Artificial intelligence for colorectal polyp detection: are we ready for prime time?

Colorectal cancer (CRC) is a leading cause of cancer-related mortality worldwide. Colonoscopy is protective against CRC through the detection and removal of neoplastic polyps. Unfortunately, the procedure is highly operator dependent with significant miss rates for polyps. Artificial intelligence (AI) and computer-aided detection software offers a promising solution by providing real-time assistance to highlight lesions that may otherwise be overlooked. Rapid advances have occurred in the field with recent prospective clinical trials demonstrating an improved adenoma detection rate (ADR) with AI assistance. Deployment in routine clinical practice is possible in the near future although further robust clinical trials are necessary and important practical challenges relating to real-world implementation must be addressed

Barriers and Pitfalls for Artificial Intelligence in Gastroenterology: Ethical and Regulatory issues

Artificial intelligence (AI)-based technologies are developing rapidly, offering great promise for gastroenterology and particularly endoscopy. However, there are complex barriers and pitfalls that must be considered before widespread real-world clinical implementation can occur. This review highlights major ethical concerns related to data privacy and sharing that are essential for the development of AI models, through to practical clinical issues such as potential patient harm, accountability, bias in decisions, and impact on workforce. Finally, current regulatory pathways are discussed, recognizing that these need to evolve to deal with unique new challenges, such as the adaptive and rapidly iterative nature of AI-based technologies, while striking a balance between ensuring patient safety and promoting innovation

Monitoring the premalignant potential of Barrett's oesophagus'.

The landscape for patients with Barrett's oesophagus (BE) has changed significantly in the last decade. Research and new guidelines have helped gastroenterologists to better identify those patients with BE who are particularly at risk of developing oesophageal adenocarcinoma. In parallel, developments in endoscopic image enhancement technology and optical biopsy techniques have improved our ability to detect high-risk lesions. Once these lesions have been identified, the improvements in minimally invasive endoscopic therapies has meant that these patients can potentially be cured of early cancer and high-risk dysplastic lesions without the need for surgery, which still has a significant morbidity and mortality. The importance of reaching an accurate diagnosis of BE remains of paramount importance. More work is needed, however. The vast majority of those undergoing surveillance for their BE do not progress towards cancer and thus undergo a regular invasive procedure, which may impact on their psychological and physical well-being while incurring significant cost to the health service. New work that explores cheaper endoscopic or non-invasive ways to identify the at-risk individual provides exciting avenues for research. In future, the diagnosis and monitoring of patients with BE could move away from hospitals and into primary care

Supporting laparoscopic general surgery training with digital technology: The United Kingdom and Ireland paradigm

Surgical training in the UK and Ireland has faced challenges following the implementation of the European Working Time Directive and postgraduate training reform. The health services are undergoing a digital transformation; digital technology is remodelling the delivery of surgical care and surgical training. This review aims to critically evaluate key issues in laparoscopic general surgical training and the digital technology such as virtual and augmented reality, telementoring and automated workflow analysis and surgical skills assessment. We include pre-clinical, proof of concept research and commercial systems that are being developed to provide solutions. Digital surgical technology is evolving through interdisciplinary collaboration to provide widespread access to high-quality laparoscopic general surgery training and assessment. In the future this could lead to integrated, context-aware systems that support surgical teams in providing safer surgical care

Learning curves and the influence of procedural volume for the treatment of dysplastic Barrett's esophagus

BACKGROUND AND AIMS: Endoscopic resections (ER) and radiofrequency ablation (RFA) are the established treatments for Barrett's-associated dysplasia and early esophageal neoplasia. The UK RFA Registry collects patient outcomes from 24 centers in the United Kingdom and Ireland treating patients. Learning curves for treatment of Barrett's dysplasia and the impact of center caseload on patient outcomes is still unknown. METHODS: We examined outcomes of 678 patients treated with RFA in the UK Registry using risk-adjusted CUSUM plots to identify change points in complete resolution of intestinal metaplasia (CR-IM) and complete resolution of dysplasia (CR-D) outcomes. We compared outcomes between those treated at high- (>100 enrolled patients), medium- (51-100) and low- (<50) volume centers. RESULTS: There was no association between center volume and CR-IM and CR-D rates, but there were lower recurrence rates in high-volume versus low-volume centers (Log Rank p=0.001).There was a significant change-point for outcomes at 12 cases for CR-D (reduction from 24.5% to 10.4%; P<0.001) and at 18 cases for CR-IM (30.7% to 18.6%; P<0.001) from RA-CUSUM curve analysis. CONCLUSION: Our data suggest that 18 supervised cases of endoscopic ablation may be required before competency in endoscopic treatment of Barrett's dysplasia can be achieved. The difference in outcomes between a high-volume and low-volume center does not support further centralization of services to only high-volume centers

Management of non-variceal upper gastrointestinal bleeding: Where are we in 2018?

Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies in the UK. Despite advancement in technology the management of AUGIB remains a challenge. The clinical community recognise the need for improvement in the treatment of these patients. AUGIB has a significant impact on resources. Endoscopic therapy is the gold standard treatment. The mortality in AUGIB is rarely related to the presenting bleed but significantly associated with concurrent comorbidities. The cost of blood transfusion in the management of patients with AUGIB is significant and misuse of blood products has been documented nationally. Risk stratification tools such as Glasgow-Blatchford Score, Rockall Score and the AIMS65 score have allowed clinicians to triage patients appropriately in order to deliver endoscopic therapy within a suitable time frame. Endoscopic therapeutic modalities such as epinephrine injection, heat thermocoagulation and mechanical clips have had a positive impact on patient’s management. However, in order to continue to improve patient’s outcomes, further developments are needed

Role of artificial intelligence in the diagnosis of oesophageal neoplasia: 2020 an endoscopic odyssey

The past decade has seen significant advances in endoscopic imaging and optical enhancements to aid early diagnosis. There is still a treatment gap due to the underdiagnosis of lesions of the oesophagus. Computer aided diagnosis may play an important role in the coming years in providing an adjunct to endoscopists in the early detection and diagnosis of early oesophageal cancers, therefore curative endoscopic therapy can be offered. Research in this area of artificial intelligence is expanding and the future looks promising. In this review article we will review current advances in artificial intelligence in the oesophagus and future directions for development

Multisensor perfusion assessment cohort study: Preliminary evidence toward a standardized assessment of indocyanine green fluorescence in colorectal surgery

Background: Traditional methods of assessing colonic perfusion are based on the surgeon's visual inspection of tissue. Fluorescence angiography provides qualitative information, but there remains disagreement on how the observed signal should be interpreted. It is unclear whether fluorescence correlates with physiological properties of the tissue, such as tissue oxygen saturation. The aim of this study was to correlate fluorescence intensity and colonic tissue oxygen saturation. Methods: Prospective cohort study performed in a single academic tertiary referral center. Patients undergoing colorectal surgery who required an anastomosis underwent dual-modality perfusion assessment of a segment of bowel before transection and creation of the anastomosis, using near-infrared and multispectral imaging. Perfusion was assessed using maximal fluorescence intensity measurement during fluorescence angiography, and its correlation with tissue oxygen saturation was calculated. Results: In total, 18 patients were included. Maximal fluorescence intensity occurred at a mean of 101 seconds after indocyanine green injection. The correlation coefficient was 0.73 (95% confidence interval of 0.65–0.79) with P < .0001, showing a statistically significant strong positive correlation between normalized fluorescence intensity and tissue oxygen saturation. The use of time averaging improved the correlation coefficient to 0.78. Conclusion: Fluorescence intensity is a potential surrogate for tissue oxygenation. This is expected to lead to improved decision making when transecting the bowel and, consequently, a reduction in anastomotic leak rates. A larger, phase II study is needed to confirm this result and form the basis of computational algorithms to infer biological or physiological information from the fluorescence imaging data

Intraoperative colon perfusion assessment using multispectral imaging

In colorectal surgery an anastomosis performed using poorly-perfused, ischaemic bowel segments may result in a leak and consequent morbidity. Traditional measures of perfusion assessment rely on clinical judgement and are mainly subjective, based on tissue appearance, leading to variability between clinicians. This paper describes a multispectral imaging (MSI) laparoscope that can derive quantitative measures of tissue oxygen saturation (SO2). The system uses a xenon surgical light source and fast filter wheel camera to capture eight narrow waveband images across the visible range in approximately 0.3 s. Spectral validation measurements were performed by imaging standardised colour tiles and comparing reflectance with ground truth spectrometer data. Tissue spectra were decomposed into individual contributions from haemoglobin, adipose tissue and scattering, using a previously-developed regression approach. Initial clinical results from seven patients undergoing colorectal surgery are presented and used to characterise measurement stability and reproducibility in vivo. Strategies to improve signal-To-noise ratio and correct for motion are described. Images of healthy bowel tissue (in vivo) indicate that baseline SO2 is approximately 75 } 6%. The SO2 profile along a bowel segment following ligation of the inferior mesenteric artery (IMA) shows a decrease from the proximal to distal end. In the clinical cases shown, imaging results concurred with clinical judgements of the location of well-perfused tissue. Adipose tissue, visibly yellow in the RGB images, is shown to surround the mesentery and cover some of the serosa. SO2 in this tissue is consistently high, with mean value of 90%. These results show that MSI is a potential intraoperative guidance tool for assessment of perfusion. Mapping of SO2 in the colon could be used by surgeons to guide choice of transection points and ensure that well-perfused tissue is used to form an anastomosis. The observation of high mesenteric SO2 agrees with work in the literature and warrants further exploration. Larger studies incorporating with a wider cohort of clinicians will help to provide retrospective evidence of how this imaging technique may be able to reduce inter-operator variability