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Robotic Endoscopy: A Small Case Series, a Giant Step for Endoscopy

      In this issue of Clinical Gastroenterology and Hepatology, a provocative new robotic device called Master and Slave Transluminal Endoscopic Robot (MASTER) was used to perform the submucosal dissection portion of an endoscopic submucosal dissection (ESD) procedure on 5 patients with gastric neoplasia confined to the mucosa.
      • Phee J.S.
      • Reddy N.
      • Chiu P.W.Y.
      • et al.
      Robotic-assisted endoscopic submucosal dissection is effective in treating patients with early-stage gastric neoplasia.
      This was an early feasibility study that reported success in all 5 patients, complete resection in a short period of time compared with similar cases performed by standard ESD techniques. There were no short-term or long-term complications. The MASTER procedures were performed by individuals with substantial ESD experience but relatively small experience with the MASTER robotic system.
      This presentation of the first human experience with a new robotic system designed for endoluminal therapy (MASTER) represents a potential quantum leap in the endoscopic management of early intestinal neoplasia. Much credit should be given to our Japanese colleagues for their extraordinary development and refinement of ESD. Their work began with the systematic and thorough evaluation of the surface mucosal and vascular architecture. The efforts in Japan were enhanced by advances in several technologies such as magnification endoscopy enhanced by dye spraying and narrow band imaging. These technologies have allowed categorization of surface architecture that can predict neoplasia, dysplasia, and early cancer. With the application of these imaging techniques to screening and surveillance programs, detection of lesions amenable to mucosal resection increased. It was quickly understood that a core principle of oncologic surgery was en bloc (R0) resection providing the ability to assess lateral as well as deep margins with complete accuracy. As a result, the evolution of endoscopic mucosal resection to ESD was accelerated. We have watched in awe as the Japanese have refined and disseminated their ESD technique not only in Japan, Korea, and China but throughout other Asian countries. Western Europe and North America are now beginning to adopt the concept and technique as well. It is very clear now that the future for gastrointestinal cancer is early detection and complete endoscopic resection.
      We have been privileged to be involved in the conception and development of Natural Orifice Transluminal Endoscopic Surgery (NOTES). The legacy of NOTES has yet to be fully written, but a major impact of the NOTES concept was to bring together gastroenterologists with interest in therapeutic endoscopy and minimally invasive surgeons. From the very beginning, one could see that some investigators (primarily gastroenterologists) tried to solve unique instrument requirements of NOTES by modifying existing flexible endoscopes and adding accessories by either passing them down the biopsy channel or adding them to an overtube. Others (primary minimally invasive surgeons) made a strong appeal for the development of a new platform that would disassociate the optics from the end effectors and allow triangulation. Their desire was to create a more “laparoscopic like” environment while still leveraging the advantages of a flexible endoscope.
      Several companies have made initial efforts to develop a new flexible endoscopic platform. Storz (Tuttlingen, Germany) developed the Enubiscope, Olympus (Tokyo, Japan) developed a prototype EndoSamurai, and Boston Scientific (Natick, MA) began developing a direct drive endoscopic system, although they have decided to abandon this effort. All these systems were modifications of endoscopes with “arms” that would allow for exchangeable accessories and some degree of triangulation. None of these systems had a computer interface, and all directly translated hand movements to end effectors. None of the systems are commercially available, and all have limitations. The system described in this issue of Clinical Gastroenterology and Hepatology is a true robotic system with a computer interface to allow transmission of hand motion to the end effectors. Two key issues that will determine whether this technology is adopted are (1) cost and (2) whether it is an “enabling” technology. Although there remains a strong drive in medicine to create less invasive therapies, this must be balanced with cost. In Japanese hands, ESD is actually quite safe and very successful but is also very time-consuming. It is a relatively inexpensive procedure compared with the surgical alternative because it can be performed in an endoscopy suite rather than in the operating room. The major investment is in the physicians' time. If the MASTER or a similar system is to advance ESD, its added value must justify the presumed increase in cost. If the equipment costs can be minimized and the technology saves substantial time in performing ESD, then this technology will advance ESD.
      As we contemplate the introduction of robotics into therapeutic endoscopy, it would be best to review the experience in minimally invasive surgery. Robotic minimally invasive surgery has advanced significantly during the past 15 years. Initially, robotic surgery was dismissed as a marketing tool without any true advantages. There has been significant animosity from surgeons directed toward the field of surgical robotics, in part because of the millions of dollars it costs to establish and maintain a robotics program combined with resentment of the fact that there is only one option of an industry provider in this market. There continues to be debate among surgeons regarding the patient value from various robotic procedures. However, there can be little debate of some advantages provided by the robotic platform such as enhanced high-definition visualization, a stable visualization and working platform, and tremor-free dissection. There is little doubt that more rapid and wider acceptance of robotic surgery would have occurred with significantly lower costs, competition with high-quality products, and support for integration of robotic surgery training into all surgery residency and fellowship programs.
      Preliminary data presented in the article in this issue
      • Phee J.S.
      • Reddy N.
      • Chiu P.W.Y.
      • et al.
      Robotic-assisted endoscopic submucosal dissection is effective in treating patients with early-stage gastric neoplasia.
      suggest that MASTER may also be an enabling technology. ESD has been adopted slowly in the West because the training required to perform ESD efficiently and safely is quite substantial. A robotic system like MASTER can make a significant contribution to the advancement of therapeutic endoscopy if it enables a greater number of practitioners to perform ESD. The endoscopists in this study were fully trained in ESD but had limited experience with MASTER. They performed only part of the ESD procedure by using MASTER, and the cases selected were relatively straightforward. Nonetheless, they completed the ESD quickly, and when compared with historical controls, they concluded that MASTER significantly facilitated rapid and safe completion of the dissection. Further studies are needed to determine whether physicians who have limited training in current ESD techniques can be taught to do a robotic-assisted ESD more easily and quickly when compared with the standard technique. If this proves to be the case, then robotic-assisted endoluminal therapies will be widely adopted.
      Robotic-assisted therapeutic endoscopy may not only be an advance for endoluminal treatments but may also represent the platform for NOTES that our minimally invasive surgery colleagues have been calling for since the beginning of the NOTES era. Either way, this report of the first robotically assisted ESD likely represents the beginning of a new era in therapeutic endoscopy, and we anxiously await reports of further advances.

      Reference

        • Phee J.S.
        • Reddy N.
        • Chiu P.W.Y.
        • et al.
        Robotic-assisted endoscopic submucosal dissection is effective in treating patients with early-stage gastric neoplasia.
        Clin Gastroenterol Hepatol. 2012; 10: 1117-1121

      Linked Article

      • Robot-Assisted Endoscopic Submucosal Dissection Is Effective in Treating Patients With Early-Stage Gastric Neoplasia
        Clinical Gastroenterology and HepatologyVol. 10Issue 10
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          Endoscopic submucosal dissection (ESD) is a new technique for endoscopic resection of early-stage gastrointestinal cancers. Though ESD achieves high rate of en bloc resection, it is technically difficult to master. The development of a novel robotic endoscopic system that has 2 arms attached to an ordinary endoscope—Master and Slave Transluminal Endoscopic Robot (MASTER)—has improved the performance of complex endoluminal procedures. We evaluated the efficacy of MASTER-assisted ESD in treatment of patients with early-stage gastric neoplasia.
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