Charles J. Lightdale, MD, Consulting Editor

The view we see is pretty much similar to the naked eye view. Many diseases are still best diagnosed when we remove tissue for pathology analysis, where the dead tissue is processed and sliced, mounted on a glass slide, stained, and looked at under a microscope by a highly trained specialist.

This system works quite well overall, but there are aspects that can be improved. The pathologist can only look at the tissue we provide, and if we can’t see where the occult disease lurks because it is too small and scattered, our biopsies can miss the diagnosis. Then there is the issue of expense. If we take more random biopsies to get a better sample, the cost goes up, and the results may not be all that much better.

Enter the brave new world of endoscopic imaging. It started with magnification endoscopes and spraying dyes for contrast or surface staining and led to new digital contrast enhancements. This magnifying glass view allowed classification of surface patterns that had good correlation with biopsy results. Still, smaller and more subtle abnormalities could be missed. The really big leap came during the past decade as optical science and powerful computers led to the development of extraordinary new tools that can be utilized during endoscopic inspection.

These new tools, such as advanced optical coherence tomography and confocal laser endomicroscopy, let us see at the level of what the pathologist can see under a microscope but in living tissue. Scanning views comparable to low-power microscopy at the 10-micron level and point views at less than the 1-micron level are possible that allow architectural and even cellular analysis in real time. Other spectroscopic techniques are being tested, and molecular imaging is in the development pipeline, using specific biochemical probes tagged with fluorescent markers that can be seen with specially designed endoscopes.

Other enhancements currently available include changing the direction of view with angled optics and reverse view to avoid missing visible lesions hidden by curves and folds. Endoscopic ultrasonography, increasingly used with fine-needle aspiration and biopsy, is being enhanced with elastography predicting tissue texture and echo signatures for needle guidance.

There are so many questions that will have to be answered. How much time will these new capabilities add to standard endoscopy? Will they be reliable, efficient, and accurate? How much will they cost, and will they be cost-effective? Will they be user-friendly or too complicated for routine use? Will the images be easy to interpret or will there be long learning curves? Can we send fewer but more accurate biopsies? Can we avoid sending biopsies at all in some cases? Can we use the results in real time to guide endoscopic therapy?

Getting a grasp on all this is the problem. Dr Sharmila Anandasabapathy, a leader in the field of endoscopic imaging, is the guest editor for this issue of the Gastrointestinal Endoscopy Clinics of North America on Advanced Imaging in Endoscopy. She picked all the key topics and rounded-up expert authors. Whether you just need an introduction to what is available or on the way, whether you are deciding to jump in now, or whether you are already using the new technologies and want an expert perspective, you must read this issue. The new imaging methods are upon us and will play a major role in defining the future of gastrointestinal endoscopy.