Andrew Weiss, CASC, recently leased 28 new endoscopes to outfit the procedure rooms of The Endo Center at Voorhees, N.J. When looking into adding the latest endoscopes to his inventory, the administrator and his physicians discovered that they offered clinical benefits that outweighed the technology's "wow" factor: greater maneuverability, high-definition imaging and improved contrast enhancement. Here's why the center's docs can't do without the equipment that they once considered more extraneous than essential.

A second look
The physicians at The Endo Center trialed HD technology several years ago, but came away unimpressed. As they began to work regularly with HD at a nearby community hospital, however, adding the technology became more of a priority for Mr. Weiss.

"At first they didn't see much of a need for HD, but then I kept hearing about what they were working with at the hospital," he explains. In the hallway outside one of The Endo Center's procedure rooms, Gary Levin, MD, recently nodded enthusiastically when asked if HD has improved his ability to detect polyps during routine diagnostic exams. "Oh, definitely," he says. "The wide-angle lenses provide a better overall view during colonoscopy."

Dr. Levin is impressed with how HD helps him notice flat lesions, the difficult-to-see abnormalities that are particularly prone to developing into cancerous growths. He's also quick to point out that HD's superior resolution reaches its true potential when combined with image contrast enhancement.

Contrast enhancement technology makes more vascular parts of the colon appear very dark, explains Dr. Levin. He says this may help physicians distinguish adenomas from hyperplastic or non-adenomatous areas of the colon.

Dr. Levin points to a study published in the January 2010 issue of the journal Endoscopy to back what he experiences in practice. In the article "Value of magnifying endoscopy in classifying colorectal polyps based on vascular pattern," researchers in Germany compared the diagnostic accuracy of contrast enhancement with and without high-magnification endoscopy — the scope Dr. Levin uses can focus down to 5mm — in the differentiation of normal and abnormal colorectal polyps.

The researchers discovered that high-contrast endoscopy with and without high magnification were comparable for differentiating between normal and abnormal growths, but contrast enhancement coupled with high magnification led to better visualization of vessel networks. They also report that standard "white-light endoscopy, with or without magnification, resulted in inferior discrimination between neoplastic and non-neoplastic polyps."

In addition to HD and contrast enhancement, the new endoscopes Dr. Levin uses feature 4-way angulation and wide-angle views, which he says allows for greater ability to examine hard-to-reach areas such as behind the folds in the colon. "Such hard-to-examine areas are responsible for some of the miss rates we experience in the detection of polyps," he explains.

Greater contrast enhancement has also greatly aided Dr. Levin during upper-endoscopy exams. In order to diagnose Barrett's esophagus with standard biopsy surveillance, samples are taken in 4 quadrants every 1cm to 2cm around the esophagus. Enhanced contrast and HD offer improvements over that labor-intensive technique. "The technology is extremely valuable in detecting subtle areas of Barrett's mucosa because it really makes these areas stand out," says Dr. Levin, which "may allow for more targeted biopsies that can rule out dysplasia."

That improved performance in practice has been proven in clinical research, says Dr. Levin. "Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett's Esophagus," a study in the July 2008 issue of Gastroenterology, reports that the use of contrast enhancement during the endoscopic surveillance of Barrett's esophagus increased detection rates of dysplasia from 43% to 57% and decreased the number of biopsies taken from an average of 8.5 to 4.7.

Easy on the eyes
Aside from the clear clinical benefits realized through improved visualization, the larger screen is just plain easier to look at during days when cases are stacked back to back. That's an important consideration for physicians working in a volume-driven specialty, says Dr. Levin.

The difference between watching a case's progression on a 20-inch conventional monitor and a 36-inch HD display is like night and day, explains Laura Raio, The Endo Center's manager of technical services and purchasing. She says every member of the clinical team can easily follow the action on the HD monitor that's placed in the physician's line of sight or on the conventional screen placed on top of a component cart behind the doc. Having screens placed in 2 areas of the procedure room keeps staff in tune with what's going on no matter where they stand. Staff focusing on the patient used to have to turn around to see the monitor, explains Ms. Raio. Now, thanks to the large HD monitors and the smaller auxiliary screens, any member of the clinical team can watch right along with the physician and have needed equipment at the ready, which she says increases case efficiencies.

Moving forward
In addition to advanced image resolution, Dr. Levin believes the most important features to consider when purchasing endoscopic equipment include the endoscopist's preferences with regard to the stiffness and maneuverability of the instrument. By all accounts, the new endoscopes have been an immediate hit at The Endo Center. Mr. Weiss believes adding the new equipment keeps his physicians at the forefront of patient care. When the center's cases move early next year to a brand-new facility 3 miles down the road, the latest in flexible endoscope technology will be one of the first items unpacked. "Our physicians are happy we added the new scopes," says Mr. Weiss. "I haven't seen a downside yet."