En bloc resection of large superficial colorectal lesions offers significant advantages. Beyond enabling the treatment of early submucosal cancers with a low risk of lymph node metastasis, it also helps prevent recurrence, reducing the need for regular, costly, and stressful colonoscopy follow-ups for patients [1]. Additionally, this approach simplifies the optical diagnostic phase, eliminating the need to identify subtle mucosal and vascular pattern irregularities. Instead, it focuses on detecting amorphous areas, for which endoscopic resection may be contraindicated owing to a high probability of deep cancer infiltration. Furthermore, considering the environmental impact of transporting patients for their colonoscopy follow-ups [2], the strategy of en bloc resection as a one-time procedure appears more ecologically sustainable. Such follow-up colonoscopies also impair significantly work productivity [3]. So, despite these clear advantages for en bloc resection, why does piecemeal endoscopic mucosal resection (EMR) remain the most widely used technique in many countries?

The highly technical nature of en bloc resection, its steep learning curve, and the associated procedural risks explain its limited global adoption [4]. Performing resections via endoscopy presents intrinsic challenges, as the endoscopist is limited by the lack of triangulation, effectively functioning as a “one-armed operator.” This limitation adds considerable difficulty to the execution of endoscopic submucosal dissection (ESD) explaining why ESD has not become widespread. Although numerous traction devices have been developed to simplify, speed, and secure the procedure, none have yet achieved perfection. In this context, robotic endoscopy represents one of the most eagerly awaited advancements in therapeutic endoscopy.

In the paper by Professor Chiu and his team published in this edition of Endoscopy, we are introduced to the first clinical results from a phase II study of robotic ESD [5] – a project that has been in development for over a decade. The EndoMaster EASE system comprises a Surgeon Console Unit (SCU), a Patient Side Cart (PSC), an endoscope, and flexible robotic instruments. The system features two remotely controlled arms: the right arm for cutting and the left arm for traction, allowing optimal exposure of the dissection plane. Notably, the robotic endoscope retains a working channel for standard endoscopic accessories.

The study involved 45 lesions resected using the robotic system with the patients under general anesthesia. The technical success rate (defined as completion solely with robotic assistance) was 86.0%, with an R0 resection rate of 83.8% in patients who achieved technical success. The median dissection speed was 20.6 mm2/minute for lesions with a median size of 34.5 mm. The video accompanying the publication demonstrates the efficacy of the two-arm robotic system.

While these early clinical results (phase II study) are not superior to recent data on the pocket creation methods [6] or traction devices [7] [8], the video provides an impressive showcase of the technology’s potential. Similarly to advancements in surgical robotics, robotic ESD may not immediately surpass the expertise of the most skilled practitioners, who achieve R0 resection rates above 90% and dissection speeds exceeding 40 mm2/minute; however, robotic systems are likely to accelerate the learning curve for less experienced endoscopists and facilitate broader adoption of these complex procedures. More importantly, robotic endoscopy has the potential to enable the performance of novel procedures that were previously infeasible without triangulation, as well as the development of endoluminal suturing techniques that can close transmural defects in the digestive tract.

Several limitations must however be considered, especially in light of the financial strain on healthcare systems worldwide. The cost of robotic ESD will undoubtedly be higher than that of traction-assisted ESD, raising concerns about whether the benefits of the robotic system will outweigh its financial burden. Additionally, the shortage of anesthesiologists and nurses is a critical factor, as the procedure has not yet been evaluated in patients not under general anesthesia and currently requires the presence of two nurses to assist. The inability to perform real-time optical diagnosis with the robotic system could also lead to inappropriate indications, as the endoscopist is required to make diagnostic decisions concurrently with the resection. Moreover, more than 80% of the cases in this study were located in the rectum or sigmoid colon, so the ability of the device to reach lesions throughout the entire colon will be a key determinant of its future success. Finally, given the increasing urgency to reduce our carbon footprint, the environmental impact of the robotic system and its consumables must be rigorously assessed in comparison to existing procedures.

In conclusion, the advent of robotics in clinical endoscopy is an exciting development, and Professor Chiu and his team deserve commendation for their long-term commitment to this field. Robotics has the potential to revolutionize therapeutic endoscopy by simplifying existing procedures and enabling the development of new ones that were previously difficult to perform without triangulation. Ultimately, these technologies will extend organ-preserving treatments, to the benefit of patients. The future of endoscopy is already upon us and it is our responsibility to shape it, always with the goal of providing the most effective and accessible care to populations worldwide.

Article published online:
11 November 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany