The Scoop on Scopes

Exploring New Products and Technologies

As technology continues to advance, endoscope manufacturers constantly work to incorporate cutting-edge developments into their products as part of the quest to provide clinicians with the most effective means of diagnosis and treatment. EndoNurse recently spoke with some leading vendors to find out more about the latest and greatest advances in scopes.

Fujinon Inc. has recently launched a new endoscope system, called the EPX-4400. “Our technology is based on world leadership in technical advances,” says Mac Nakamura, president of Fujinon, Medical Division North American Operations, in a press release. “Fujinon recently earned a Technical Emmy award from the National Academy of Television Arts and Sciences for Lens Technology Developments for Solid State Imaging Cameras in High Definition Formats. While other manufacturers are discussing such technologies, we are making them a reality for the endoscopist, which ultimately benefits the patient. The EPX-4400 is a crowning example of the most advanced optical technologies and the latest in digital image processing.”

The EPX-4400 is the first commercially available fully digital endoscope system. “The new system incorporates a digital scope, digital processing, and an available HD (high definition) output,” says Kurt Cannon, vice president of corporate accounts at Fujinon. “High definition is available in analog and digital varieties. The EPX-4400’s digital format allows for improved imaging.”

The EPX-4400 system features high resolution imaging. According to Fujinon, this allows the system to provide nearly twice the resolution of comparable systems when used in conjunction with Fujinon 450 Series endoscopes. Fujinon also offers a new technology that can be used with this the EPX-4400 and is designed to replace chromoendoscopy — Fuji Intelligent Chromo Endoscopy (FICE).

“FICE is Fujinon’s new multi-band imaging product incorporated into the EPX-4400. FICE is a software application that uses a process called Spectral Estimation Technology to allow the visualization of tissue using variants of the traditional white light spectrum,” says Cannon. “Since the application is software-based, it is designed to provide multiple variations of the light spectrum customized to each physician’s needs.”

FICE is designed to enable visual enhancement of suspect structures that may not be visible under normal endoscopic conditions. This may allow physicians to biopsy targeted areas as opposed to taking random biopsies, potentially improving their ability to make quality diagnoses. The full EPX-4400 system includes the VP-4400 Video Processor and XL-4400 Light Source and is compatible with 400 Series endoscopes, providing the potential for many combinations of endoscopes with the endoscopy capabilities of FICE and high-resolution imaging.

Another recent product from Fujinon is the Double Balloon Enteroscopy (DBE) System. “The DBE system is the first and only endoscope in the world that is not only able to visualize the small bowel, but can therapeutically treat in the small bowel as well,” Cannon explains. “We can now treat patients endoscopically where, without DBE, they were required to go for surgical intervention. We believe that the product will dramatically improve patient outcomes in this area.”

This product was designed to address the relative difficulty in accessing the small intestine via an endoscope. A recent study on double-balloon endoscopy found that this technique offers better insertability and maneuverability compared with more conventional methods, and contends that double-balloon endoscopy has the potential to drastically change the approach for small intestinal diseases in the future. It shows that double-balloon endoscopes can be inserted into deeper portions of the small intestine both orally and anally, and it allows observation and treatment of the small intestine without general anesthesia.¹

The same study reports that this method is relatively safe and does not frequently result in complications. It has proved useful for the diagnosis and treatment of conditions such as small intestinal bleeding, small intestinal tumor, stenosis of the small intestine, and polyposis syndrome.

Olympus America Inc. recently announced the launch of a new HD endoscope platform from its EVIS EXERA II 180 series. This new system, according to Olympus, is the world’s first to deliver both HD and narrow band imaging (NBI) technology.

“High definition imaging was once the exclusive domain of professional cinematography and the consumer electronics world,” said F. Mark Gumz, president and chief operating officer of Olympus America Inc. in a press release. “With the introduction of this ground-breaking system from Olympus, physicians will be able to see a greater level of detail during examinations, which may help to enhance patient diagnoses.”

The HD signal from the new CV-180 video processor more than doubles the number of scan lines produced by conventional systems, according to Olympus, when used in conjunction with the new high definition GIF-H180 gastroscope or CF-H180A/L colonoscope. Olympus says the resulting images will offer gastroenterologists remarkably clear views of anatomical structures and fine capillaries.

NBI is a real-time, on-demand technology that was designed by Olympus to enhance visualization of the capillary network and mucosal morphology during endoscopic observation of the gastrointestinal (GI) tract. The technology is designed to be similar to chromoendoscopy without the messiness associated with the application of dye. NBI addresses the need to distinguish the capillary patterns of the mucosal surface layer from the background mucosa, which conventional chromoendoscopy typically does not improve upon. NBI was made to work by limiting the light source to specific wavelength bands, thus providing greater contrast to capillaries and other fine anatomical structures and improving visibility.

“We’ve been using the high definition system with NBI technology for some time and our initial experience has been promising,” stated Dr. Prateek Sharma, associate professor of medicine, University of Kansas School of Medicine, in a press release. “In our ongoing studies, we’ve found it useful with our patient population of Barrett’s esophagus. With NBI, in these studies, we’ve been able to differentiate areas of high-grade dysplasia from non-dysplastic lesions by looking at the mucosal and vascular patterns, which are not clearly visible on white light endoscopy. We believe this will allow us to target our biopsies and hopefully detect these lesions. Based on our initial experience, NBI has the potential to impact how we do endoscopy in the future.”

The new 180 series HDTV system includes the CV-180 video processor and CLV-180 light source, the GIF-H180 gastroscope and CF-H180A/L wide-angle colonoscope, which also provides a 170- degree field of vision. This system is expected to be available for purchase in January 2006.

Karl-Storz Endoscopy-America, Inc. recently launched the Flex-X2™ Uretero-Reno-Fiberscope, which is designed to offer increased resistance to laser damage during use. “The introduction of the original Flex-X™ was revolutionary,” Howard Klymas, marketing manager, Karl Storz, said in a press release describing the product. “The revolution now continues with the Flex-X2 Uretero- Reno-Fiberscope. The key feature of the Flex-X2 is its laser-resistant distal tip with Laserite™ material that helps resolve the issue of scope damage caused by laser burns. That also helps protect the hospital’s investment from unnecessary downtime and repairs.”

The Flex-X2 offers active 270-degree up and down deflection via single-lever control, and is designed to enhance complex navigation and adapt to a range of anatomical shapes. The device’s shaft is made from proprietary polymers to promote faster, easier passage of the scope, according to Karl Storz.

“The crush-resistant shaft of the Flex-X2 also resists back-table trauma, which is a frequent cause of shaft breakage,” Klymas added in the release. “And now with 1:1 rotations, the shaft is torque stable. The Flex-X2 Uretero-Reno-Fiberscope also provides improved strain relief for greater durability, and a unique shock absorber system enhances maneuverability.”

In addition to new products, manufacturers may also incorporate new and emerging properties or features to existing products. “A lot of colonoscopes have a forward water jet that allows you to spray water forward and wash as you go,” Cannon says. “One of the things that we’ve started to incorporate into our colonoscopes is a channel that is brushable, which from a cleaning and disinfection standpoint is critical.” He notes that, typically, other scopes on the market can only be flushed with water, enzyme, and disinfectant, as opposed to actually being able to bush them. “That’s one thing we feel is going to be important because as more and more colonoscopies are done, you can ensure the cleanliness of the product. From a nursing standpoint that’s a critical feature.

“Some of the other features we’ve been incorporating are smaller diameter scopes with larger channel sizes, as CCD chips get smaller we can actually decrease the size of the scope and also then increase the size of the channels slightly because the chip takes up less space,” Cannon continues. “The last emerging feature for us is the advent of more high-resolution CCD chips; megapixel — million-plus pixel — CCD chips, and that’s using FujiFilm proprietary technology.”

Carl Liebert, group marketing manager for video imaging at Karl Storz, notes that the chips that receive images for scopes continue to evolve. “One of the things that will facilitate distalchip technology in smaller scopes is the evolution of the CMOS sensor,” he says. “These can be made smaller than the CCD chips that are traditionally used in scopes.” Liebert says that as CMOS image quality improves, they will provide a potential replacement to CCD technology. “Once image quality gets there, the cost is a fair amount less, so that will in turn reduce the cost of these distal-chip scopes.”

When sorting through the range of product features and claims, clinicians may find it helpful to hone in on key items that can be important in gauging quality and value. “Durability of the product is something that everyone seems to be looking at nowadays because it impacts long-term cost of the product,” says Cannon. “The ‘feel’ of a scope is also very important, and we’ve spent a lot of time and money on R&D to ensure that our product feels how it should feel to the doctor. We’ve also seen that clinicians are looking heavily into up-front cost, and also the service aspect and long-term cost. So, it’s kind of the value proposition you can provide the customer in terms of cost and durability and also the feel of the scope, and ultimately give the patients what they need and get it done quickly and confidently.”

“One aspect is ease of use,” says Liebert. “You try to automate things as much as possible.” He also notes that cost considerations must be looked at with a short- and long-term approach. “You want to get something today that’s pretty advanced and meets your current needs, but I think people’s mindsets are changing — their horizons aren’t two years anymore — they’re five, six, even eight years, so they really want to buy things that are upgradeable. Things that, if you invest in something today, can you put a new camera or scope into it three years from now? Can you add new technology to it? That all adds up to value and long-term cost of ownership.”

Liebert also says imaging systems will begin to be evaluated for the completeness of their offerings in the near future, as opposed to looking at specific specifications such as lines and resolution. “You’ll have something that works in GI, urology, laparoscopy, basically every kind of ‘oscopy’ that a hospital does, regardless of location; whether it’s a GI suite, the OR, or a freestanding outpatient facility, one imaging system will be able to handle all your needs. That’s a development goal going forward that technology will help to facilitate.”

1. Yamamoto H, Kita H. Double-balloon endoscopy. Curr Opin Gastroenterol. 2005 Sep;21(5):573-7.

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