An On-line Endoscopic Image Filing System

Abstract: The introduction of the electronic endoscope has opened the way to tremendous possibilities in handling endoscopic images in terms of filing, storage and retrieval. Although there have been many approaches to retaining endoscopic data, no system has been found to be applicable to all endoscopy units. An integrated filing system that allows storage and recall of endoscopic data in a rapid and convenient manner is essential for a busy endoscopy unit. A hybrid filing system developed by combining analog and digital devices is currently in use in many endoscopy units and fulfills this purpose to some extent. We have developed an on-line system of endoscopic image filing together with a local area network by connecting the hospital host computer, different endoscopy units and terminals located in distant places within the hospital. This system assured filing of digitalized endoscopic and endoscopic ultrasound images together with simultaneous rapid and reliable access to the filed data. Future improvements will include simultaneous recording of endoscopic reports and application of image analyzing software.     

Intraductal ultrasound in the biliary tract

Although endoscopic ultrasonography (EUS) represents a major advance in endoscopic imaging, endosonography using dedicated echoendoscopes has some serious drawbacks, including the diameter of the echoendoscope (12 to 13 mm), the lack of intraluminal examination of the pancreatobiliary duct system due to the size of the instrument, unsatisfactory image quality and resolution for small lesions, and the need for a second examination separate from the previous routine endoscopy. Recently developed ultrasonographic miniprobes (diameter, about 2 mm; frequency, 12 to 20 MHz) can be passed through the working channel of standard endoscopes to provide high-frequency ultrasound images. These miniprobes may overcome some of the noted drawbacks and add to the safety and convenience of patients. Moreover, in various diseases of the gastrointestinal tract and the pancreatobiliary ductal system, the diagnostic accuracy of miniprobe ultrasonography has been proven to be superior to that of EUS. Miniprobe ultrasonography is a promising tool that adds new capabilities to the armamentarium of gastroenterologic diagnostic assessment.     

Usefulness of positron emission tomography in primary intestinal follicular lymphoma

Double-balloon enteroscopy (DBE) and video capsule endoscopy are useful for the diagnosis of lymphoma in the small intestine. However, DBE cannot be safely performed in cases with passage disturbance due to wall thickening and stenosis. Additionally, video capsule endoscopy cannot be performed in such cases because of the risk of retention. Here, we report 4 cases of primary follicular lymphoma of the gastrointestinal tract that could be detected using 18F-fluoro-deoxyglucose positron emission tomography combined with computed tomography (PET-CT). The endoscopic findings of these 4 cases included lesions with wall thickening, which comprised macroscopically clusters of nodules, dense clusters of whitish granules or small nodules, fold thickening and ulcers with irregular margins that occupied the whole lumen with edematous mucosa. All patients fulfilled the World Health Organization grade 1 criteria. 18 F-fluorodeoxyglucose PET-CT can help predict the risks that may result from certain endoscopic examinations, such as DBE and video capsule endoscopy.     

肝硬化门静脉高压无创性检测方法的认识与评价

门静脉高压是导致肝硬化患者出现严重并发症和死亡的主要原因之一。肝静脉压力梯度(HVPG)是评价门静脉高压及其严重程度最准确的方法,但因具有创伤性和不适性,故需特别关注肝硬化门静脉高压无创性检测方法。通过血液学指标、超声检查和CT以及胶囊内镜等无创性检查方法,可初步评估代偿期肝硬化患者是否存在食管胃底静脉曲张。上消化道内镜检查是确定食管胃底静脉曲张的金标准。通过上消化道内镜或超声内镜检测食管静脉曲张压力,可判断药物或分流手术降低重度食管静脉曲张压力的疗效。虽然这些无创性检测方法可有效地评估门静脉高压的严重状况,但对轻度门静脉高压评估能力有限,有待进一步完善和提高。     

Video endoscopy

The advent of the video endoscope is the most profound change in the design of gastrointestinal endoscopes since the introduction of the optical fibre bundle. As a television system, it is more expensive than existing systems but surpasses them in quality in my opinion. However, the CCD endoscope will not survive only as a special system for television. Although all the currently available and prototype instruments are acceptable for most aspects of diagnostic endoscopy, there is debate as to whether or not the CCD endoscope will replace the fibrescope. I think that this is a distinct possibility, but in order for the video endoscope to supplant the fibrescope it must not only equal it in all respects but must also surpass it in some significant way. This potential superiority hinges on the inherent versatility of the method by which the video endoscope obtains an endoscopic image. This leads readily to any number of methods of electronic and computerized storage, recall, comparison and transmission of endoscopic data, capabilities that can be used to advantage in many areas. In research that utilizes endoscopic methods it will prove invaluable; properly interfaced with other technological developments it can greatly increase the efficiency of an endoscopy unit. Remarkable as these possibilities may be, however, it is the prospect of computerized and electronic manipulation of the endoscopic images that most threatens the position of the fibrescope. If emerging CCD technology provides useful methods of diagnosis that go beyond simple observation in the visible light spectrum, then the argument will be decided in favour of the video endoscope. What form this will take, and when it will come to pass, remain to be seen.     

Gastrointestinal endoscopy in pregnancy

Gastrointestinal endoscopy has a major diagnostic and therapeutic role in most gastrointestinal disorders; however, limited information is available about clinical efficacy and safety in pregnant patients. The major risks of endoscopy during pregnancy include potential harm to the fetus because of hypoxia, premature labor, trauma and teratogenesis. In some cases, endoscopic procedures may be postponed until after delivery. When emergency or urgent indications are present, endoscopic procedures may be considered with some precautions. United States Food and Drug Administration category B drugs may be used in low doses. Endoscopic procedures during pregnancy may include upper gastrointestinal endoscopy, percutaneous endoscopic gastrostomy, sigmoidoscopy, colonoscopy, enteroscopy of the small bowel or video capsule endoscopy, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. All gastrointestinal endoscopic procedures in pregnant patients should be performed in hospitals by expert endoscopists and an obstetrician should be informed about all endoscopic procedures. The endoscopy and flexible sigmoidoscopy may be safe for the fetus and pregnant patient, and may be performed during pregnancy when strong indications are present. Colonoscopy for pregnant patients may be considered for strong indications during the second trimester. Although therapeutic endoscopic retrograde cholangiopancreatography may be considered during pregnancy, this procedure should be performed only for strong indications and attempts should be made to minimize radiation exposure.     

Differences in endoscopic views during biopsy through the right and left lower biopsy channels of the upper gastrointestinal endoscope

Background: It has not been established as to which side the biopsy (instrument) channel should be placed in the tip of a front‐viewing upper gastrointestinal (GI) endoscope to allow an en‐face approach to lesions on various aspects of the stomach wall. Methods: Using a front‐viewing two‐channel endoscope, we identi?ed a difference in endoscopic views during biopsy between lower‐right and lower‐left channels. Colored marks were distributed on the lesser curvature (LC), greater curvature (GC), anterior wall (AW), and posterior wall (PW) in the ‘stomach’ of a dummy for mock‐performance of upper GI endoscopy. When biopsy forceps through the different channels touched the marks, an endoscopic photograph was taken. Furthermore, when biopsy specimens were obtained from PW lesions in several patients, endoscopic views were compared between the two biopsy channels. Results: In the dummy study, no remarkable difference was detected in targeting the marks on AW, LC, or GC of the stomach. The dummy and the patient study showed that the lower‐right approach could target PW lesions with a more adequate endoscopic view than from the lower left. The lower‐left approach targeted PW lesions on the higher body with a nearly blinded endoscopic view. Specimens from PW of the upper body, which could be precisely obtained under direct visual control through the lower‐right channel, were no smaller than those obtained using the channel on the lower left. Conclusion: The present study suggests that the lower‐right channel may be preferable to the lower‐left channel in the tip of a front‐viewing upper GI endoscope.     

The wireless capsule: new light in the darkness

The development of wireless capsule endoscopy offers the potential to examine the whole small intestine, with its 5-meter length, and has the advantage of being painless. Using a miniature CMOS camera and a short focal length lens, images are obtained, as the optical window of the capsule sweeps past the gut wall, without requiring air inflation of the gut lumen. The capsule endoscope is propelled by peristalsis through the gastrointestinal tract. The video images are transmitted using radiotelemetry to an array of aerials attached to the body which allows image capture. The images are stored on a small portable recorder carried on a belt and subsequently downloaded for analysis. The system allows more than 7 h of continuous recording of images of the gastrointestinal tract. The patients are free to continue their daily routine during the examination. The capsule endoscope has performed well in trials in patients with difficult gastrointestinal bleeding and in comparative studies with push enteroscopy. It has received both a CE mark and FDA approval for use in patients. It has been used to date in about 4,000 patients. The current clinical data are reviewed.     

Curative endoscopic ultrasound-assisted submucosal resection of a gastric stromal tumor

Endoscopic submucosal resection has been proposed as a feasible alternative for the diagnosis and treatment of small submucosal tumors (< 3 cm), as compared to classic interventions (surgical intervention or frequent follow-up). Therapeutic options should be established after precise endoscopic ultrasound assessment of the tumor characteristics. We present the case of a 60 year-old patient, admitted to the Emergency Department for upper gastrointestinal (GI) bleeding. Upper GI endoscopy showed a submucosal tumor on the posterior gastric wall, with hyperemic covering mucosa, without central ulceration. Endoscopic ultrasound identified a 10-mm well-delimited hypoechoic lesion, with the origin in the third hyperechoic layer (submucosa). After injection of 1:10000 epinephrine in the submucosa, with subsequent elevation of the protrusive formation, we performed an endoscopic submucosal resection without any complications. Pathology exam showed a gastric stromal tumor with low mitotic activity, the endoscopic resection being considered curative. The absence of independent risk factors determined by ultrasound endoscopy (size > 3 cm, irregular margins, hyperechoic foci > 3 mm, cystic spaces > 4 mm, presence of intratumoral Doppler signal), as well as the low mitotic activity, permitted the subsequent follow-up of the patient. A control endoscopic examination performed after 4 weeks showed the healing of the post-resection ulceration. In conclusion, ultrasound endoscopy allowed the establishment of a correct presumptive diagnosis and the subsequent assistance of endoscopic submucosal resection, used for pathological confirmation and for curative endoscopic treatment.     

10 Future developments in endoscopic imaging

Endoscopic imaging capabilities have significantly improved over the past 10 years. Improvements in fibreoptic technology have made possible the development of very thin endoscopes that can directly visualize the biliary and pancreatic ducts. The application of the CCD to endoscopy has made electronic endoscopy possible, and holds promise for stereoendoscopy. The ability to digitize endoscopic images can be developed to store, transmit, magnify, enhance and otherwise manipulate data obtained during endoscopy, and will probably be utilized routinely in the future. Laser and ultrasound technology are likely to enhance significantly our ability to examine ultrastructural aspects of gastrointestinal organs and surrounding tissues, and may play an important role in cancer surveillance programs. Vital staining techniques are likely to find widespread use in early cancer detection programmes, and may be useful to follow prospectively lesions observed or treated during endoscopy. Finally, the new developments in ‘virtual imaging’ may find applications in the field of gastrointestinal endoscopy and other ‘minimally invasive’ surgical procedures.     

Endoscopic ultrasound: moving from diagnostics to therapeutics

Endoscopic ultrasound was initially introduced in the 1980s as a diagnostic modality using echoendoscopes with radial scanning that permitted reconstruction of cross-sectional images similar to computed tomography The close proximity of the ultrasound transducer to the gastrointestinal wall and retroperitoneal structures allowed a detailed examination that is not possible with cross-sectional imaging such as computed tomography and magnetic resonance imaging. It proved to be highly accurate and useful in the staging of gastrointestinal malignancies, as well as in characterizing the nature of subepithelial lesions and disorders of the pancreaticobiliary system. The introduction of linear echoendoscopes facilitated fine needle aspiration because, with linear scanning, it was able to trace the path of the tip of the needle during the puncture process. In addition to being very useful for tissue acquisition for diagnostic purposes, the principles behind endoscopic ultrasound-guided fine needle aspiration paved the way for the development of therapeutic endoscopic ultrasound. Substances could now be delivered by endoscopic ultrasound into targeted areas, an example being an endoscopic ultrasound-guided celiac plexus block and neurolysis. In addition, the endoscopic ultrasound-guided puncture of fluid collections, abscesses and obstructed biliary and pancreatic ductal systems facilitated the passage of guidewires, thus allowing therapeutic drainage procedures to be performed using the Seldinger technique. This review summarizes the diagnostic capability of endoscopic ultrasound and then moves on to elaborate in detail its therapeutic capability and potential.     

Development of virtual histology and virtual biopsy using laser-scanning confocal microscopy

The aim of this project is to acquire a direct image of histology from in vivo gastrointestinal mucosa. In other words, the task of 'endo-microscope' is to observe the cellular architecture of tissue in vivo during routine endoscopic examination. As the first step to completing this study, resected fresh specimens from the oesophagus. stomach and colon were examined by laser-scanning confocal microscopy (LCM) (Fluoview, Olympus, Tokyo). Fresh untreated mucosal specimens obtained by endoscopic pinch biopsy, polypectomy or endoscopic mucosal resection were collected and placed in normal saline and examined by LCM, collecting the reflective light of a 488-nm wavelength argon laser beam. As the second step, a probe-type LCM 'endo-microscope' was designed and applied to observe the human oral-cavity mucosa. The probe has 4.5-mm outer diameter and 20-cm length, which enables easy access to oral cavity mucosa. The estimated special resolution of the probe is 1-5 microm. A real-time microscopic image directly from ex vivo fresh specimens was acquired. The acquired LCM images corresponded well with the conventional H-E light microscopic images. Cell wall, nucleus and cytoplasm were simultaneously visualized by LCM scanning. This novel method enables serial imaginary microscopic sections on fresh specimens. In addition, a probe-type LCM 'endo-microscope' was designed and was applied to observe human oral cavity mucosa. Virtual histological images from the living oral squamous cell were successfully obtained. LCM images from ex vivo fresh specimens demonstrated the features of the H-E staining histological image. In the next step to accomplish our project, we developed a LCM probe with 4.5-mm outer diameter to obtain a virtual image of human oral cavity mucosa.     

POSSIBILITY OF THE DEVELOPMENT AND CLINICAL USE OF A CAPSULE ULTRASOUND ENDOSCOPE

Development of technology has made it possible to produce the micromachine. In the field of endoscopy, wireless capsule endoscopy (CE) has been developed and opened up a new field in endoscopic study. The common indication in clinical cases is limited to the diagnosis of lesions in the deeper small intestine. Clinical application of this system is increasing at a remarkable rate, though target organs and endoscopic performance are limited. On the other hand, endoscopic ultrasound (EUS) technology has advanced rapidly during the last 20 years. The improvement of ultrasound scanners, including the size of the scanner, quality of image and plural changeable frequency has been successfully developed. On the basis of these technological advances, we can discuss the potential ability of developing a capsule ultrasound endoscopy.     

Computed virtual chromoendoscopy system (FICE): A new tool for upper endoscopy?

OBJECTIVES: A newly developed computed virtual chromoendoscopy system, Fuji Intelligent Color Enhancement (FICE) technology, decomposes images by wavelength, then directly produces reconstructed images with enhanced mucosal surface contrast. The aims of the present study were to determine the quality of information provided by computed virtual chromoendoscopy for detecting gastrointestinal polyps and to identify the best channel setting for imaging. PATIENTS AND METHODS: Thirty-one upper endoscopy procedures were performed in 31 patients using Fujinon 1.3-million-pixel endoscopes with zoom. A polyp was diagnosed in 45% of the patients. Six experienced endoscopists, who had never used the computed virtual chromoendoscopy system before, analysed the 31 endoscopy reports. Each endoscopy report included 11 images (one conventional image and one image for each FICE channel). The endoscopists used a 10-cm analog visual scale to determine the three best FICE channels, and to evaluate the quality and pit pattern of the chromoendoscopy images. RESULTS: Channel 4 (red: 520; green: 500; blue: 405) was considered the best channel in 39.7% of the reports (p<0.0001) and was among the best three in 77%. For 94.1% of the reports, the best FICE channel image was considered superior to the conventional image (p<0.0001). Median pit pattern score was 9.43 for computed virtual chromoendoscopy and 7.08 for conventional endoscopy (p<0.001). CONCLUSION: Fuji Intelligent Color Enhancement (FICE) channel 4 images were significantly better than conventional images. Computed virtual chromoendoscopy enabled better analysis of the pit pattern and the normal-pathological mucosal junction. Computed virtual chromoendoscopy can be used to identify gastroduodenal polyps and to assist in complete polypectomy.     

Endoscopic detection of early lower gastrointestinal cancer

The prognosis for patients with malignancies of the lower gastrointestinal tract is strictly dependent on early detection of premalignant and malignant lesions. What should an ideal screening and surveillance colonoscopy be able to accomplish? The technique should allow detection of large but also discrete mucosal alterations. Ideally, endoscopic discrimination between neoplastic and non-neoplastic lesions would be possible during the ongoing procedure. At present, endoscopy can be performed with powerful new endoscopes. Comparable to the rapid development in chip technology, the optical features of the newly designed endoscopes offer resolutions, which allow new surface details to be seen. In conjunction with chromoendoscopy, the newly discovered tool video colonoscopy is much easier and more impressive today than with the previously used fibre-optic endoscopes. Recently, new endoscopic technologies such as narrow band imaging, endocytoscopy, or confocal laser endoscopy have allowed the discovery of a whole new world of image details which will surely improve the diagnostic yield in the field of early malignancies. This review summarises newly available technologies and clinical data about the diagnosis of early lower gastrointestinal cancers.     

Economic aspects and evidence-based decision making in evaluating patients with suspected small bowel disorders

Obscure gastrointestinal hemorrhage is defined as overt or occult bleeding present after normal endoscopic examination of the upper and lower gastrointestinal tracts. Approximately 5% of patients with gastrointestinal hemorrhage can be classified as having obscure bleeding, with most patients found to have responsible lesions in the small intestine. The advent of video capsule endoscopy and deep enteroscopy allows for endoscopic access and therapeutic options in the small intestine. In our current era of cost minimization, reductions in capital equipment expenditures, and a high rate of malpractice claims against clinicians, the decision regarding whether a clinical enterprise should offer small bowel endoscopy using any of the more recent technologies requires an understanding of several factors. This article highlights some of the economic and medicolegal aspects of deep small bowel endoscopy. The following topics will be discussed: costs involved to perform endoscopic imaging of the small bowel; downstream revenue effect resulting from deep enteroscopy; coding, billing, and reimbursement issues; cost-effectiveness studies for diagnostic testing; algorithms for diagnostic evaluation of patients with suspected small bowel pathology; and medicolegal ramifications associated with endoscopic procedures of the small bowel.     

Evolving role of artificial intelligence in gastrointestinal endoscopy

Artificial intelligence (AI) is a combination of different technologies that enable machines to sense, comprehend, and learn with human-like levels of intelligence. AI technology will eventually enhance human capability, provide machines genuine autonomy, and reduce errors, and increase productivity and efficiency. AI seems promising, and the field is full of invention, novel applications; however, the limitation of machine learning suggests a cautious optimism as the right strategy. AI is also becoming incorporated into medicine to improve patient care by speeding up processes and achieving greater accuracy for optimal patient care. AI using deep learning technology has been used to identify, differentiate catalog images in several medical fields including gastrointestinal endoscopy. The gastrointestinal endoscopy field involves endoscopic diagnoses and prognostication of various digestive diseases using image analysis with the help of various gastrointestinal endoscopic device systems. AI-based endoscopic systems can reliably detect and provide crucial information on gastrointestinal pathology based on their training and validation. These systems can make gastroenterology practice easier, faster, more reliable, and reduce inter-observer variability in the coming years. However, the thought that these systems will replace human decision making replace gastrointestinal endoscopists does not seem plausible in the near future. In this review, we discuss AI and associated various technological terminologies, evolving role in gastrointestinal endoscopy, and future possibilities.     

Recent advances in photoacoustic endoscopy

Imaging based on photoacoustic effect relies on illuminating with short light pulses absorbed by tissue absorbers, resulting in thermoelastic expansion, giving rise to ultrasonic waves. The ultrasonic waves are then detected by detectors placed around the sample. Photoacoustic endoscopy (PAE) is one of four major implementations of photoacoustic tomography that have been developed recently. The prototype PAE was based on scanning mirror system that deflected both the light and the ultrasound. A recently developed mini-probe was further miniaturized, and enabled simultaneous photoacoustic and ultrasound imaging. This PAE-endoscopic ultrasound (EUS) system can offer high-resolution vasculature information in the gastrointestinal (GI) tract and display differences between optical and mechanical contrast compared with single-mode EUS. However, PAE for endoscopic GI imaging is still at the preclinical stage. In this commentary, we describe the technological improvements in PAE for possible clinical application in endoscopic GI imaging. In addition, we discuss the technical details of the ultrasonic transducer incorporated into the photoacoustic endoscopic probe.     

Significance of telemedicine for video image transmission of endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography procedures

Background

With the rapid and marked progress in gastrointestinal endoscopy, the education of doctors in many new diagnostic and therapeutic procedures is of increasing importance. Telecommunications (telemedicine) is very useful and cost-effective for doctors?? continuing exposure to advanced skills, including those needed for hepato-pancreato-biliary diseases. Nevertheless, telemedicine in endoscopy has not yet gained much popularity. We have successfully established a new system which solves the problems of conventional ones, namely poor streaming images and the need for special expensive teleconferencing equipment.

Methods

The digital video transport system, free software that transforms digital video signals directly into Internet Protocol without any analog conversion, was installed on a personal computer using a network with as much as 30?Mbps per channel, thereby providing more than 200 times greater information volume than the conventional system. Kyushu University Hospital in Japan was linked internationally to worldwide academic networks, using security software to protect patients?? privacy.

Results

Of the 188 telecommunications link-ups involving 108 institutions in 23 countries performed between February 2003 and August 2009, 55 events were endoscopy-related, 19 were live demonstrations, and 36 were gastrointestinal teleconferences with interactive discussions. The frame rate of the transmitted pictures was 30/s, thus preserving smooth high-quality streaming.

Conclusions

This paper documents the first time that an advanced tele-endoscopy system has been established over such a wide area using academic high-volume networks, funded by the various governments, and which is now available all over the world. The benefits of a network dedicated to research and education have barely been recognized in the medical community. We believe our cutting-edge system will be a milestone in endoscopy and will improve the quality of gastrointestinal education, especially with respect to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures.