Abhilash Perisetti
Benjamin Tharian2
Tony C. Tham
Hemant Goyal- 1Department of Gastroenterology and Hepatology, Kansas City Veteran Affairs Medical Center, Kansas City, MO, United States
- 2Digestive Health Institute, Bayfront Health St. Petersburg Medical Group, St. Petersburg, FL, United States
- 3Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, United Kingdom
- 4Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
Editorial on the Research Topic
Recent updates in advanced gastrointestinal endoscopy
Advanced gastrointestinal endoscopy (AGE) is a subsection in the field of gastroenterology that specializes in advanced therapeutic endoscopic techniques such as complex gastrointestinal (GI) luminal, pancreatico-biliary endoscopy, and even extending beyond the lumen into third space (such as endoscopic submucosal dissection and per-oral endoscopic myotomy). With advances in optic fiber technology and endoscopy skills, gastroenterologists are positioned at the forefront of treating complex GI conditions unexplored in the past. GI cancers account for almost one-quarter of all global cancer incidence and have increased significantly in younger populations. Interventional endoscopy has a significant role in managing GI cancers, including screening, early diagnosis, and resecting lesions, thus curing them without the need for invasive surgery.
Luminal “AGE”
In this focused issue of “Recent updates in advanced gastrointestinal endoscopy,” we highlight the role of advanced endoscopic techniques for luminal (first-space) esophagogastric, small intestinal, and colorectal disease states. Prevalent esophageal conditions, such as chronic gastroesophageal reflux disease (GERD), can predispose to Barrett's esophagus related neoplasia (BERN) (1). Early BERN detection with high-resolution endoscopy (chromoendoscopy, narrow-band imaging [NBI], autofluorescence, confocal laser endomicroscopy [CLE]) has revolutionized the field with a significant impact on morbidity and mortality. Multiple Enhanced endoscopic techniques for GERD (Mann, Gajendran, Perisetti, et al.) have emerged recently, such as anti-reflux mucosectomy (via ablation), transoral incisionless fundoplication (TIF), full-thickness plication, endostapler including gastroesophageal junction altering techniques (suturing, gastroplication, anti-reflux devices). Similarly, identification of early gastric cancer with high-magnification endoscopy (NBI, CLE) and luminal endoscopic ultrasound (EUS) can precisely stage and assist in early resection (Jiang et al.). Small bowel evaluation has been an area of limitation for endoscopists given the challenges to reach distal jejunum and ileum. With technical advances (Nehme et al.), the Sonde and Ropeway Enteroscopy have paved the way for push enteroscopy, single- and double-balloon, spiral enteroscopy, and eventually, device-assisted motorized enteroscopy. These devices are utilized in surgically altered anatomy, such as balloon-assisted (single/double) endoscopic retrograde cholangiopancreatography (ERCP) and device-assisted ERCP (Nehme et al.).
Large complex colonic polyps, which were treated surgically in the past, are now resected endoscopically using advanced polypectomy techniques such as mucosal and submucosal resection and dissection (Mann, Gajendran, Umapathy, et al.). Further, full-thickness resection devices provide an opportunity to remove early lesions in a one-step manner.
Non-luminal “AGE”
With the advent of natural orifice transluminal endoscopic surgery (NOTES), accessing the peritoneal cavity (second space) became possible (2). However, closing the bowel wall defects remained a challenge. This led endoscopists to access the submucosal tunnel (third space) revolutionizing the field with novel techniques such as submucosal tunneling, myotomy, dissection and diverticulectomy (3). Superficial luminal GI submucosal tumors are now being treated with curative resection. In this focused issue, the efficacy and safety of myotomy in sigmoidization of esophagus in achalasia is noted with good clinical and technical success with low rate of adverse events (Xu et al.). The role of EUS has been extended from diagnostic to therapeutics such as peripancreatic fluid drainage, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage, transmural access EUS-guided gastrojejunostomy, EUS-guided celiac plexus neurolysis or block, EUS-guided liver biopsy (4). EUS has also helped us access vascular structures such as (5) gastric varices and portal vessels for variceal coiling and portal pressure monitoring. Use of injection therapy has allowed us to perform EUS-guided anti-tumor therapy such as ethanol for pancreatic neuroendocrine tumors and local radiofrequency ablation for unresectable pancreatic tumors (Yousaf et al.). Finally, development of over-the-scope-clips (OTSC), lumen apposing and non-lumen apposing stents are helping endoscopists to diagnose and manage common complications such as bleeding, perforation and fistulous tracts.
The future of “AGE”
With emergence of aforementioned techniques, the field of AGE seems to be optimistic and promising for further novel approaches. Artificial intelligence (Xiao et al.) has unfolded predictive capacity of detecting precancerous and cancerous lesions (Fu et al.) with machine learning and convolutional neural network (6–8). Automated polyp characterization (size, optical pathology), cecum detection, bowel preparation scoring and esophagogastric neoplasia detection (Jiang et al.) is now possible with the use of AI. AGE is currently seeing an unprecedented progress with AI to predict, detect and manage neoplastic lesions with a precision which was never imagined. AGE could potentially use robotic techniques (9) such as robotic flexible endoscopy, forceps manipulation, transluminal access, neoguide endoscopic system and endoscopic capsules. However, with all of these techniques, there is considerable learning curve for which extensive training and research is needed to assess the intricacies, determine the pathway for appropriate credentialing and reporting of adverse events. This could be performed using quality (Song et al.) metrics as a cornerstone for any procedure with its outcomes. Further, given the complexity of the endoscopic work, a collaborative effort with interventional radiology and surgical teams can bring out the best outcomes.
Author contributions
AP: topic overview, outline, idea generation, writing, and editing. HG: critical editing, idea generation, and finalizing the article. TT and BT: finalizing the article. All authors contributed to the article and approved the submitted version.
Conflict of interest
BT was Medical Consultant for BSC, Medtronic and Olympus.
The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
2. Lee SH, Cho WY, Cho JY. Submucosal endoscopy, a new era of pure natural orifice translumenal endoscopic surgery (NOTES). Clin Endosc. (2012) 45:4–10. doi: 10.5946/ce.2012.45.1.4
3. Draganov PV, Aihara H, Karasik MS, Ngamruengphong S, Aadam AA, Othman MO, et al. Endoscopic submucosal dissection in north america: a large prospective multicenter study. Gastroenterology. (2021) 160:2317–27.E2. doi: 10.1053/j.gastro.2021.02.036
4. Johnson KD, Laoveeravat P, Yee EU, Perisetti A, Thandassery RB, Tharian B. Endoscopic ultrasound guided liver biopsy: recent evidence. World J Gastrointest Endosc. (2020) 12:83–97. doi: 10.4253/wjge.v12.i3.83
5. Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: current insights and emergingtechniques. World J Gastroenterol. (2021) 27:6874–87. doi: 10.3748/wjg.v27.i40.6874
6. Goyal H, Sherazi SAA, Gupta S, Perisetti A, Achebe I, Ali A, et al. Application of artificial intelligence in diagnosis of pancreatic malignancies by endoscopic ultrasound: a systemic review. Therap Adv Gastroenterol. (2022) 15:17562848221093873. doi: 10.1177/17562848221093873
7. Goyal H, Sherazi SAA, Mann R, Gandhi Z, Perisetti A, Aziz M, et al. Scope of artificial intelligence in gastrointestinal oncology. Cancers. (2021). 13:5494. doi: 10.3390/cancers13215494
8. Goyal H, Mann R, Gandhi Z, Perisetti A, Zhang Z, Sharma N, et al. Application of artificial intelligence in pancreaticobiliary diseases. Ther Adv Gastrointest Endosc. (2021) 14:2631774521993059. doi: 10.1177/2631774521993059
Keywords: advanced endoscopy, ERCP, EUS, pancreaticobiliary cancer, advanced gastrointestinal endoscopy training
Citation: Perisetti A, Tharian B, Tham TC and Goyal H (2023) Editorial: Recent updates in advanced gastrointestinal endoscopy. Front. Med. 9:1126846. doi: 10.3389/fmed.2022.1126846
Received: 18 December 2022; Accepted: 22 December 2022;
Published: 05 January 2023.
Edited and reviewed by: Angel Lanas, University of Zaragoza, Spain
Copyright © 2023 Perisetti, Tharian, Tham and Goyal. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Abhilash Perisetti, 
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