cologuard, and its abilities to screen for cancer and polyps noninvasively, is a wonder- ful opportunity to get the reluctant individual screened. This could lead to an increase in pa- tients being referred for colonoscopy and, endos- copists could become even busier. I think primary care physicians are going to see these patients first. They will discuss the benefits of colorectal cancer screening. If the patients do not want to be referred for a colonoscopy, pri- mary care physicians can order the Cologuard test first, which the patient can take at home. If the test comes back positive, then the patient is referred for a follow up colonoscopy. RZ: These alternatives are complements to colo- noscopy. Tests, such as Cologuard, FIT and virtual colonoscopy, are to be utilized for patients who do not want to undergo a colonoscopy or for patients who are not candidates for colonoscopy. Colonos- copy remains the gold standard. Q: What role do you foresee colonoscopy playing in the GI field 10 years from now? WC: Eventually we will have screening based on risk stratification. Through family history, demo- graphics and, to an extent, genetic testing we will be able to tell what people need what test. We will begin to do less diagnostic colonoscopies and more therapeutic colonoscopies. We've eliminated di- agnostic ERCP and now just perform therapeutic ERCP. I believe this will eventually happen with colonoscopy; it makes more sense for the utiliza- tion of resources. It will take us 10 to 15 years to get everything sorted out and establish new guidelines, however. In the meantime, diagnostic colonoscopy will remain a leading test in GI.