Eye-controlled endoscopy - a benchtop trial of a novel robotic steering platform - iGAZE2.

The endoscopic control system has remained similar in design for many decades The remit of advanced therapeutic endoscopy continues to expand requiring precision control and high cognitive workloads. Robotic systems are emerging, but all still require bimanual control and expensive and large new systems. Eye tracking is an exciting area that can be used as an endoscope control system. This is a study to establish the feasibility of an eye-controlled endoscope and compare its performance and cognitive demand to use of a conventional endoscope. An eye gaze-control system consisting of eye-tracking glasses, customised software and a small motor unit was built and attached to a conventional endoscope. Twelve non-endoscopists used both the eye gaze system and a conventional endoscope to complete a benchtop task in a simulated oesophagus and stomach. Completion of tasks was timed. Subjective feedback was collected from each participant on task load using the NASA Task Load Index. Participants were significantly quicker completing the task using iGAZE2 vs a conventional endoscope (65.02 ± 16.34s vs 104.21 ± 51.31s, p = 0.013) Participants were also significantly quicker completing retroflexion using iGAZE2 vs a conventional endoscope (8.48 ± 3.08 vs 11.38 ± 5.36s, p = 0.036). Participants reported a significantly lower workload (raw NASA-TLX score) when using iGAZE2 vs the conventional endoscope (152.1 ± 63.4 vs 319.6 ± 81.6, p = 0.0001) (Fig. 7). Users found iGAZE2 to have a significantly lower temporal demand, mental demand, effort, mental demand, physical demand, and frustration level. The eye gaze system is an exciting, small, and retrofittable system to any endoscope. The system shows exciting potential as a novel endoscopic control system with a significantly lower workload and better performance in novices suggesting a more intuitive control system.

Orientation in upper gastrointestinal endoscopy-the only way is up.

BACKGROUND: Oesophagogastroduodenoscopy is the gold standard investigation for the upper gastrointestinal (UGI) tract. Orientation during endoscopy is challenging and United Kingdom training focusses on technical competence and procedural safety. The reported location of UGI pathologies is crucial to post-endoscopic planning. AIM: To evaluate endoscopists' ability to spatially orientate themselves within the UGI tract. METHODS: A cross sectional descriptive study elicited, using an anonymised survey, the ability of endoscopists to orientate themselves within the UGI tract. The primary outcome was percentage of correct answers from all surveyed; secondary outcomes were percentage of correct answers from experienced vs novice endoscopists. Pearson's χ 2 test was applied to compare groups. RESULTS: Of 188 respondents, 86 were experienced endoscopists having completed over 1000 endoscopies. 44.4% of respondents correctly identified the anterior stomach and 47.3% correctly identified the posterior of the second part of the duodenum (D2). Experienced endoscopists were significantly more likely than novice to identify the anterior stomach correctly [61.6% vs 31.3%, X 2 (1, n = 188) = 11.10, P = 0.001]. There was no significant difference between the two groups in identifying the posterior of D2. CONCLUSION: The majority of endoscopists surveyed were unable to identify key landmarks within the UGI tract. Endoscopic orientation appears to improve with experience yet there are some areas still not well recognised. This has potential considerable impact on post-endoscopic management of patients with posterior duodenal ulcers being more likely to perforate and associated with a higher rebleeding risk. We suggest the development of a consensus statement on endoscopic description.

Eye tracking technology in endoscopy: Looking to the future.

The visual patterns of an endoscopist, that is, what the endoscopist is looking at during luminal endoscopy, is an interesting area with an evolving evidence base. The tools required for gaze analysis have become cheaper and more easily accessible. A comprehensive literature search was undertaken identifying 19 relevant papers. Gaze analysis has been used to identify certain visual patterns associated with higher polyp detection rates. There have also been increasing applications of gaze analysis as an objective study tool to compare the effectiveness of endoscopic imaging technologies. Gaze analysis also has the potential to be incorporated into endoscopic training. Eye movements have been used to control and steer a robotic endoscope. This review presents the current evidence available in this novel and evolving field of endoscopic research.

Perceptions of Digital Teaching During COVID-19; A National Survey of 359 Internal Medicine Trainees.

Introduction: The Covid-19 pandemic brought significant disruption to post-graduate medical education. Lecture-based training days were rapidly converted to webinars. This study aims to assess the perceptions of digital training in internal medical trainees. Methods: IMTs (internal medicine trainees) nationally were surveyed on their perceptions of digital training, ease of access, engagement, and interactivity via a 10-item questionnaire. A mixed-method approach using qualitative and quantitative questions was used. Likert scales were analysed using a mean result of above 3 to indicate agreement. Results: 359 trainees responded. Trainees agreed that they preferred digital training to face-to-face teaching (mean 3.68); digital training was more engaging (mean 4.25), easier to access (mean 4.49), and as effective for learning as face-to-face teaching (mean 4.69). The most reported advantages were no travel (89%) and the ability to watch later on (88%). 63% of trainees reported loss of social interaction as a disadvantage. Discussion: This survey suggests that digital teaching has a potential role in IMT training beyond the pandemic.

Does computer-aided diagnostic endoscopy improve the detection of commonly missed polyps? A meta-analysis.

BACKGROUND/AIMS: Colonoscopy is the gold standard diagnostic method for colorectal neoplasia, allowing detection and resection of adenomatous polyps; however, significant proportions of adenomas are missed. Computer-aided detection (CADe) systems in endoscopy are currently available to help identify lesions. Diminutive (≤5 mm) and nonpedunculated polyps are most commonly missed. This meta-analysis aimed to assess whether CADe systems can improve the real-time detection of these commonly missed lesions. METHODS: A comprehensive literature search was performed. Randomized controlled trials evaluating CADe systems categorized by morphology and lesion size were included. The mean number of polyps and adenomas per patient was derived. Independent proportions and their differences were calculated using DerSimonian and Laird random-effects modeling. RESULTS: Seven studies, including 2,595 CADe-assisted colonoscopies and 2,622 conventional colonoscopies, were analyzed. CADe-assisted colonoscopy demonstrated an 80% increase in the mean number of diminutive adenomas detected per patient compared with conventional colonoscopy (0.31 vs. 0.17; effect size, 0.13; 95% confidence interval [CI], 0.09-0.18); it also demonstrated a 91.7% increase in the mean number of nonpedunculated adenomas detected per patient (0.32 vs. 0.19; effect size, 0.05; 95% CI, 0.02-0.07). CONCLUSION: CADe-assisted endoscopy significantly improved the detection of most commonly missed adenomas. Although this method is a potentially exciting technology, limitations still apply to current data, prompting the need for further real-time studies.

Using Mixed Reality Headsets to Deliver Remote Bedside Teaching During the COVID-19 Pandemic: Feasibility Trial of HoloLens 2.

BACKGROUND: COVID-19 has had a catastrophic impact in terms of human lives lost. Medical education has also been impacted as appropriately stringent infection control policies precluded medical trainees from attending clinical teaching. Lecture-based education has been easily transferred to a digital platform, but bedside teaching has not. OBJECTIVE: This study aims to assess the feasibility of using a mixed reality (MR) headset to deliver remote bedside teaching. METHODS: Two MR sessions were led by senior doctors wearing the HoloLens headset. The trainers selected patients requiring their specialist input. The headset allowed bidirectional audiovisual communication between the trainer and trainee doctors. Trainee doctor conceptions of bedside teaching, impact of the COVID-19 pandemic on bedside teaching, and the MR sessions were evaluated using pre- and postround questionnaires, using Likert scales. Data related to clinician exposure to at-risk patients and use of personal protective equipment (PPE) were collected. RESULTS: Prequestionnaire respondents (n=24) strongly agreed that bedside teaching is key to educating clinicians (median 7, IQR 6-7). Postsession questionnaires showed that, overall, users subjectively agreed the MR session was helpful to their learning (median 6, IQR 5.25-7) and that it was worthwhile (median 6, IQR 5.25-7). Mixed reality versus in-person teaching led to a 79.5% reduction in cumulative clinician exposure time and 83.3% reduction in PPE use. CONCLUSIONS: This study is proof of principle that HoloLens can be used effectively to deliver clinical bedside teaching. This novel format confers significant advantages in terms of minimizing exposure of trainees to COVID-19, reducing PPE use, enabling larger attendance, and delivering convenient and accessible real-time clinical training.

A novel gaze-controlled flexible robotized endoscope; preliminary trial and report.

BACKGROUND: Interventional endoluminal therapy is rapidly advancing as a minimally invasive surgical technique. The expanding remit of endoscopic therapy necessitates precision control. Eye tracking is an emerging technology which allows intuitive control of devices. This was a feasibility study to establish if a novel eye gaze-controlled endoscopic system could be used to intuitively control an endoscope. METHODS: An eye gaze-control system consisting of eye tracking glasses, specialist cameras and a joystick was used to control a robotically driven endoscope allowing steering, advancement, withdrawal and retroflexion. Eight experienced and eight non-endoscopists used both the eye gaze system and a conventional endoscope to identify ten targets in two simulated environments: a sphere and an upper gastrointestinal (UGI) model. Completion of tasks was timed. Subjective feedback was collected from each participant on task load (NASA Task Load Index) and acceptance of technology (Van der Laan scale). RESULTS: When using gaze-control endoscopy, non-endoscopists were significantly quicker when using gaze-control rather than conventional endoscopy (sphere task 3:54 ± 1:17 vs. 9:05 ± 5:40 min, p = 0.012, and UGI model task 1:59 ± 0:24 vs 3:45 ± 0:53 min, p < .001). Non-endoscopists reported significantly higher NASA-TLX workload total scores using conventional endoscopy versus gaze-control (80.6 ± 11.3 vs 22.5 ± 13.8, p < .001). Endoscopists reported significantly higher total NASA-TLX workload scores using gaze control versus conventional endoscopy (54.2 ± 16 vs 26.9 ± 15.3, p = 0.012). All subjects reported that the gaze-control had positive 'usefulness' and 'satisfaction' score of 0.56 ± 0.83 and 1.43 ± 0.51 respectively. CONCLUSIONS: The novel eye gaze-control system was significantly quicker to use and subjectively lower in workload when used by non-endoscopists. Further work is needed to see if this would translate into a shallower learning curve to proficiency versus conventional endoscopy. The eye gaze-control system appears feasible as an intuitive endoscope control system. Hybrid gaze and hand control may prove a beneficial technology to evolving endoscopic platforms.

Grass-roots junior doctor communication network in response to the COVID-19 pandemic: a service evaluation.

BACKGROUND: COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions. LOCAL PROBLEM: A survey of doctors revealed only 20% felt confident that they would know to whom they could raise concerns and that most were getting information from a combination of informal work discussions, trust emails, social media and medical literature. METHODS: This quality improvement project was undertaken aligning with Standards for Quality Improvement Reporting Excellence 2.0 guidelines. Through an iterative process, a digital network (Imperial Covid cOmmunications Network; ICON) using existing smartphone technologies was developed. Concerns were collated from the junior body and conveyed to the leadership team (vertical-bottom-up using Google Form) and responses were conveyed from leadership to the junior body (vertical-top-down using WhatsApp and Zoom). Quantitative analysis on engagement with the network (members of the group and number of issues raised) and qualitative assessment (thematic analysis on issues) were undertaken. RESULTS: Membership of the ICON WhatsApp group peaked at 780 on 17 May 2020. 197 concerns were recorded via the Google Form system between 20 March and 14 June 2020. There were five overarching themes: organisational and logistics; clinical strategy concerns; staff safety and well-being; clinical (COVID-19) and patient care; and facilities. 94.4% of members agreed ICON was helpful in receiving updates and 88.9% agreed ICON improved collaboration. CONCLUSIONS: This work demonstrates that a coordinated network using existing smartphone technologies and a novel communications structure can improve collaboration between senior leadership and junior doctors. Such a network could play an important role during times of pressure in a healthcare system.

Endoscopic submucosal dissection: an update on tools and accessories.

Endoscopic submucosal dissection (ESD) is a minimally invasive therapeutic procedure to remove larger polyps or early non-metastatic lesions. It has long been used in Asia, but is now fast growing in popularity in the West. There are multiple challenges faced by ESD practitioners. While the practice of ESD in gastric lesions is relatively well established, the oesophagus with its narrow lumen and challenging workspace, and the colon with its tortuous course and folds are more challenging frontiers. The nature of performing a procedure endoscopically means that conventional methods offer no mechanism for providing counter-traction while performing dissection, impeding visibility and increasing the rate of complications. There are a multitude of tools available to those performing ESD for the different stages of the procedure. This article reviews the accessories currently used in regular ESD practice including the knives used to cut and dissect lesions, the cap and hood devices used to improve visibility and safety, injection fluids to lift the submucosal plane, haemostatic devices, generators, and finally, emerging traction apparatus. There is some evidence behind the use of these tools, however, ESD remains the domain of a small number of practitioners and the practice relies heavily on expert experience. Evolution of the ESD toolbox will make the procedure more accessible to more endoscopists, which in turn will drive the development of a more substantial evidence base to evaluate efficacy and safety of the multitude of tools.

Use of the HoloLens2 Mixed Reality Headset for Protecting Health Care Workers During the COVID-19 Pandemic: Prospective, Observational Evaluation.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has led to rapid acceleration in the deployment of new digital technologies to improve both accessibility to and quality of care, and to protect staff. Mixed-reality (MR) technology is the latest iteration of telemedicine innovation; it is a logical next step in the move toward the provision of digitally supported clinical care and medical education. This technology has the potential to revolutionize care both during and after the COVID-19 pandemic. OBJECTIVE: This pilot project sought to deploy the HoloLens2 MR device to support the delivery of remote care in COVID-19 hospital environments. METHODS: A prospective, observational, nested cohort evaluation of the HoloLens2 was undertaken across three distinct clinical clusters in a teaching hospital in the United Kingdom. Data pertaining to staff exposure to high-risk COVID-19 environments and personal protective equipment (PPE) use by clinical staff (N=28) were collected, and assessments of acceptability and feasibility were conducted. RESULTS: The deployment of the HoloLens2 led to a 51.5% reduction in time exposed to harm for staff looking after COVID-19 patients (3.32 vs 1.63 hours/day/staff member; P=.002), and an 83.1% reduction in the amount of PPE used (178 vs 30 items/round/day; P=.02). This represents 222.98 hours of reduced staff exposure to COVID-19, and 3100 fewer PPE items used each week across the three clusters evaluated. The majority of staff using the device agreed it was easy to set up and comfortable to wear, improved the quality of care and decision making, and led to better teamwork and communication. In total, 89.3% (25/28) of users felt that their clinical team was safer when using the HoloLens2. CONCLUSIONS: New technologies have a role in minimizing exposure to nosocomial infection, optimizing the use of PPE, and enhancing aspects of care. Deploying such technologies at pace requires context-specific information security, infection control, user experience, and workflow integration to be addressed at the outset and led by clinical end-users. The deployment of new telemedicine technology must be supported with objective evidence for its safety and effectiveness to ensure maximum impact.

The evolution of lower gastrointestinal endoscopy: where are we now?

Lower gastrointestinal endoscopy has evolved over time, fulfilling a widening diagnostic and therapeutic remit. As our understanding of colorectal cancer and its prevention has improved, endoscopy has progressed with improved diagnostic technologies and advancing endoscopic therapies. Despite this, the fundamental design of the endoscope has remained similar since its inception. This review presents the important role lower gastrointestinal endoscopy serves in the prevention of colorectal cancer and the desirable characteristics of the endoscope that would enhance this. A brief history of the endoscope is presented. Current and future robotic endoscopic platforms, which may fulfil these desirable characteristics, are discussed. The incorporation of new technologies from allied scientific disciplines will help the endoscope fulfil its maximum potential in preventing the increasing global burden of colorectal cancer. There are a number of endoscopic platforms under development, which show significant promise.