101 research outputs found

    Efficiency in colonoscopy

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    Global trends, including demographic changes, are significantly increasing the demand and cost of healthcare. Endoscopy services are no exception and, even before the Covid-19 pandemic, significant pressure resulted in many units failing to meet cancer wait targets. The need to improve efficiency has never been greater and particularly so for colonoscopy which significantly reduces morbidity and mortality from colorectal cancer. Today, advances in colonoscope technologies and emergence of artificial intelligence offer the potential for improved colonoscopy practice. The aim of this thesis is to explore how efficiency in colonoscopy can be enhanced throughout the patient pathway. Five major studies were performed evaluating bowel preparation (CLEANSE), polyp detection (AI-DETECT), optical diagnosis (DISCARD3), insertion technique (WAVE) and post-colonoscopy colorectal cancer (AI-DETECT). CLEANSE is an evaluation of a novel low-volume same-day bowel preparation regime (Plenvu) and showed this offers a more efficient bowel cleansing option than standard regimens. AI-DETECT is a randomised study evaluating a computer-aided detection (CADe) system (GI Genius) and showed a borderline significant improvement in polyp detection is achieved amongst high performing endoscopists. DISCARD3 is a major evaluation of optical diagnosis with a “resect and discard” strategy exploring the learning curve, quality assurance process, causes of error and economic impact. This study shows such a strategy is feasible and safe and could potentially be implemented with a quality assurance process in place within the English Bowel Cancer Screening Progamme (BCSP). WAVE is a randomised study evaluating colonoscopy insertion technique. This showed a ‘hybrid’ insertion technique is more efficient than a water-exchange colonoscopy technique. REFLECT is a retrospective evaluation of post-colonoscopy colorectal cancer cases identified at national level and showed after local root cause analysis a significant proportion were in fact detected cancers. These studies provide valuable insights that we hope will ultimately lead to more efficient colonoscopy whilst maintaining quality and enhancing patient care.Open Acces

    Remote access computed tomography colonography

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    This thesis presents a novel framework for remote access Computed Tomography Colonography (CTC). The proposed framework consists of several integrated components: medical image data delivery, 2D image processing, 3D visualisation, and feedback provision. Medical image data sets are notoriously large and preserving the integrity of the patient data is essential. This makes real-time delivery and visualisation a key challenge. The main contribution of this work is the development of an efficient, lossless compression scheme to minimise the size of the data to be transmitted, thereby alleviating transmission time delays. The scheme utilises prior knowledge of anatomical information to divide the data into specific regions. An optimised compression method for each anatomical region is then applied. An evaluation of this compression technique shows that the proposed ‘divide and conquer’ approach significantly improves upon the level of compression achieved using more traditional global compression schemes. Another contribution of this work resides in the development of an improved volume rendering technique that provides real-time 3D visualisations of regions within CTC data sets. Unlike previous hardware acceleration methods which rely on dedicated devices, this approach employs a series of software acceleration techniques based on the characteristic properties of CTC data. A quantitative and qualitative evaluation indicates that the proposed method achieves real-time performance on a low-cost PC platform without sacrificing any image quality. Fast data delivery and real-time volume rendering represent the key features that are required for remote access CTC. These features are ultimately combined with other relevant CTC functionality to create a comprehensive, high-performance CTC framework, which makes remote access CTC feasible, even in the case of standard Web clients with low-speed data connections

    Eye-tracking the moving medical image: Development and investigation of a novel investigational tool for CT Colonography

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    Colorectal cancer remains the third most common cancer in the UK but the second leading cause of cancer death with >16,000 dying per year. Many advances have been made in recent years in all areas of investigation for colorectal cancer, one of the more notable being the widespread introduction of CT Colonography (CTC). CTC has rapidly established itself as a cornerstone of diagnosis for colonic neoplasia and much work has been done to standardise and assure quality in practice in both the acquisition and interpretation of the technique. A novel feature of CTC is the presentation of imaging in both traditional 2D and the ‘virtual’ 3D endoluminal formats. This thesis looks at expanding our understanding of and improving our performance in utilizing the endoluminal 3D view. We present and develop novel metrics applicable to eye-tracking the moving image, so that the complex dynamic nature of 3D endoluminal fly-through interpretation can be captured. These metrics are then applied to assess the effect of important elements of image interpretation, namely, reader experience, the effect of the use Computer Aided Detection (CAD) and the influence of the expected prevalence of abnormality. We review our findings with reference to the literature of eye tracking within medical imaging. In the co-registration section we apply our validated computer-assisted registration algorithm to the matching of 3D endoluminal colonic locations between temporally separate datasets, assessing its accuracy as an aid to colonic polyp surveillance with CTC

    New Techniques in Gastrointestinal Endoscopy

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    As result of progress, endoscopy has became more complex, using more sophisticated devices and has claimed a special form. In this moment, the gastroenterologist performing endoscopy has to be an expert in macroscopic view of the lesions in the gut, with good skills for using standard endoscopes, with good experience in ultrasound (for performing endoscopic ultrasound), with pathology experience for confocal examination. It is compulsory to get experience and to have patience and attention for the follow-up of thousands of images transmitted during capsule endoscopy or to have knowledge in physics necessary for autofluorescence imaging endoscopy. Therefore, the idea of an endoscopist has changed. Examinations mentioned need a special formation, a superior level of instruction, accessible to those who have already gained enough experience in basic diagnostic endoscopy. This is the reason for what these new issues of endoscopy are presented in this book of New techniques in Gastrointestinal Endoscopy

    Developing and evaluating expertise in colonoscopy

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    The quality and safety of colonoscopy have become of paramount importance with the worldwide expansion in the utilisation of this procedure, especially with the introduction of colorectal cancer screening in many countries. It is well known that colonoscopic performance varies significantly between practitioners. This thesis explores the effects of assessment in colonoscopy and polypectomy on performance and practice as well as trying to define the factors which differentiate the very best practitioners from the clinically competent. Until 2011, there was no formalised way of certifying polypectomy competence. We looked at the effects of the introduction of mandatory polypectomy assessment on trainee endoscopists applying for certification of competency in the United Kingdom. This work showed that documentation of polypectomy competence significantly improved after these changes were introduced. A global survey of polypectomy practice was undertaken to evaluate international guidance on polypectomy skills training and how trainers deliver teaching on polypectomy around the world, as well as trainees’ experience of gaining polypectomy skills. Significant variability in endoscopists’ experience of polypectomy training was found with few formal national guidelines published. This led to an evaluation of expert endoscopists who underwent an accreditation process with some similarities before commencing Bowel Cancer Screening (BCS). We examined whether it was possible to predict future performance from a single assessment and found that criteria used to assess whether candidates were competent could not predict the best performers from those who passed. Several hundred expert BCS colonoscopists were then monitored over a three year period to determine changes in performance over time and whether long-term performance could be predicted. The best predictors of performance over time for all metrics were initial performance. In order to identify key features of expertise in endoscopy, experienced colonoscopists were interviewed to distinguish characteristics of true endoscopic experts. These interviews revealed the importance of both technical and non-technical skills in defining expertise.Open Acces

    Appearance Modelling and Reconstruction for Navigation in Minimally Invasive Surgery

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    Minimally invasive surgery is playing an increasingly important role for patient care. Whilst its direct patient benefit in terms of reduced trauma, improved recovery and shortened hospitalisation has been well established, there is a sustained need for improved training of the existing procedures and the development of new smart instruments to tackle the issue of visualisation, ergonomic control, haptic and tactile feedback. For endoscopic intervention, the small field of view in the presence of a complex anatomy can easily introduce disorientation to the operator as the tortuous access pathway is not always easy to predict and control with standard endoscopes. Effective training through simulation devices, based on either virtual reality or mixed-reality simulators, can help to improve the spatial awareness, consistency and safety of these procedures. This thesis examines the use of endoscopic videos for both simulation and navigation purposes. More specifically, it addresses the challenging problem of how to build high-fidelity subject-specific simulation environments for improved training and skills assessment. Issues related to mesh parameterisation and texture blending are investigated. With the maturity of computer vision in terms of both 3D shape reconstruction and localisation and mapping, vision-based techniques have enjoyed significant interest in recent years for surgical navigation. The thesis also tackles the problem of how to use vision-based techniques for providing a detailed 3D map and dynamically expanded field of view to improve spatial awareness and avoid operator disorientation. The key advantage of this approach is that it does not require additional hardware, and thus introduces minimal interference to the existing surgical workflow. The derived 3D map can be effectively integrated with pre-operative data, allowing both global and local 3D navigation by taking into account tissue structural and appearance changes. Both simulation and laboratory-based experiments are conducted throughout this research to assess the practical value of the method proposed

    Optimizing endoscopic strategies for colorectal cancer screening : improving colonoscopy effectiveness by optical, non-optical, and computer-based models

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    Introduction: Le cancer colorectal demeure un grave problĂšme de santĂ© publique au Canada. Les programmes de dĂ©pistage pourraient rĂ©duire l'incidence du cancer colorectal et la mortalitĂ© qui lui est associĂ©e. Une coloscopie de haute qualitĂ© est considĂ©rĂ©e comme un moyen rentable de prĂ©venir le cancer en identifiant et en Ă©liminant les lĂ©sions prĂ©curseurs du cancer. Bien que la coloscopie puisse servir de mesure prĂ©ventive contre le cancer, la procĂ©dure peut imposer un fardeau supplĂ©mentaire Ă  la santĂ© publique par l'enlĂšvement et l'Ă©valuation histologique de polypes colorectaux diminutifs et insignifiants, qui prĂ©sentent un risque minime d'histologie avancĂ©e ou de cancer. La technologie de l'amĂ©lioration de l'image permettrait aux mĂ©decins de rĂ©sĂ©quer et de rejeter les polypes diminutifs ou de diagnostiquer et de laisser les polypes rectosigmoĂŻdiens diminutifs sans examen histopathologique. MalgrĂ© la disponibilitĂ© de systĂšmes informatiques de caractĂ©risation des polypes, la pratique du diagnostic optique reste limitĂ©e en raison de la crainte d'un mauvais diagnostic de cancer, d'une mauvaise surveillance des patients et des problĂšmes mĂ©dico-lĂ©gaux correspondants. Il est donc indispensable d'Ă©laborer des stratĂ©gies alternatives de rĂ©section et d'Ă©limination non optiques pour amĂ©liorer la prĂ©cision et la sĂ©curitĂ© du diagnostic optique et l'adapter Ă  la pratique clinique. Ces stratĂ©gies doivent rĂ©pondre Ă  des critĂšres cliniques simples et ne nĂ©cessitent pas de formation supplĂ©mentaire ni de dispositifs d'amĂ©lioration de l'image. De plus, la pratique sĂ»re du diagnostic optique, la prise de dĂ©cision appropriĂ©e concernant la technique de polypectomie ou l'intervalle de surveillance dĂ©pendent de l'estimation prĂ©cise de la taille des polypes. La variabilitĂ© inter-endoscopistes dans la mesure de la taille des polypes exige le dĂ©veloppement de mĂ©thodes fiables et validĂ©es pour augmenter la prĂ©cision de la mesure de la taille. Une balance virtuelle intĂ©grĂ©e Ă  un endoscope haute dĂ©finition est actuellement disponible pour le calcul automatique de la taille des polypes, mais sa faisabilitĂ© clinique n'a pas encore Ă©tĂ© Ă©tablie. En dehors des points susmentionnĂ©s, une coloscopie de haute qualitĂ© nĂ©cessite l'examen complet de la muqueuse colique, ainsi que la visualisation de la valve ilĂ©ocĂŠcale et de l'orifice appendiculaire. À ce jour, aucune solution informatique n'a Ă©tĂ© capable d'assister les endoscopistes pendant les coloscopies en temps rĂ©el en dĂ©tectant et en diffĂ©renciant les points de repĂšre cĂŠcaux de façon automatique. Objectifs: Les objectifs de cette thĂšse sont : 1) d'Ă©tudier l'effet de la limitation du diagnostic optique aux polypes de 1 Ă  3 mm sur la sĂ©curitĂ© du diagnostic optique pour le traitement des polypes diminutifs et l'acceptation par les endoscopistes de son utilisation dans les pratiques en temps rĂ©el tout en prĂ©servant ses potentiels de temps et de rentabilitĂ© ; 2) Ă©laborer et examiner des stratĂ©gies non optiques de rĂ©section et d'Ă©limination qui peuvent remplacer le diagnostic optique tout en offrant les mĂȘmes possibilitĂ©s d'Ă©conomie de temps et d'argent ; 3) examiner la prĂ©cision relative d'un endoscope Ă  Ă©chelle virtuelle pour mesurer la taille des polypes ; 4) former, valider et tester un modĂšle d'intelligence artificielle qui peut prĂ©dire la complĂ©tude d'une procĂ©dure de coloscopie en identifiant les points de repĂšre anatomiques du cĂŠcum (c'est-Ă -dire la valve ilĂ©o-cĂŠcale et l'orifice appendiculaire) et en les diffĂ©renciant les uns des autres, des polypes et de la muqueuse normale. MĂ©thodes: Pour atteindre le premier objectif de cette thĂšse, une analyse post-hoc de trois Ă©tudes prospectives a Ă©tĂ© rĂ©alisĂ©e pour Ă©valuer la proportion de patients chez lesquels des adĂ©nomes avancĂ©s ont Ă©tĂ© dĂ©couverts et le diagnostic optique a entraĂźnĂ© une surveillance retardĂ©e dans trois groupes de taille de polypes : 1–3, 1–5, et 1–10 mm. Pour atteindre le second objectif de cette thĂšse, deux stratĂ©gies non optiques ont Ă©tĂ© dĂ©veloppĂ©es et testĂ©es dans deux Ă©tudes prospectives: une stratĂ©gie de rĂ©section et d'Ă©limination basĂ©e sur la localisation qui utilise la localisation anatomique des polypes pour classer les polypes du cĂŽlon en non-nĂ©oplasiques ou nĂ©oplasiques Ă  faible risque et une stratĂ©gie de rĂ©section et d'Ă©limination basĂ©e sur les polypes qui attribue des intervalles de surveillance en fonction du nombre et de la taille des polypes. Dans les trois Ă©tudes, la concordance de l'attribution d'intervalles de surveillance basĂ©e sur un diagnostic optique Ă  haute confiance ou sur des stratĂ©gies non optiques avec les recommandations basĂ©es sur la pathologie, ainsi que la proportion d'examens pathologiques Ă©vitĂ©s et la proportion de communications immĂ©diates d'intervalles de surveillance, ont Ă©tĂ© Ă©valuĂ©es. Le troisiĂšme objectif de cette thĂšse a Ă©tĂ© abordĂ© par le biais d'une Ă©tude de faisabilitĂ© pilote prospective qui a utilisĂ© la mesure de spĂ©cimens de polypes immĂ©diatement aprĂšs leur prĂ©lĂšvement, suite Ă  une polypectomie par un pied Ă  coulisse Vernier comme rĂ©fĂ©rence pour comparer la prĂ©cision relative des mesures de la taille des polypes entre les endoscopistes et un endoscope Ă  Ă©chelle virtuelle. Enfin, le quatriĂšme objectif de cette thĂšse a Ă©tĂ© Ă©valuĂ© par l'enregistrement et l'annotation prospective de vidĂ©os de coloscopie. Des images non modifiĂ©es de polype, de valve ilĂ©o-caecale, d'orifice appendiculaire et de muqueuse normale ont Ă©tĂ© extraites et utilisĂ©es pour dĂ©velopper et tester un modĂšle de rĂ©seau neuronal convolutionnel profond pour classer les images pour les points de repĂšre qu'elles contiennent. RĂ©sultats: La rĂ©duction du seuil du diagnostic optique favoriserait la sĂ©curitĂ© du diagnostic optique en diminuant de maniĂšre significative le risque d'Ă©carter un polype avec une histologie avancĂ©e ou la mauvaise surveillance d'un patient avec de tels polypes. En outre, les stratĂ©gies non optiques de rĂ©section et d'Ă©limination pourraient dĂ©passer le critĂšre de rĂ©fĂ©rence d'au moins 90% de concordance dans l'attribution des intervalles de surveillance post-polypectomie par rapport aux dĂ©cisions basĂ©es sur l'Ă©valuation pathologique. De plus, il a Ă©tĂ© dĂ©montrĂ© que l'endoscope Ă  Ă©chelle virtuelle est plus prĂ©cis que l'estimation visuelle de la taille des polypes en temps rĂ©el. Enfin, un modĂšle d'apprentissage profond s'est rĂ©vĂ©lĂ© trĂšs efficace pour dĂ©tecter les repĂšres cĂŠcaux, les polypes et la muqueuse normale, Ă  la fois individuellement et en combinaison. Discussion: La prĂ©diction histologique optique des polypes de 1 Ă  3 mm est une approche efficace pour amĂ©liorer la sĂ©curitĂ© et la faisabilitĂ© de la stratĂ©gie de rĂ©section et d'Ă©cartement dans la pratique. Les approches non optiques de rĂ©section et d'Ă©limination offrent Ă©galement des alternatives viables au diagnostic optique lorsque les endoscopistes ne sont pas en mesure de rĂ©pondre aux conditions de mise en Ɠuvre systĂ©matique du diagnostic optique, ou lorsque la technologie d'amĂ©lioration de l'image n'est pas accessible. Les stratĂ©gies de rĂ©section et de rejet, qu'elles soient optiques ou non, pourraient rĂ©duire les coĂ»ts supplĂ©mentaires liĂ©s aux examens histopathologiques et faciliter la communication du prochain intervalle de surveillance le mĂȘme jour que la coloscopie de rĂ©fĂ©rence. Un endoscope virtuel Ă  Ă©chelle rĂ©duite faciliterait l'utilisation du diagnostic optique pour la dĂ©tection des polypes diminutifs et permet une prise de dĂ©cision appropriĂ©e pendant et aprĂšs la coloscopie. Enfin, le modĂšle d'apprentissage profond peut ĂȘtre utile pour promouvoir et contrĂŽler la qualitĂ© des coloscopies par la prĂ©diction d'une coloscopie complĂšte. Cette technologie peut ĂȘtre intĂ©grĂ©e dans le cadre d'une plateforme de vĂ©rification et de gĂ©nĂ©ration de rapports qui Ă©limine le besoin d'intervention humaine. Conclusion: Les rĂ©sultats prĂ©sentĂ©s dans cette thĂšse contribueront Ă  l'Ă©tat actuel des connaissances dans la pratique de la coloscopie concernant les stratĂ©gies pour amĂ©liorer l'efficacitĂ© de la coloscopie dans la prĂ©vention du cancer colorectal. Cette Ă©tude fournira des indications prĂ©cieuses pour les futurs chercheurs intĂ©ressĂ©s par le dĂ©veloppement de mĂ©thodes efficaces de traitement des polypes colorectaux diminutifs. Le diagnostic optique nĂ©cessite une formation complĂ©mentaire et une mise en Ɠuvre Ă  l'aide de modules de caractĂ©risation informatisĂ©s. En outre, malgrĂ© la lenteur de l'adoption des solutions informatiques dans la pratique clinique, la coloscopie assistĂ©e par l'IA ouvrira la voie Ă  la dĂ©tection automatique, Ă  la caractĂ©risation et Ă  la rĂ©daction semi-automatique des rapports de procĂ©dure.Introduction: Colorectal cancer remains a critical public health concern in Canada. Screening programs could reduce the incidence of colorectal cancer and its associated mortality. A high-quality colonoscopy is appraised to be a cost-effective means of cancer prevention through identifying and removing cancer precursor lesions. Although colonoscopy can serve as a preventative measure against cancer, the procedure can impose an additional burden on the public health by removing and histologically evaluating insignificant diminutive colorectal polyps, which pose a minimal risk of advanced histology or cancer. The image-enhance technology would enable physicians to resect and discard diminutive polyps or diagnose and leave diminutive rectosigmoid polyps without histopathology examination. Despite the availability of computer-based polyp characterization systems, the practice of optical diagnosis remains limited due to the fear of cancer misdiagnosis, patient mismanagement, and the related medicolegal issues. Thus, alternative non-optical resection and discard strategies are imperative for improving the accuracy and safety of optical diagnosis for adaptation to clinical practice. These strategies should follow simple clinical criteria and do not require additional education or image enhanced devices. Furthermore, the safe practice of optical diagnosis, adequate decision-making regarding polypectomy technique, or surveillance interval depends on accurate polyp size estimation. The inter-endoscopist variability in polyp sizing necessitates the development of reliable and validated methods to enhance the accuracy of size measurement. A virtual scale integrated into a high-definition endoscope is currently available for automated polyp sizing, but its clinical feasibility has not yet been demonstrated. In addition to the points mentioned above, a high-quality colonoscopy requires the complete examination of the entire colonic mucosa, as well as the visualization of the ileocecal valve and appendiceal orifice. To date, no computer-based solution has been able to support endoscopists during live colonoscopies by automatically detecting and differentiating cecal landmarks. Aims: The aims of this thesis are: 1) to investigate the effect of limiting optical diagnosis to polyps 1–3mm on the safety of optical diagnosis for the management of diminutive polyps and the acceptance of endoscopists for its use in real-time practices while preserving its time- and cost-effectiveness potentials; 2) to develop and examine non-optical resect and discard strategies that can replace optical diagnosis while offering the same time- and cost-saving potentials; 3) to examine the relative accuracy of a virtual scale endoscope for measuring polyp size; 4) to train, validate, and test an artificial intelligence-empower model that can predict the completeness of a colonoscopy procedure by identifying cecal anatomical landmarks (i.e., ileocecal valve and appendiceal orifice) and differentiating them from one another, polyps, and normal mucosa. Methods: To achieve the first aim of this thesis, a post-hoc analysis of three prospective studies was performed to evaluate the proportion of patients in which advanced adenomas were found and optical diagnosis resulted in delayed surveillance in three polyp size groups: 1‒3, 1‒5, and 1‒10 mm. To achieve the second aim of this thesis, two non-optical strategies were developed and tested in two prospective studies: a location-based resect and discard strategy that uses anatomical polyp location to classify colon polyps into non-neoplastic or low-risk neoplastic and a polyp-based resect and discard strategy that assigns surveillance intervals based on polyp number and size. In all three studies, the agreement of assigning surveillance intervals based on high-confidence optical diagnosis or non-optical strategies with pathology-based recommendations, as well as the proportion of avoided pathology examinations and the proportion of immediate surveillance interval communications, was evaluated. The third aim of this thesis was addressed through a prospective pilot feasibility study that used the measurement of polyp specimens immediately after retrieving, following a polypectomy by a Vernier caliper as a reference to compare the relative accuracy of polyp size measurements between endoscopists and a virtual scale endoscope. Finally, the fourth aim of this thesis was assessed through prospective recording and annotation of colonoscopy videos. Unaltered images of polyp, ileocecal valve, appendiceal orifice and normal mucosa were extracted and used to develop and test a deep convolutional neural network model for classifying images for the containing landmarks. Results: Reducing the threshold of optical diagnosis would promote the safety of optical diagnosis by significantly decreasing the risk of discarding a polyp with advanced histology or the mismanagement of a patient with such polyps. Additionally, the non-optical resect and discard strategies could surpass the benchmark of at least 90% agreement in the assignment of post-polypectomy surveillance intervals compared with decisions based on pathologic assessment. Moreover, the virtual scale endoscope was demonstrated to be more accurate than visual estimation of polyp size in real-time. Finally, a deep learning model proved to be highly effective in detecting cecal landmarks, polyps, and normal mucosa, both individually and in combination. Discussion: Optical histology prediction of polyps 1‒3 mm in size is an effective approach to enhance the safety and feasibility of resect and discard strategy in practice. Non-optical resect and discard approaches also offer feasible alternatives to optical diagnosis when endoscopists are unable to meet the conditions for routine implementation of optical diagnosis, or when image-enhanced technology is not accessible. Both optical and non-optical resect and discard strategies could reduce additional costs related to histopathology examinations and facilitate the communication of the next surveillance interval in the same day as the index colonoscopy. A virtual scale endoscope would facilitate the use of optical diagnosis for the detection of diminutive polyps and allows for appropriate decision-making during and after colonoscopy. Additionally, the deep learning model may be useful in promoting and monitoring the quality of colonoscopies through the prediction of a complete colonoscopy. This technology may be incorporated as part of a platform for auditing and report generation that eliminates the need for human intervention. Conclusion: The results presented in this thesis will contribute to the current state of knowledge in colonoscopy practice regarding strategies for improving the efficacy of colonoscopy in the prevention of colorectal cancer. This study will provide valuable insights for future researchers interested in developing effective methods for treating diminutive colorectal polyps. Optical diagnosis requires further training and implementation using computer-based characterization modules. Furthermore, despite the slow adoption of computer-based solutions in clinical practice, AI-empowered colonoscopy will eventually pave the way for automatic detection, characterization, and semi-automated completion of procedure reports in the future
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