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Recent advances in endoscopic imaging technology increasingly have allowed highly accurate in vivo assessment of tissue, including specific pathologic diagnoses of inflammation and neoplasia. As endoscopic imaging technology advances, we are increasingly asked whether tissue biopsy of suspicious lesions is critical or can be replaced with "optical" biopsy.
Histology will remain a key component of gastrointestinal diagnoses, but there will be important changes in how we can integrate with pathology services. These will include reduction in the number of low-yield biopsies such as random biopsies in Barrett’s esophagus, inflammatory bowel disease, and small distal non-neoplastic colorectal polyps and increasing targeting of biopsy using advanced imaging. Lastly, health care reform will increasingly drive us to reform our practices towards lower-cost, higher-value services, which include reductions in the histological evaluation of low-risk tissues. The main value of histologic analysis is the very high level of magnification, resolution, and contrast provided by standard light microscopy. Increasingly, endoscopes are capable of achieving similar levels of magnification, resolution, and contrast.
As the number of endoscopies has increased over the last few decades – over 20 million procedures are now performed annually – the cost associated with these has increased substantially. Although the cost of the endoscopy itself is an important component, the cost of ancillary services, including histology as well as anesthesia, is becoming increasingly important. This is particularly true in screening and surveillance colonoscopies, where now more than 50% of all procedures generate a histologic sample.
Advances in endoscopic optics have achieved remarkable levels of resolution and magnification over the last several decades. Important advances include the development of high-definition optical enhanced imaging and, more recently, confocal endomicroscopy. Also, inexpensive technologies such as chromoendoscopy have dramatically increased the yield of neoplasia in inflammatory bowel disease, compared with random biopsies alone. In Barrett’s esophagus, use of high-definition optical enhanced endoscopes has been shown to increase the yield of dysplasia with fewer biopsies. Confocal endomicroscopy also has been shown to be highly accurate for detection of neoplasia in Barrett’s esophagus, with overall accuracy of use exceeding 95%. A limitation of highly focused imaging technology is the small field of view that is imaged. A recent major advance is volumetric laser endomicroscopy, which provides high-resolution, high magnification imaging of large surface areas, including the entire esophagus.
Apart from advances in technology, a major impetus for adoption of optical biopsy technique will be payment reform such as bundled payments which provide payments for the endoscopy and all ancillary services such as pathology. In summary, optical biopsy with advanced endoscopic instruments now rivals the accuracy and resolution of ex vivo microscopy. The increasing cost of health care will drive reform with pressure to reduce the utilization and cost of low-value histology services. Lastly, the community of endoscopists must increasingly learn the skills to make highly accurate endomicroscopic diagnoses.
Dr. Michael B. Wallace, MPH, Professor of Medicine, Mayo Clinic, Jacksonville, Fla.
Recent advances in endoscopic imaging technology increasingly have allowed highly accurate in vivo assessment of tissue, including specific pathologic diagnoses of inflammation and neoplasia. As endoscopic imaging technology advances, we are increasingly asked whether tissue biopsy of suspicious lesions is critical or can be replaced with "optical" biopsy.
Histology will remain a key component of gastrointestinal diagnoses, but there will be important changes in how we can integrate with pathology services. These will include reduction in the number of low-yield biopsies such as random biopsies in Barrett’s esophagus, inflammatory bowel disease, and small distal non-neoplastic colorectal polyps and increasing targeting of biopsy using advanced imaging. Lastly, health care reform will increasingly drive us to reform our practices towards lower-cost, higher-value services, which include reductions in the histological evaluation of low-risk tissues. The main value of histologic analysis is the very high level of magnification, resolution, and contrast provided by standard light microscopy. Increasingly, endoscopes are capable of achieving similar levels of magnification, resolution, and contrast.
As the number of endoscopies has increased over the last few decades – over 20 million procedures are now performed annually – the cost associated with these has increased substantially. Although the cost of the endoscopy itself is an important component, the cost of ancillary services, including histology as well as anesthesia, is becoming increasingly important. This is particularly true in screening and surveillance colonoscopies, where now more than 50% of all procedures generate a histologic sample.
Advances in endoscopic optics have achieved remarkable levels of resolution and magnification over the last several decades. Important advances include the development of high-definition optical enhanced imaging and, more recently, confocal endomicroscopy. Also, inexpensive technologies such as chromoendoscopy have dramatically increased the yield of neoplasia in inflammatory bowel disease, compared with random biopsies alone. In Barrett’s esophagus, use of high-definition optical enhanced endoscopes has been shown to increase the yield of dysplasia with fewer biopsies. Confocal endomicroscopy also has been shown to be highly accurate for detection of neoplasia in Barrett’s esophagus, with overall accuracy of use exceeding 95%. A limitation of highly focused imaging technology is the small field of view that is imaged. A recent major advance is volumetric laser endomicroscopy, which provides high-resolution, high magnification imaging of large surface areas, including the entire esophagus.
Apart from advances in technology, a major impetus for adoption of optical biopsy technique will be payment reform such as bundled payments which provide payments for the endoscopy and all ancillary services such as pathology. In summary, optical biopsy with advanced endoscopic instruments now rivals the accuracy and resolution of ex vivo microscopy. The increasing cost of health care will drive reform with pressure to reduce the utilization and cost of low-value histology services. Lastly, the community of endoscopists must increasingly learn the skills to make highly accurate endomicroscopic diagnoses.
Dr. Michael B. Wallace, MPH, Professor of Medicine, Mayo Clinic, Jacksonville, Fla.
Recent advances in endoscopic imaging technology increasingly have allowed highly accurate in vivo assessment of tissue, including specific pathologic diagnoses of inflammation and neoplasia. As endoscopic imaging technology advances, we are increasingly asked whether tissue biopsy of suspicious lesions is critical or can be replaced with "optical" biopsy.
Histology will remain a key component of gastrointestinal diagnoses, but there will be important changes in how we can integrate with pathology services. These will include reduction in the number of low-yield biopsies such as random biopsies in Barrett’s esophagus, inflammatory bowel disease, and small distal non-neoplastic colorectal polyps and increasing targeting of biopsy using advanced imaging. Lastly, health care reform will increasingly drive us to reform our practices towards lower-cost, higher-value services, which include reductions in the histological evaluation of low-risk tissues. The main value of histologic analysis is the very high level of magnification, resolution, and contrast provided by standard light microscopy. Increasingly, endoscopes are capable of achieving similar levels of magnification, resolution, and contrast.
As the number of endoscopies has increased over the last few decades – over 20 million procedures are now performed annually – the cost associated with these has increased substantially. Although the cost of the endoscopy itself is an important component, the cost of ancillary services, including histology as well as anesthesia, is becoming increasingly important. This is particularly true in screening and surveillance colonoscopies, where now more than 50% of all procedures generate a histologic sample.
Advances in endoscopic optics have achieved remarkable levels of resolution and magnification over the last several decades. Important advances include the development of high-definition optical enhanced imaging and, more recently, confocal endomicroscopy. Also, inexpensive technologies such as chromoendoscopy have dramatically increased the yield of neoplasia in inflammatory bowel disease, compared with random biopsies alone. In Barrett’s esophagus, use of high-definition optical enhanced endoscopes has been shown to increase the yield of dysplasia with fewer biopsies. Confocal endomicroscopy also has been shown to be highly accurate for detection of neoplasia in Barrett’s esophagus, with overall accuracy of use exceeding 95%. A limitation of highly focused imaging technology is the small field of view that is imaged. A recent major advance is volumetric laser endomicroscopy, which provides high-resolution, high magnification imaging of large surface areas, including the entire esophagus.
Apart from advances in technology, a major impetus for adoption of optical biopsy technique will be payment reform such as bundled payments which provide payments for the endoscopy and all ancillary services such as pathology. In summary, optical biopsy with advanced endoscopic instruments now rivals the accuracy and resolution of ex vivo microscopy. The increasing cost of health care will drive reform with pressure to reduce the utilization and cost of low-value histology services. Lastly, the community of endoscopists must increasingly learn the skills to make highly accurate endomicroscopic diagnoses.
Dr. Michael B. Wallace, MPH, Professor of Medicine, Mayo Clinic, Jacksonville, Fla.
