The Indian market in 2014 saw more than 15 percent increase in the endoscopes market, with the impetus provided by 3D and HD instruments.

The growing popularity of minimally invasive surgery (MIS) is leading to an increased adoption of endoscopy devices. An increase in MIS is correlated with lower incidences of post-operative complications, minimal scarring, and shorter hospital stays, which collectively act to improve surgery experiences both for hospitals and patients. Patients and surgeons continue to demand less-invasive surgical technologies, and the most common, least invasive procedures are currently conducted through a flexible endoscope. Healthcare professionals are exploring the use of endoscopes to conduct procedures with a less-invasive approach.

The global endoscopy market is expected to grow at a CAGR of 5.53 percent over 2015-19, according to Technavio. Endoscopy has remarkably changed the way in which diseases are detected. It is different from conventional methods. The adoption of endoscopy is on the rise led by the benefits offered by the minimally invasive type. Capsule endoscopes and robot-assisted endoscopes have revolutionized the endoscopy market. North America accounts for the largest market share in the global market led by a large number of endoscopic treatment options followed by Europe and Japan. Increase in healthcare spending, rising affordability, and changing lifestyle patterns attribute to the growth of emerging economies such as India and China. Major market players in the endoscopy devices market include Aesculap, Inc., Artherx, Inc., Boston Scientific Corporation, Conmed Corporation, Cook Medical, and Covidien plc.

Indian Market Dynamics

The Indian endoscopy equipment in 2014 is estimated at Rs.600 crore, with rigid equipment valued at Rs.390 crore and flexible equipment Rs.235 crore.

In the flexible endoscopes segment, Olympus Medical Systems continues to dominate the market, whereas in the rigid segment, Karl Storz has the highest share. Other major players are Fujinon (marketed by J Mitra), Pentax Medical India, Stryker Medical, and Richard Wolf. Escolab, Surgdent, Promis Medical, and some Chinese brands and refurbished brands.

The vendors are creating awareness among the buyers on endoscope reprocessing. The proper cleaning, disinfection, and sterilization of the equipment is as important as their proper use. Microbial burden from an endoscope needs to be removed, the instrument disinfected, (HLD, high level disinfection must be made a standard gradually for medical devices that touch mucous membranes, such as endoscopes and complete sterilization that results in the complete elimination of all forms of microbial life, must be followed. The Indian users, especially the nurses and ward boys who handle this equipment also are being educated of these aspects.

The surgeon is no longer satisfied with just a high definition image. It is seen to lose depth perception. He demands 3D capability from his instrument. Once the endoscopes are inserted into the body, the image transfer begins, and the surface of the internal parts can be seen. What is sought is the conversion of the HD data obtained from a 3D image for better evaluation. No matter how high-definition the image an endoscope may produce, it is still flat, making it difficult for the surgeon to see how close the tumor is to potentially critical nerves or tissue behind it, for example. 3D images enhance visibility and provide greater depth perception. This is found essential in complicated brain surgeries to avoid nerve damage. The advantage of 3D visualization is higher accuracy, so the surgeon can be much more precise, which is highly relevant during intervention in a surgery.

With the recent launch of 3D videoscopes, where a camera is already attached to the endoscope from major endoscopy players Olympus and Karl Storz, 3D will increasingly become a potential option in operating rooms. Improved precision and smoother transitions mean that operating times are 15 percent shorter, even when it is an experienced surgeon. The key, however, continues to be making it easy to switch, as 3D glasses are a huge limiter for physician adoption. With the adoption of Intuitive Surgical's da Vinci robot, the 3DHD vision system has been met with more positive response, since the 3D is already incorporated into the screen's console. There are a number of hurdles to overcome when it comes to 3DHD adoption, but with some fine tuning, there may be a place for it after all.

Technology Trends

Exciting improvements and innovations in the last few years result in better technology, better equipment, and bold, innovative uses of improved technology.

Flexible endoscopes. The trend of using flexible endoscopes before, during, and after a laparoscopic surgical procedure is expected to continue. Some laparoscopic procedures are also moving toward laparo-endoscopic single site (LESS) surgeries, which allow a surgeon to perform a traditional laparoscopic procedure through a single incision in the umbilicus, which can potentially extend the benefits of MIS. It is an exciting time in the flexible endoscope industry with growing technological innovations promoting enhanced diagnosis and treatment methodologies.

"The endoscopy market has seen major growth over the last two years. We expect this trend to continue for some more time."

Sumit Kumar
Managing Director,
Pentax Medical India Private Limited

Autofluorescence bronchoscopy has improved the detection of abnormal tissue by exploiting the special characteristics of tissue autofluoresence. Consequently, this examination does not involve any special pre-operative treatment of patients. Abnormal tissue, which can easily be overlooked when viewed with pure white light, can be visualized more clearly through autofluorescence bronchoscopy. These areas can, therefore, be examined more closely and more systematic biopsies can also be performed. Additionally, endoscope manufacturers are beginning to release high pixel count CMOS imaging sensors to replace higher cost CCD sensors.

Technical Progression in CE

Capsule endoscopy (CE) is the fastest growing segment among the endoscope product types. Capsule endoscopy has transformed investigation of the small bowel providing a non-invasive, well tolerated means of accurately visualizing the distal duodenum, jejunum, and ileum. Relentless technical progression leads to considerable improvements in capsule endoscopes. Superior quality multi-element lenses and adaptive illumination allow a wider angle of view and enhanced picture clarity. Power management strategies have increased the duration and performance of capsule endoscopes and are imperative to facilitate other capsule technological advancements.

Steerable capsules. The development of steerable capsules represents a major leap in the evolution of capsule technology. If the capsule motion through the gut was an active process, areas of interest could be inspected carefully, while interaction with the capsule could allow targeted biopsy or even drug delivery. Capsule endoscopy is now an invaluable tool for investigating the small bowel since it outperforms other investigation modalities while remaining acceptable to patients. Technology is swiftly advancing and therefore if these standards can be met, CE would have a clear advantage over conventional endoscopy particularly in the context of screening.

Wireless capsule endoscopy. This is a revolutionary clinical alternative to traditional flexible scopes, which enables inspection of the digestive system with minimal discomfort for the patient or the need for sedation, mitigating some of the risks of flexible endoscopy. Wireless video endoscopy or wireless capsule endoscopy (WCE) is a noninvasive technology designed primarily to provide diagnostic imaging of the small intestine, an anatomic site that has proven peculiarly difficult to visualize. Limited views of the esophagus, stomach, and cecum may also be acquired. In the past few years, significant research attention has been attracted to upgrade the WCE from a diagnostic-only tool to an active medical robot having not only diagnostic capabilities but also therapeutic functionalities such as biopsy, microsurgery, and targeted drug delivery. Although WCE has entered the medical scene as a disruptive technology, it presents a number of limitations including the inability to actively control locomotion and camera orientation, which leads to low diagnostic specificity and false-positive results. Therefore, the natural evolution of clinical WCE consists of integrating mechanisms for closed-loop active locomotion and providing the capsule with sensors and tools for diagnosis and therapy.

Second Opinion
Make in India Endoscopy for Smart India

An endoscopy unit in gastroenterology needs a range of equipment like gastro duodeno scope, double balloon enteroscope, colonoscope, and side viewing scopes. Additional equipment for hepato biliary pancreatic system require mother baby scope and spy glass among others.

Scopes have changed from fibro optic scopes to video endoscopes which are digital in nature. Light sources have changed from halogen to xenon and now to LED. Hitherto air insufflation was done for procedures, now changed to carbon dioxide which reduces abdominal discomfort, especially after prolonged procedures like endoscopic retrograde cholangio pancreatography, stent placement, and endoscopic ultrasound. Availability of a single processor for different scopes has increased the procedures for other departments like bronchoscopy, laryngoscopy structured marketing, training of endoscopy staff periodically, and availability of service engineers when required would increase sales in a better way. Possible requirements that will propel the market growth would include reachability in sales and service in tier-II and tier-III cities. Smooth upgradation to latest endoscope system and buy back will definitely draw the client to the company. Standardization of spares and accessories would ease when a doctor changes scope from one company to another reducing medical waste. Good after-sales services, availability of technical personnel for initial few cases to train the endoscopy staff in maintenance of equipment will be importance. With increasing population to get a good number of personnel to cater to marketing and sales across india is a big challenge. Endoscopy systems are now imported from Japan, China, Germany, and other countries. To make them available at the earliest is a big challenge. Volatile currency rates would also make sales of equipment tough.

With Make in India campaign any of the endoscope makers can have a plant in India or any Indian entrepreneur can take up the task of manufacturing world-class endoscopes. We shall definitely succeed as cost of production would come down drastically, with reduced cost of training and better availability of spares.

Dr Sreedhara V
Senior Application Manager,
Surgical Gastroenterologist,
Sparsh Hospital, Bangalore

Second Opinion
Evolving with Technology

Endoscopy literally refers to looking inside the body, usually through the natural orifices and occasionally through artificially created openings on the body surface. The method, orifice and equipment varies according to the organ of interest. The nomenclature changes with the organs to be examined are usually prefixed with the organ's name followed by scopy - esophagogastroduodenoscopy suggesting examination of the esophagus, stomach, and duodenum; colonoscopy (colon); and enteroscopy (small intestine). The equipment involved in conducting the GI procedures are called endoscopes. The size, length, and thickness vary according to the organ of evaluation. The endoscopes have gone a significant change since the time of their invention and have become both user and patient friendly. Though the procedure entails introduction of a flexible tube either through the mouth or the rectum, this tube transmits cold light usually from an external light source for illumination of the organ and carries back an image to a screen for visualization. The image obtained is a magnified one and highlights the findings on the screen. The procedure can be either a diagnostic or a therapeutic one.

The list of therapeutic endoscopy is beyond imagination of the lay people and ranges from retrieval of ingested foreign bodies to removal of tumors and biliary stones, control of active GI bleeding, and various other modalities. The endoscopic procedure is more discomforting than painful and the tolerance to the procedure varies among the people. Lately, these procedures are done under sedation to make them more patient friendly. The cleaning of these reusable scopes is an often asked question by the patients. It is usually a multistep process entailing manual cleaning of the scope followed by disinfecting and sterilization process prior to reuse. Lately, the market is flooded with various endoscopes and accessories, each one highlighting the superiority over the other. Some of the major players in the GI endoscopic equipment market include Olympus, Pentax, Fujinon, Karl Storz, and some new entrants.

Dr Jayanta Mukherjee
Consultant Gastroenterologist,
ILS Hospitals, AMRI, Kolkatta


Endoscopy visualization system. The demand for the endoscopy visualization system and components market is expected to increase at a significant growth rate. With technological advancement, cost-effective endoscopic treatments and procedures, increased demand for minimally invasive surgeries, fast recovery, productive insights, and innovations such as 3D systems with HD technology, growing access to trained clinicians, and rising healthcare expenditure in emerging markets, this market is anticipated to grow in next 10 years. With more number of players entering the endoscopy visualization system and components market, there is increased competition with regards to technology, high equipment purchase cost, regulatory approval process, and cut in healthcare spending. These factors remain the key restrains for the endoscopy visualization system and components market.

There is an ongoing advancement in imaging technologies that aims to improve visualization of vascular network and surface texture of the mucosa, leading to improvement in tissue characterization, differentiation, and diagnosis. These include technologies like chromoendoscopy, narrow band imaging, FICE and autofluorescence endoscopy, and point enhancement or virtual histology technologies includings endocytoscopy and confocal endomicroscopy.

10 Diagnostic Imaging Trends for 2018



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