The endoscopy market has grown over the past couple of years, and is set to do so for some more time. However with the tendency of purchasing more products from fewer manufacturers, the adoption pattern within the endoscopy space has become not entirely product performance based, but also strong brand awareness and identity has become a necessity.

Endoscopy technology has changed the manner of detecting diseases and performing surgeries, with less invasive methods that are gaining attention across the globe. It is a fast-moving field, and new techniques are continuously emerging. In recent decades, endoscopy has evolved and branched out from a diagnostic modality to enhanced video and computer-assisting imaging with impressive interventional capabilities. The modern endoscopy has seen advances not only in types of endoscopes available, but also in types of interventions amenable to the endoscopic approach. To date, there are a lot more developments that are being trialed.

In the face of increasing hospital consolidation into one network and the trend of oligopoly purchasing, i.e., purchasing more products from fewer manufacturers, the adoption pattern within the endoscopy space has become not entirely product performance based, but also strong brand awareness and identity has become a necessity. Going forward, the increasing emphasis placed on value and the concomitant need to demonstrate improved clinical outcomes will become a critical point of consideration for manufacturers, and will be the most significant factor shaping the design and development of new generation of endoscopic devices.

Indian Market Dynamics

Indian Endoscopes

The endoscopy market may be segmented into products and applications. Products may be further classified as endoscopes, visualization equipment, and other instruments and accessories, and endoscopes further as rigid, flexible, surgical, and capsule. The visualization equipment includes endoscopy cameras, video processors, video converters, camera heads, light sources, wireless displays, and transmitters and receivers.

However, it is difficult to obtain sales data in such detail. The Indian vendors broadly include the visualization equipment as part of endoscopes.

Olympus is the leader in the endoscopy market with presence in rigid, flexible, balloon endoscopes, and accessories. In the flexible segment, it has an estimated 58 percent market share. Pentax commands an estimated 23 percent market share. Fujifilm and Karl Storz along with local, refurbished, and Chinese brands are aggressive.

In the rigid segment, Karl Storz and Stryker are neck-to-neck, with a combined market share of almost 50 percent. Olympus, Richard Wolf, Escolab, and Surgdent are aggressive. The local, Chinese and refurbished players have a significant combined share in this segment.

Global Market

The global endoscopy equipment market is expected to grow from USD 32.5 billion in 2015 to USD 45.2 billion by 2020, reflecting a five-year compound annual growth rate (CAGR) of 6.8 percent. The laparoscopy market is estimated at USD 10 billion and USD 16.2 billion in 2015 and 2020, respectively, demonstrating a five-year CAGR of 10 percent.

The arthroscopy market would grow from USD 4.6 billion in 2015 to USD 6.3 billion by 2020, with a five-year CAGR of 6.6 percent. The visualization and documentation systems segment should demonstrate the highest CAGR, at almost 10 percent. The endoscope segment commanded the largest market in 2015 and should continue strong growth through 2020, according to BCC Research.

Over the next five years, the endoscopy market should grow significantly. Major growth drivers include global aging population; the increase in the number of individuals with cancer, diabetes, and obesity; and the rise in patients' preference for minimally invasive surgeries. Additionally, shorter hospital stays, faster recoveries, and reduced medical budgets should enhance growth. Growth obstacles include the shortage of qualified endoscopic technicians, the high cost of initial investment, contamination risk, and patient safety during endoscopic procedures.

Growing incidences of gastrointestinal conditions and colon cancer and high demand for minimally invasive surgeries significantly contribute to the growth of endoscopy devices market. Availability of favorable reimbursement policies for endoscopic procedures also contributes to the increased adoption of endoscopy devices.

Demand for minimally invasive procedures for both diagnostic and therapeutic applications will also drive the endoscopy devices market. Minimally invasive procedures offer advantages such as minimal scarring, shorter hospital stay, and less post-operative complications, thus reducing the overall procedural cost. Hence, minimally invasive surgeries are being increasingly adopted worldwide.

Geriatric population is at a higher risk of diseases such as gastrointestinal conditions, ophthalmic diseases, GI cancer, orthopedic diseases, and others. With the growth in the number of such cases, the demand for endoscopy devices is anticipated to grow correspondingly.

Devices for surgical interventions will together have the largest market share over the next five years. Endoscopic visualization systems will have a significant position in the overall endoscopy devices market, as these devices are responsible for procedural imaging.

Products such as capsule endoscopes will undergo the fastest market growth. Asia-Pacific is the fastest growing regional market. The market growth of this region is primarily facilitated by growing medical tourism, rapid development of healthcare infrastructure, and growing popularity of minimally invasive surgical procedures.

Overall, new applications for the technology, as well as new innovations in the technology itself, would encourage market expansion. Advancements in the technology have resulted in several improvements, including increased angles in the field of view in endoscopes; reduced outer diameters of scopes; endoscopy systems that are integrated with high-resolution technologies such as 3-D systems; capsule endoscopes; and miniaturized endoscopy systems.

Advances in Digital Imaging

The well-recognized rapid advances in television technology that provide the viewer with a more engaging, immersive experience have also occurred in endoscopic imaging. Endoscopists are becoming increasingly able to detect subtle, minute mucosal changes that were previously indistinguishable from normal tissue. This is due to improved standards in resolution and magnification, combined with image enhancement techniques available to the endoscopist at the touch of a button.

Endoscopy in high definition and high magnification. The endoscope has switched from standard definition to digital, high-definition white-light imaging. Pentax, Olympus, and Fujinon are presently leading the field in endoscopic imaging, and currently have advanced high-definition endoscopic systems available for clinical use. They offer improved ability to distinguish subtle mucosal differences in tissue in close proximity to each other, which is partly due to improved resolution (defined by pixel density).

Standard definition endoscopes offered images of approximately 300,000 pixels whereas the new high-definition endoscopes, when combined with the latest processors, can achieve image quality of over 2 million pixels. Furthermore, all three of these companies offer endoscopes with high magnification to further enhance imaging. A standard endoscope magnifies an image by 30-35 times normal. However, these companies produce high-definition endoscopes that can optically magnify images by up to 150 times.

Image enhancement. In addition to high-definition white-light imaging, current market-leading endoscopes also provide further image enhancement by offering the endoscopist the ability to filter certain wavelengths of light. iScan, OE, narrow-band imaging (NBI), and intelligent chromo endoscopy are all post-processing optical technologies that are designed to enhance subtle architectural or vascular patterns on the mucosal surface and, therefore, enhance an endoscopist's ability to detect subtle lesions within the gastrointestinal tract.

However, these techniques do have their limitations. For example, NBI is excellent at demonstrating the changes in microvasculature seen in early gastric and esophageal lesions. However, it is not so effective at identifying some of the associated mucosal changes seen in these conditions, an area in which Fuji Intelligent Chromo Endoscopy excels. Similarly, the viewing of lesions at a distance is problematic with these techniques. Blue laser imaging has been developed to overcome these issues, through combining narrow-band laser light with high-definition white light.

Molecular imaging. This is a rapidly growing discipline in medical imaging, utilizing unique molecular signatures for targeted imaging of pathology. This technique relies upon the development of exogenous molecular probes that specifically locate and highlight desired pathology. The potential for molecular imaging goes beyond that of just aiding in the detection of lesions.

Other possible applications of this technology are within the field of therapy, where molecular imaging could enhance drug delivery and monitor drug response. Autofluorescence is an area of molecular imaging that is based upon the detection of natural tissue fluorescence emitted by endogenous molecules (fluorophores), such as collagen, flavins, and porphyrins. Studies have demonstrated that dysplastic or cancerous tissue emit a different autofluorescence spectrum compared to normal tissue.

Consequently, wide-field autofluorescence imaging was integrated with high-definition white-light endoscopy and NBI to produce trimodal endoscopic imaging. This technique is not yet in clinical use and there is little data from large-scale clinical trials, although the data from smaller studies appears promising. Similarly, the use of near-infrared endoscopy and fluorescent activatable probes has limited clinical data, but early work demonstrates promise.

Device-assisted enteroscopy. The small bowel remained the last frontier in gastroenterology for a long period after the start of endoscopy. Even with the advent of better endoscopes and colonoscopies, barium meal and follow- through remained the preferred method of investigation of the small bowel. Although push enteroscopy was present from the 1980s it was not until the advent of device-assisted enteroscopy that the small bowel was finally conquered.

Device-assisted enteroscopy includes double balloon enteroscopy, single balloon enteroscopy, and spiral enteroscopy. The other method of visualizing the small bowel was capsule enteroscopy. Capsule enteroscopy too revolutionized endoscopy as it gave patients a degree of freedom never before enjoyed and would be the best screening tool available. However, its main disadvantage remains the inability to obtain biopsies.

Way Ahead

As the science behind endoscopy technologies improves, so does the ability of the endoscopist to visualize and treat lesions. It is without doubt that the improved ability to identify pre-cancerous or early cancerous lesions that have previously evaded even the most diligent endoscopist will have a significant impact on prognosis.

Alongside this, the impact these technologies could have in reducing the need for biopsies and therefore, the number of procedures will significantly alter the management of strained healthcare resources.

However, one must acknowledge that much of this technology is still in its early stages and is yet to be fully tested in clinical practice. Similarly, although these technologies provide an exciting platform for the endoscopist, they are still reliant on the diligence and expertise of their user.

These techniques are only as good as the quality of training and the acquisition of knowledge that precedes their use. One can believe, however, that as with high-definition endoscopy, some of these technologies will emerge into mainstream use providing significant benefit to patient outcomes.

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