COME OUT, COME OUT Thanks to remarkable new advances in GI visualization, polyps have no place to hide.

With endoscopy, it's all about what you can see and what you can't. Sharp focus and depth perception are key elements, but so is the ability to reveal targets that might be hiding beneath other anatomy. It's an ongoing challenge for manufacturers, who continue to develop both visual and mechanical innovations that can help you uncover and recognize what you're looking for. Here are some recent examples.

Olympus Evis Exera III
"The difference in detail you get now is even more pronounced than your best high-definition television. It's incredible," says Steven Lichtenstein, DO, director of the division of gastroenterology and medical director at Mercy Fitzgerald Hospital in Philadelphia, Pa. "The dual focus is almost microscopic."

Olympus reps say the company has worked to combine all the key elements of endoscopy: image quality, control and the ability to advance the scope through the colon with as little discomfort on the part of the patient, and as much ease on the part of the endoscopist, as possible.

The resolving power of the HD imaging is designed to differentiate very finely detailed structures of tissue, blood vessels and anything else that might have clinical relevance. There's also a "pre-freeze" function, which is intended to eliminate the frustration of trying to capture a still image for the patient record that isn't blurred. The pre-freeze continually buffers a set of the most recent still images from the video and automatically pulls out the sharpest one.

"I've been practicing for 19 years," says Dr. Lichtenstein, "and between the ease of insertion, and getting from the rectum to the cecum, I think this new generation is the easiest to use."

Pentax RetroView
Polyps hide, RetroView seeks, says Pentax Medical, the manufacturer of this innovative scope, which has a 25% smaller retroflex radius and 210-degree angulation, making it easier to maneuver and easier to spot polyps behind folds in the colon.

"It's remarkably easy to turn around, especially in the end of the colon," says Luis Lara, MD, medical director of the Pancreas Disease Clinic Department of Gastroenterology at the Cleveland Clinic in Weston, Fla. "And everybody in our practice felt there was really no learning curve."

The maneuverability was a huge advantage in a recent case, says Dr. Lara. "We had a patient who'd had 3 failed colonoscopies. She had a very redundant sigmoid with diverticulosis and diverticular strictures, and a CT scan showed that she possibly had a lesion, so it was imperative that we try to do a colonoscopy and see what was going on."

The RetroView, he says, succeeded where other scopes had failed: "It was amazing. I could see where the area of sigmoid narrowing was. I could also appreciate that if I had not had the extreme angulation together with the thinner lumen toward the end, it would have been extremely difficult to get through it. We ended up saving this lady from having to have unnecessary surgery."

EndoChoice Fuse
The 3-monitor Fuse system offers a panoramic view, with 3 side-by-side monitors displaying a 330-degree field of vision. It's a lot to take in, but Steve Morris, MD, FACP, says it doesn't take long to adjust.

"The learning curve was much quicker than I thought," says Dr. Morris, a managing partner of Atlanta (Ga.) Gastroenterology Associates. "By the time I did 2 or 3 cases back to back, it felt very natural. You focus on the middle screen, so you're not stretching any peripheral vision, and you realize that the two peripheral screens are just an enlarged viewing area. There's some overlap with the middle screen, which helps with advancing the scope because you really can better see where the lumen is."

But the biggest advantage, says Dr. Morris, comes in the extubation. "We know from years of experience that you really see the lumen better as you're withdrawing the endoscope," he says. "I think my colleagues and I have all had the epiphany in the short time that we've been using it, that we would have missed something, that there's a polyp behind the fold that we would not have seen."

Clinical studies bear him out. The accepted consensus is that conventional scopes have an adenoma miss rate in the range of 24 to 31%. A recent comparative study (tinyurl.com/l6z6mle) found that the Fuse system detected 48 adenomas in a cohort of 88 patients, compared with 28 that were detected by traditional forward-viewing scopes.

"It's very clever," says Dr. Morris. "It's one of those things that you look at and wonder why didn't somebody do this sooner. We really have made major strides in the last 10 years — with high-def, flat screens, better monitors — but all that's really incremental, whereas this is much more disruptive technology."

Medivators Endocuff
A standout in the mechanical realm of improving visuals, the Endocuff can be placed on the tip of any standard colonoscope. Its "fingers" hug and flatten the folds during extubation, exposing underside polyps that might otherwise evade detection.

"It's an exciting development," says Seth A. Gross, MD, director of endoscopy at Tisch Hospital, NYU Langone Medical Center in New York. "My colleagues and I have definitely found polyps that they didn't see with the forward view. We feel we were doing an excellent exam with current colonoscopy and that this made it better."

The single-use device is also a boon when it comes to resection, says Dr. Gross: "The fingers kind of just pull it right in front of you and bring it right into the light. And because the fingers are holding the folds down, it helps stabilize you, too, and allows for removal of those hidden polyps."