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Endoscopic Technologies Improve Diagnosis

(Feb 1, 2009)

Advances in endoscopic technology are allowing physicians at NewYork-Presbyterian Hospital to visualize the gastrointestinal (GI) tract and to detect mucosal and anatomic abnormalities in an unprecedented fashion. One advancement, narrow band imaging (NBI), is helping endoscopists detect precancerous mucosal changes earlier, potentially reducing the mortality associated with esophageal and colorectal cancers. Another new technology, balloon enteroscopy, is allowing gastroenterologists to access the small intestine, whereas it was previously mostly inaccessible with standard endoscopy.

"In patients with Barrett's esophagus, NBI has improved our surveillance approach and has helped us target biopsies," explained Charles Lightdale, MD. "It is also allowing us to detect residual and recurrent lesions in patients with advanced disease who have already undergone ablative treatment."

"With high-definition endoscopy and NBI, we're not just getting a better image, but also more information," added Mark Pochapin, MD. "The image is so detailed, we can see flat polyps or lesions throughout the GI tract that we might have missed otherwise."

NBI illuminates the mucosa with wavelengths of narrow bands of blue and green light. According to Drs. Lightdale and Pochapin, NBI enhances the visibility of capillaries, veins, and other subtle tissue structures by optimizing the absorbance and scattering characteristics of light. Superficial blood vessels appear brown under NBI. Since precancerous areas of the mucosa often contain an increased concentration of this blood supply, NBI is an ideal technology to improve the appearance of these areas because it shows increased vascularity and, as Dr. Pochapin said, literally "outlines the polyps."

The reigning standard of endoscopic care for patients with Barrett's esophagus includes random biopsies in each of the 4 quadrants of the esophagus every 1 to 2 cm of Barrett's length. However, Dr. Lightdale said, by using NBI, he can identify abnormal mucosa and target biopsies to only those areas that appear irregular. Indeed, research has shown this approach reduces the number of biopsies needed to perform an exhaustive endoscopic examination, while increasing the diagnostic yield of the procedure. Dr. Lightdale specifically looks for mucosa with villous patterns, or mucosa that appears fine or clumpy; if esophageal ridges are clubbed, enlarged, or thin, these areas require biopsy as well. Tiny islands of Barrett's tissue remaining after the initial ablation stand out in much greater contrast using NBI, and are much easier to target for complete obliteration of all Barrett's tissue.

According to Dr. Pochapin, the use of NBI has become the standard of care at the Hospital for all GI procedures. Brian Bosworth, MD, for example, is using NBI to detect early dysplastic changes in ulcerative colitis patients at risk for developing colorectal cancer. The ability to screen for dysplasia using NBI is "a quantum leap above standard endoscopy and microscopy," Dr. Bosworth said. "It allows us to quickly and efficiently image the mucosa."

He pointed to 2 studies presented at the 2008 Digestive Diseases Week (Rastogi et al; Abstract 1163) showing that NBI increases the detection of more lesions with dysplasia than white light endoscopy does. Regarding the diagnostic advantage NBI confers on Barrett's esophagus-related endoscopic examinations, Dr. Bosworth agreed that "this means we can do fewer biopsies on normal tissue, and focus on only the areas that raise suspicion."

Low-grade dysplasia is not visible under white light endoscopy, but is clearly seen under NBI, Dr. Bosworth emphasized. Furthermore, NBI requires approximately half the time of chromoendoscopy. As it has transformed the management of Barrett's esophagus patients, NBI is changing the standard of care for patients with inflammatory bowel disease who are at risk for developing colorectal cancer.

"It’s becoming the standard of practice that patients with inflammatory bowel disease who are at increased risk for dysplasia undergo surveillance endoscopy with both white light and NBI," Dr. Bosworth said.

According to Vinita Jacob, MD, who joined the Jill Roberts Center for Inflammatory Bowel Disease at NewYork-Presbyterian/Weill Cornell in July, NBI is also helping resolve a debate regarding the clinical significance of flat low-grade dysplasia. NewYork-Presbyterian's protocol is to remove discreet polypoid areas that are situated in otherwise noninflamed areas of mucosa and conduct close surveillance in these patients. To be sure, while NBI helps detect these dysplasia-associated lesions or masses, patients with noncircumscribed lesions without defined borders still undergo colectomy.

"We are building a robust database of our colitis patients with dysplasia in an effort to identify endoscopic, pathologic, and serologic markers that may help us predict who will develop dysplasia," said Dr. Bosworth, who is co-investigator on this study with senior researcher Ellen Scherl, MD. "The idea is that the risk for colorectal cancer if these lesions are removed early and completely may be no higher among our colitis patients than among any other individuals."

In addition to the NBI scopes, some gastroenterologists at the Hospital are also researching a new technology called the "third eye" retroscope – so named, according to Dr. Pochapin, because "it is a tiny camera in a catheter which goes out the tip of theendoscope and turns back in on itself, almost in the shape of a 'J.'" Research has shown that even the most astute GI surgeons miss approximately 6% of all GI polyps because they are not visible in standard colonoscopy. This scope's design characteristic allows surgeons to spot more flat polyps or polyps located behind folds in the colon. Dr. Pochapin's group plans to lead a study using the device in patients deemed at high risk for colon cancer to determine if the technology will allow for the identification of polyps.

Physicians and surgeons at the Hospital are also using 2 relatively new techniques and/or devices designed to assist in the performance of diagnostic and therapeutic procedures within the bowel. Led by Jeffrey W. Milsom, MD, and Richard L. Whelan, MD, the first, carbon dioxide (CO2) insufflation, distends the bowel with CO2 gas, allowing surgeons increased access without the complications associated with standard insufflation (ie, abdominal pain). The second, double-balloon endoscopy, uses a specialized endoscope featuring 2 balloons – the first attached to the distal end of the scope, the second to a transparent tube sliding over the endoscope. When inflated with air, the balloons cling to sections of the small intestine and pleat it over the endoscope, effectively "shortening" it. Shortening of the small intestine over the endoscope enables a comprehensive examination of the entire small intestine, enabling targeted intervention that makes biopsies, injections, and removal and ablation techniques in the small intestine possible, without surgery.

The double-balloon endoscopy device, which received FDA approval in 2004, produces high-quality images and reduces patient discomfort. If a lesion is found in the small intestine that requires surgery, "tattooing" of the region and biopsies for tissue diagnosis by double-balloon endoscopy can also provide important information to help surgeons plan for the appropriate type of surgery, potentially resulting in smaller incisions and less-invasive operations as well as shorter recovery times; however, double-balloon endoscopy often mitigates the need for surgery, according to Peter D. Stevens, MD.

"Double-balloon endoscopy is particularly helpful in patients with celiac disease, lymphoma or other therapeutic challenges," he noted. "It fits in where intraoperative endoscopy or surgery would have been before."

Contributing faculty for this article:
Brian Bosworth, MD; Vinita Jacob, MD; Charles
Lightdale, MD; Mark B. Pochapin, MD;
Ellen J. Scherl, MD; Peter D. Stevens, MD

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