Veterans Affairs Palo Alto Hospital

High-Definition Endoscopy

By Grant Ellis

Professor Roy Soetikno and Gastroenterology Fellow Dr. Tonya Kaltenbach during an endoscopy at the Palo Alto Veteran’s Hospital Endoscopy Unit.

This year in the United States, an estimated 134,000 new cases of colon cancer will be diagnosed. More than 55,000 patients will succumb to the disease, which is the second most common cause of cancer death.

Colon cancer is preventable. The first line of defense against this disease is the detection and removal of pre-cancerous or early cancerous lesions — before the lesions grow deep into the intestinal wall or spread to other organs. Thousands of screening colonoscopies are performed every day.

The trouble is, colonoscopy isn’t easy. Cancers, and particularly early superficial cancers, can be extremely hard to identify. And endoscopists don’t get a second look. They have to base diagnostic judgments on a single real-time session with the endoscope. When the examination is complete, the moving images are gone and unrepeatable. They aren’t available for reference, consultation, or teaching.

The good news is that Dr. Roy Soetikno, head of the Gastrointestinal Section and Endoscopy Unit at the Veterans Affairs Palo Alto Hospital and an acknowledged visionary in the field, has developed a simple way for physicians to revisit colonoscopies using Apple technology. He uses the Mac to record, playback, and edit endoscopies. His teaching videos, assembled and edited with Final Cut Pro, are winning awards and raising the quality of diagnosis and treatment in this challenging field.

Capture and Playback

The Endoscopy Unit at the VA Palo Alto Hospital, which includes five attending doctors, nine trainees, and 10 nurses (plus visiting medical and surgical residents), is known for pioneering leading-edge techniques. Soetikno wanted a way to capture the motion video display he saw on endoscopes screens. He turned to the Mac.

“Endoscopy is about video, so we took advantage of the Mac’s unique video capabilities,” says Soetikno, who is also an associate professor of medicine at nearby Stanford University. “We started by creating a mini-studio on a cart that we can move between endoscopy rooms. The mini-studio had a Power Mac, 23-inch HD Apple Cinema displays, and a UPS battery. With our battery, we were able to take it to the ICU or the Radiology Department without turning the system off.” The mini-studio cart, which has since been replaced by an upgraded version, revolutionized endoscopy in the Endoscopy Unit.

“One reason we built this cart is that during a procedure we may have a fleeting recollection of something we saw seconds ago,” says Soetikno. “We think, ‘Did I miss something there? What was that?’ We can stop the procedure, rewind, and take another look. Without the Mac we could never bring those moving images back. Using the Mac we can also develop complex treatment strategy that is safe and effective.

“As a result of focusing on the difficult-to-see early cancers and replaying them, we’ve imprinted their signatures on our brains. When we say we’ve spotted one of them, other people may look at the screen and wonder what we’re talking about. They can’t see them, but we can. That’s another advantage we get from video replay on the Mac.”

Seeing the Subtleties

Image quality has also been a problem for endoscopists. Most of them work with standard-definition video displays that make it difficult to pick up subtle differences in tissue — the surface of a polyp, or the signature of an early cancer in the colon wall.

“With standard definition video images, we just don’t see the details of some of these lesions,” says Dr. Roy Soetikno. “We need higher resolution and better contrast to find diseases at an earlier stage.”

The major endoscope manufacturers (Olympus, Pentax, and Fujinon) have addressed this problem by upgrading to high-definition displays. The Unit recently took delivery of its HD endoscopes, the Olympus EVLS Exera II and the Fujinon Super-CCD, and the Unit’s staff is clearly impressed by the quality of the images.

“We performed a colonoscopy on an 80-year-old man this morning,” says Dr. Tonya Kaltenbach, a fellow in gastroenterology who is training under Soetikno. “He had a large polyp. The size of the polyp made us more concerned about a cancer. HD imaging enabled us to scrutinize the pattern of the polyp, which is very informative, and determine that it was not cancerous. We were able to make a treatment decision on the spot and remove the lesion safely and completely through the endoscope.

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