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the Science Behind Positive Patient Outcomes
Reprinted from September 2014
Supported by
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Ultra-Slim Configuration Advances
Upper Endoscopy and Colonoscopy
Faculty
Sunguk Jang, MD
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Staff, Division of Gastroenterology
Section of Therapeutic Endoscopy
Cleveland Clinic Foundation
Cleveland, Ohio
Introduction
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Jason B. Samarasena, MD
Director, Advanced Endoscopic Imaging
H.H. Chao Comprehensive Digestive Disease Center
Assistant Clinical Professor of Medicine
University of California, Irvine
Orange, California
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Upper endoscopy and colonoscopy permit the direct evaluation of
gastroendonews.com
the mucosal surface of the gastrointestinal (GI) tract and
the effective
treatment of many conditions that were previously only treated by surgery.1 However, patient discomfort and longer procedure duration can
increase the probability for complications and make it less likely that
the procedure’s goals will be met. Additionally, the formation of loops
during the procedure, redundant colons, difficult or complex flexures,
and the presence of strictures are all factors associated with increased
patient discomfort.2
Innovations in endoscopy equipment hold the potential to improve
the experience for the patient and physician, and to extend what is
clinically feasible using an endoscopic approach. A new generation
of ultra-slim endoscopes from the Olympus EVIS EXERA III platform
advances visualization, scope maneuverability, and workflow. The new
instruments are appropriate for any patient, but may especially benefit
patients with altered anatomy, diverticular disease, or strictures.
Common Procedures, Common Challenges
In esophagogastroduodenoscopy (EGD), reducing endoscope
diameter addresses 2 specific needs. First, strictures or lesions may
prevent the endoscope from reaching the intended location.3 Second,
transnasal EGD (TN-EGD) requires a scope with a diameter less than
6 mm.4 Therefore, reducing scope diameter may influence utility, and
in some conditions equipment traits can make the difference between
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a successful procedure and failure to obtain a specimen or relieve a
stricture.5 In the United States, EGD is typically performed by mouth
in patients under conscious or moderate sedation. However, slimmer
scopes may reduce or eliminate the need for anesthesia during procedures. Direct comparison of unsedated TN-EGD and unsedated or
sedated transoral EGD (TO-EGD) demonstrated a lower rate of gag
reflex and smaller changes in arterial oxygen saturation and pulse
rate in patients who underwent TN-EGD.6 Overall, TN-EGD is a more
comfortable and tolerable procedure for the patient and may result
in a safer and more useful examination.4,7 Additionally, unsedated
upper endoscopy reduces sedation costs and can increase patient
satisfaction.
Colonoscopy also presents challenges related to equipment size and
capability. In many cases, obtaining a complete colonoscopy, extending
to the cecum, may be difficult. Altered anatomy as a result of colorectal
cancer, diverticula, prior surgery, or inflammatory bowel disease is associated with incomplete procedures.3,5 Strictures, lesions, and inflamed
tissue create narrowing and may prevent passage of a standard-sized
endoscope.3 In situations where conventional colonoscopes are too
large, some endoscopists use pediatric instruments or other endoscopes, although these instruments may be too short or floppy to reach
the cecum.5,8 In addition to anatomic impediments, endoscope looping
may occur during colonoscopy.5,8 Looping deforms the wall of the colon,
causing pain to the patient, and can result in loss of control of the endoscope and perforation of the colon.5 The primary challenge of colonoscopy derives from the necessity of pushing the endoscope through the
colon, which is too flaccid to resist or redirect the force.9 Carefully chosen scope maneuvers, including pulling back as needed and reducing
bends in the scope as they occur, decrease colon stretching and reduce
procedural pain. However, endoscopists are often unaware of loops
forming and subsequent perforation of the colon. Direct visualization
of the endoscope during the procedure improves loop detection and
resolution.5
Advances in Scope Technology
The newest-generation colonoscope (PCF-PH190L/I) and upper
endoscope (GIF-XP190N) employ innovations in 3 areas: physical
dimensions, angulation range and bending design, and optical system
(Table).10,11 The slim diameter of the colonoscope (9.5 mm) makes insertion easier under all conditions, but is especially valuable for difficult
Gastrointestinal
Videoscope
(GIF-XP190N)
Physical dimensions, mm
Distal end outer diameter
Insertion tube outer diameter
Working length
Channel inner diameter
9.7
9.5
1,680
3.2
5.4
5.8
1,100
2.2
Optical system
Narrow band imaging
Enhanced image quality
Field of view, degrees
Brightness
Yes
Yes
140
2 light guide lenses
Yes
Yes
140
2 light guide lenses
Angulation range, bending
section, degrees
Up
Down
Right
Left
180
180
160
160
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210
90
100
100
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Adapted from references 11 and 12.
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Figure 1. Olympus GIF-XP190N EVIS EXERA III gastrointestinal
videoscope.
Image courtesy of Olympus.
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cases of stricture or lumen narrowing. The ultraslim gastroscope is suitable for TN-EGD, with a distal end outer diameter of 5.4 mm and an insertion
tube diameter of 5.8 mm (Figure 1).4,11 In addition,
this is the first ultra-slim gastroscope with electrosurgery compatibility from Olympus. 11 The colonoscope and gastroscope have working channels
of 3.2 and 2.2 mm, respectively.10,11 Therefore,
although the scopes are ultra-slim, they have
ample working channels, allowing for increased
suction volume and a greater variety of device
selection.
The optical system of the Olympus UltraSlim EVIS EXERA III scopes has 3 new features
that enhance performance: 2 light guides that
increase brightness and reduce device-use shadows, increased viewing angle (140 degrees for
both the gastroscope and ultra-slim colonoscope),
and narrow band imaging (NBI) capability.10-12
NBI uses wavelengths in the blue-green range
to visualize tissue and enhance mucosal and vascular pattern observation.13 The EVIS EXERA III
colonoscope features 2 distinct insertion tube
technologies that together constitute Olympus’
proprietary Responsive Insertion Technology:
High Force Transmission and Passive Bending (Figure 2).12 Physicians move endoscopes
through the colon by pushing, pulling, and
applying torques. High Force Transmission transfers physician-applied forces in a 1:1 ratio with a
minimum loss of force. High Force Transmission
is beneficial in situations where the colon has
many bends or where loops have formed in the
endoscope, and allows operators to use less force,
reducing physician effort and stress.14 Physician
fatigue has been identified as a potentially significant variable in adenoma detection.15 Additionally, Passive Bending helps move scopes through
flexures more easily. The Passive Bending segment is located behind the tip and active bending segment of the instrument. When the scope
contacts the colon wall, the Passive Bending segment senses the change in pressure and bends
in the direction of the lumen, creating a gentle curve that allows the scope to slide forward
around flexures. ScopeGuide reveals endoscope
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Colonovideoscope
(PCF-PH190L/I)
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Feature
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Table. Features of Olympus Ultra-Slim EVIS EXERA III Colonoscope
And Upper Endoscope
Keys to Success in the Clinic
Ultra-Slim Advantages in Upper Endoscopy
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position in real time and alongside the endoscopic
view on the same monitor.16 The real-time image
of the insertion tube shows the location and shape
of the instrument. Loops can be identified as they
form, and a hand coil allows the precise location of
the scope to be identified for applying hand pressure accurately and effectively.17 ScopeGuide can
be enabled with the PCF-PH190L/I colonoscope
through the use of the MAJ-1878 ScopeGuide probe
passed through the instrument channel.
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the Science Behind Positive Patient Outcomes
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Sedation requirements are typically reduced
when using the slimmer scope for TN-EGD instead
of TO-EGD, benefiting the patient and reducing
the likelihood of complications.4 Reduced use of
anesthesia also may shorten the procedure time.4
Kadayifci and colleagues performed a prospective,
randomized clinical study in 100 patients scheduled
B
for upper endoscopy to investigate the potential of
minimal sedation in this procedure.7 All patients
had undergone an unsedated TO-EGD within the
Figure 2. Responsive Insertion Technology of the EVIS EXERA III
past 12 months. Half of these patients underwent
colonoscope.
unsedated TO-EGD using a traditional endoscope
and the other half underwent unsedated TN-EGD
(A)Passive Bending redistributes pressure when the scope meets resistance so that the
using an ultra-slim scope. The investigators found
insertion tube automatically bends to adjust to the acute curves of the colon.
(B)High Force Transmission transfers rotational torque down the length of the insertion
that 82% of patients reported the TN-EGD procetube, allowing the scope to react more sensitively to physician handling.
dure to be much more tolerable than their previous
7
Images
courtesy of Olympus.
TO-EGD endoscopy.
Furthermore, Kawai and colleagues used an
ultra-slim transnasal scope to compare the diagnostic performance of conventional white light endoscopy (WLE)
and colleagues investigated cecal intubation times with the use of
with NBI in the detection of esophageal lesions.18 All 105 patients
scopes incorporating both Passive Bending and High Force Transmisincluded in the study underwent TN-EGD and were examined using
sion technologies.19 Using a post hoc analysis of 2 prospective trials including 1,077 patients, the investigators found that mean cecal
WLE, NBI, and Lugol staining. Results showed that NBI had almost
intubation times were significantly shorter when using instruments
100% detection of squamous cell carcinoma and noninvasive highwith Passive Bending and High Force Transmission technologies than
grade intraepithelial neoplasia. However, WLE only detected 66.7% of
without (P=0.005). The investigators suggest that by reducing intusquamous cell carcinomas. The investigators concluded that the use
bation times, clinician fatigue and patient discomfort also may be
of NBI in TN-EGD is useful for differentiating between inflammatory
reduced during the insertion phase of colonoscopy.19
lesions and the early stage of esophageal cancer.18
Conclusion
Studies have demonstrated the advantages of using advanced
technology scopes in colonoscopy as well. For instance, Rastogi
Clear observation of the GI tract is an absolute requirement for
disease surveillance and treatment; innovations in endoscopy
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Advantages in Colonoscopy
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8. Witte TN, Enns R. The difficult colonoscopy. Can J Gastroenterol. 2007;21(8):487-490.
9. Loeve AJ, Fockens P, Breedveld P. Mechanical analysis of insertion problems and
pain during colonoscopy: why highly skill-dependent colonoscopy routines are
necessary in the first place ... and how they may be avoided. Can J Gastroenterol.
2013;27(5):293-302.
10. Olympus. EVIS EXERA III colonovideoscope PCF-PH190L/I. 2012.
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11. Olympus. EVIS EXERA III gastrointestinal videoscope GIF-XP190N. 2012.
12. Olympus. 190-series colonoscopes, EVIS EXERA III. 2014.
13. Valdastri P, Simi M, Webster RJ, 3rd. Advanced technologies for gastrointestinal
endoscopy. Annu Rev Biomed Eng. 2012;14(1):397-429.
14. Olympus. Evis Exera III Video. http://link.videoplatform.limelight.com/media/?mediaI
d=6f2f7ba9feec40a8b1e69ea6927f349c&width=480&height=321&playerForm=4632
01359c694be2ae93af3071ff9273. Accessed July 23, 2014.
15. Lee TJ, Rees CJ, Blanks RG, et al. Colonoscopic factors associated with adenoma detection in a national colorectal cancer screening program. Endoscopy. 2014;46(3):203-211.
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equipment aid physicians in providing optimal care to patients with
minimal patient discomfort. The optical system of EVIS EXERA III provides greater brightness, increased viewing angle, and push-button availability of NBI. The slimmer profile of both gastroscope and
colonoscope, combined with an ample working channel, supports
TN-EGD for upper endoscopy patients and permits mobility around
strictures and inflamed areas of the GI tract. Electrosurgery functionality supports therapy. Finally, the greater ease of use of the instruments, due to proprietary Responsive Insertion Technology, aids
insertion and completion of procedures and protects physicians with
high-volume practices. Added value is derived from the possibility of
reduced use of anesthesia during procedures, which may lower the
risk for complications, reduce sedation costs, and improve patient
satisfaction.20,21
16. Ellul P, Fogden E, Simpson C, et al. Colonic tumour localization using an endoscope
positioning device. Eur J Gastroenterol Hepatol. 2011;23(6):488-491.
References
1. American Society for Gastrointestinal Endoscopy Standards Practice Committee, Early
DS, Ben-Menachem T, et al. Appropriate use of GI endoscopy. Gastrointest Endosc.
2012;75(6):1127-1131.
17. Ambardar S, Arnell TD, Whelan RL, et al. A preliminary prospective study of the usefulness of a magnetic endoscope locating device during colonoscopy. Surg Endosc.
2005;19(7):897-901.
2. Brooker JC, Saunders BP, Shah SG, et al. A new variable stiffness colonoscope makes
colonoscopy easier: a randomized controlled trial. Gut. 2000;46(6):801-805.
18. Kawai T, Takagi Y, Yamamoto K, et al. Narrow-band imaging on screening of esophageal lesions using an ultrathin transnasal endoscopy. J Gastroenterol Hepatol.
2012;27(suppl 3):34-39.
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3. Loffeld RJ, van der Putten AB. The completion rate of colonoscopy in normal daily
practice: factors associated with failure. Digestion. 2009;80(4):267-270.
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6. Tsuboi M, Arai M, Maruoka D, et al. Utility of unsedated transnasal endoscopy for pharyngeal observation during esophagogastroduodenoscopy. A prospective study to
assess cardiopulmonary function. Scand J Gastroenterol. 2013;48(7):884-889.
21. Mannath J, Subramanian V, Hawkey CJ, et al. Narrow band imaging for characterization of high grade dysplasia and specialized intestinal metaplasia in Barrett’s esophagus: a meta-analysis. Endoscopy. 2010;42(5):351-359.
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7. Kadayifci A, Atar M, Parlar S, et al. Transnasal endoscopy is preferred by transoral
endoscopy experienced patients. J Gastrointestin Liver Dis. 2014;23(1):27-31.
20. Petrini JL, Egan JV, Hahn WV. Unsedated colonoscopy: patient characteristics and
­satisfaction in a community-based endoscopy unit. Gastrointest Endosc. 2009;69
(3 Pt 1):567-572.
Disclosures: Dr. Jang reported no conflicts of interest. Dr. Samarasena reported that he has served as a consultant for Pentax Medical Company and received honoraria from Covidien, Ltd. and Mauna Kea Technologies, S.A.
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Disclaimer: This article is designed to be a summary of information. While it is detailed, it is not an exhaustive clinical review. McMahon Publishing, Olympus, and
the authors neither affirm nor deny the accuracy of the information contained herein. No liability will be assumed for the use of the article, and the absence of typographical errors is not guaranteed. Readers are strongly urged to consult any relevant primary literature.
Copyright © 2014, McMahon Publishing, 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in
whole or in part, in any form.
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5. Waye JD. Difficult colonoscopy. Gastroenterol Hepatol. 2013;9(10):676-678.
19. Rastogi A, Kaltenbach T, Soetikno R, et al. Cecal intubation times with colonoscopes
incorporating passive bending and high-force transmission technology: a multicenter
randomized controlled trial. Presented at the American College of Gastroenterology
Annual Scientific Meeting; October 11-16, 2013.
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4. Atar M, Kadayifci A. Transnasal endoscopy: Technical considerations, advantages and
limitations. World J Gastrointest Endosc. 2014;6(2):41-48.