Sam is joined by Mr Emilio Lozano to discuss a tool called LumenEye, which is used to perform what some refer to as “mini colonoscopies” in a range of scenarios. Emilio is a general surgeon with a special interest in anorectal neoplasia colorectal and general surgery in spinal injury patients and benign colorectal disease. LumenEye was created by MedTech company SurgEease. Emilio provides insights into the different types of endoscopies, including flexible sigmoidoscopy and colonoscopy, and explains which procedures are used for different patients and situations.
Transcript
Sam
Welcome to Can I Butt In, the Bowel Research UK podcast where we welcome bowel cancer and bowel disease, patients, researchers, healthcare professionals and carers to butt in and share their experiences. We’re picking a topic every episode and getting to the bottom of it. I’m your host, Sam Alexandra Rose. I’m the Patient and Public Involvement Manager at Bowel Research UK, and as a patient myself, I’m excited to bring more patient and researcher voices into the spotlight.
Hi, everybody. Today we’re talking about what you may like to call mini colonoscopies performed using a tool called LumenEye created by the med-tech company SurgEase. So we’ll be looking at the benefits of this procedure to the patient and the NHS and how it’s different to other examinations. So with me today is Emilio Lozano. Emilio is a general surgeon. He trained and qualified abroad in Caracas, Venezuela. He practised general and colorectal surgery in multiple healthcare settings. In Venezuela, Spain and England since 2006, Emilio has a special interest in anorectal neoplasia colorectal and general surgery in spinal injury patients and benign colorectal disease. He’s a fellow of the European Board of Surgery and runs the video proctoscopy clinic using LumenEye at Stoke Mandeville Hospital. So Emilio, welcome to the podcast.
Emilio
Thank you for having me, Sam.
Sam
We love to talk about new technology on the podcast. So yeah, it’s a pleasure to be talking about this today. And I thought we should start just by explaining to those who are lucky enough to not have had flexible sigmoidoscopy or a colonoscopy before, what the difference is between the two? Because, as I understand, LumenEye is an alternative to flexible sigmoidoscopy in some circumstances. But I don’t think everybody is going to know the difference between a flexi sig. It’s what we call it for short and the colonoscopy. So could we start there just by sort of explaining the difference between the flexi sig and the colonoscopy, please?
Emilio
So flexi sig and colonoscopies are endoscopic procedures involved using a fibre optic instrument. A long tube with a camera, video capabilities and. Also have some channels to insufflate air and to apply some suction. Essentially a colonoscopy is the test used to investigate the whole large bowel, so the instrument is progressed from the rectum to the right side of the column to the secum. Where the small bowel joins the large bowel essentially on the right side. So it’s a complete examination of the large bowel. It requires bowel preparation, it requires the patient to drink a strong laxative. That flushes the colon out and gets the ball prepared. Some patients find this a little bit unpleasant, but it’s very important. Yeah, is very important because that basically is what allows us the endoscopies to check, accurately check the lining on the mucosa of the of the bowel. Or lesions. Is used for many indications and importantly, for cancer detection. Flexible sigmoidoscopy uses the same instrument, the same fibre optic instrument, but it only progresses to the left side of the bowel. Halfway through the large bowel, this is essentially a limited colonoscopy procedure called flexi sig. It addresses issues arising on the known issues on the left side or when the symptoms are suggestive of a lesion on the left side, which isn’t the most common reason for problems, mostly on the sigmoid colon. It can be done also with the bowel preparation. Or in some specific circumstances, can be done with retrograde preparation with enemas, essentially, and some dye before. So it’s the difference between the two is the length of colon. Assessed in a colonoscopy, the whole large bowel is assessed and on a flexible sigmoidoscopy is mostly the left side, the sigmoid descending. Up to the left side or higher in the left side, with the splenic flexure, yes. So that’s essentially the main difference.
Sam
And it doesn’t take quite as long as it to do a flexi sig compared to a colonoscopy. I think a flexi sig is sort of around like a 10 minute, quite short. Because I guess if you’re seeing less of it, it takes not quite as long.
Emilio
Well, it’s less to less, less corners to negotiate and it’s less unpleasant. It’s not sedation. It’s not necessarily offered on a flexi. Yeah, whereas for a colonoscopy, usually a painkillers and sedatives are given to keep the patient comfortable. Procedure could be quite unpleasant, particularly when turning the corners of the bowel. About the runs from the right side to the left, all across the abdomen. So and. It’s sometimes unpleasant, and the inflation is absolute requirement to navigate the instrument inside.
Sam
So LumenEye then is an alternative to a flexi sig essentially?
Emilio
Well, I will. I will not say that it replaces, it takes place instead of a flexi sig. The LumenEye is essentially an enhanced version of. Well known procedure, outpatient procedure and colorectal surgery called a rigid sigmoidoscopy. And there are two ways of exploring in the outpatient department classical ways. One is the proctoscopy, which is a short tube. Just to have a look at the lower rectum and the anus. And the next step is a rigid sigmoidoscopy which reaches distances of variable distances, but mostly about 15 centimetres. The low sigmoid and the rectal sigmoid junction. The whole rectum and the operation on the on the lower, the upper anal canal. So LumenEye is an enhanced version of rigid sigmoidoscopy, so it’s an instrument that allows it has some features that allows better ergonomics and better biopsy capabilities than the traditional rigid sigmoidoscopy. Is an outpatient department procedure and it doesn’t. It requires just a single and for bowel preparation, and sometimes it can be done without. If the rectum and the secum are empty. But essentially that is, it doesn’t replace a flexible sigmoidoscopy.
Sam
OK.
Emilio
It cannot look beyond that point. Some lesions, but most lesions are located, more sinister lesions are located in the recto sigmoid junction or the upper rectum. But there might be lesions further upstream that cannot be reached with a rigid sig or the LumenEye. So it needs to be carefully weighted when this is needed. The symptoms can guide which procedure to do. I think if it’s available in the outpatient department, that gives an extra diagnostic capacity, but most patients will require a flexi anyway. Or a colonoscopy.
Sam
- And we’ll, yeah, we’ll talk a little bit later about who might benefit from having a LumenEye and flexi sig and things like that. So in terms of the clinician then so who can use the LumenEye? Where is it currently being used?
Emilio
Anyone with basic knowledge of or the skill to do a rigid sigmoidoscopy can use the LumenEye and will find it very convenient, very ergonomic. We currently basically use LumenEye in many, many settings. Essentially, we started an outpatient clinic using the LumenEye to check response to chemoradiotherapy and rectal cancer, for example. Where this patient had a colonoscopy, initially a diagnosis of a rectal cancer. And they had neoadjuvant chemoradiotherapy, which is the initial treatment for most advanced rectal cancers to make the cancer shrink before surgery. And these patients are followed up after treatment. And there’s no need in these patients to use a very long instrument to check on a lesion that’s known to be in about 10 or less centimetres from the anal verge. So in those cases, the endoscopy department pressures on having a look at this, we can check with LumenEye, document the findings. And check for the clinical response to this therapy to chemoradiotherapy. So that’s very convenient. So that clinic is running since 2022. And is about providing surveillance, close surveillance after radiation for about rectal cancer.
Sam
That’s really good. Yeah.
Emilio
That’s the main use for LumenEye. Also, as part of the colorectal department. Sometimes there is need for what’s called tissue diagnosis. Let’s say rectal cancer has been biopsied using a flexible sigmoidoscopy, for example. And the biopsy is not optimal because it’s too superficial. And the pathologist could not see if there is any cancer or not in the area. Then these patients can be referred to the LumenEye clinic. For further deep biopsies that can be done in the outpatient department and we have found that with LumenEye you can get deeper biopsies than you can with a flexible instrument. So that’s another use. So for surveillance of colorectal or rectal cancer post chemoradiotherapy for further biopsies when the diagnosis is not clear or there’s no tissue diagnosis in suspected cancers of the rectum. There is also many uses. We normally use LumenEye in theatres. Where we can check the position of the tumour. During a robotic or laparoscopic procedure. Rectal resection. Then the bedside assistant can check the position of the tumour using LumenEye, which is very ergonomic. Even the patient is all you know, covered in sterile dressings and even with the rubber you have the rubber on top of the patient. So it’s difficult to access that area.
Sam
Yeah.
Emilio
It gives that advantage and it gives the advantage of all the team members being able to see where the tumour is. And to see that we are below the tumour to, you know, take it all out. So that’s one of the, one of the… and then measuring the distance of the joint, if we were to join the bowel with the rectum, it can be measured with LumenEye in a very convenient fashion. So that’s another. Another use and also about checks for many other indications. Particularly for spinal patients and check for proctitis, polyps, suspicious lesions of the of the anus and rectum with LumenEye. So it’s a, it’s a very convenient… and the possibility of documenting to have a graphical picture or a video of the of the findings is very, very useful and very convenient. So it’s a great advantage to have this device.
Sam
Yeah, that sounds like loads of different applications. That’s really cool. Yeah. So I didn’t know about sort of the deeper biopsies and yeah, checking during robotic surgery. That’s really interesting. And I can see the benefit for the patient as well because like you say, if you know where the polyp is and you can access it with a less invasive procedure, why put the patient through kind of a larger colonoscopy if it’s not sort of necessary at the time, you can get it an easier way. Yeah, definitely.
Emilio
That these patients are the ones that were telling you I was telling you about surveillance of rectal cancer. You need to have. Going to the protocol is to do a sight check, a rectal check every three months for two years, so that’s really high frequency and the target was not fulfilled because if there was no capacity in endoscopy to do this frequency. And the patients needed to attend and it was very, very difficult for them to follow up, to give enough appointments for these patients. Working at high volume centres so there are many patients having this treatment. And in this clinic, by using the LumenEye, we can follow them up better than before. So we have noticed that patients are followed on time. And if there is any doubt about the clinical response, then we can biopsy then and. There. It all stays within the MDT environment. And we can all discuss about the best way to manage these patients if they don’t.
Sam
So with a flexible sigmoidoscopy and colonoscopy, you can not just see everything, but you can also like biopsy and take a sample and that can go to histology to be checked. I guess LumenEye is the same that it can take those biopsies as well.
Emilio
Yeah. So it has a working channel and deep, deep and large biopsies can be taken using it. The fact that it directly faces and is directly controls a rigid instrument allows for more deep, deeper sampling of an area and the rectum. It has some disadvantages. It cannot bend. The rigid instrument cannot bend sideways. And sometimes lesions that are behind falls in the rectum cannot be checked, but in those cases we basically have good communication with the endoscopy department and if there’s any doubt, then we get a flexi. If it’s something that’s beyond the reach of the of equipment and flexi helps in those situations.
Sam
Right, because sometimes things are. We spoke just breaking the podcast fourth wall for a second here when we had our conversation a little while ago before recording, we spoke about how sometimes there’s a polyps. It’s sort of quite low down near the rectum that some instruments can’t actually sort of bend that way to pick them up. So you have to have quite a specific instrument for that.
Emilio
Yeah, it can be, it can be done also with flexible. I think it’s a bit more or more difficult. I think the access to the lower rectum and the upper anal canal is easier when looking straight, not coming from top. So there’s a way. There’s a way of flipping tip of the endoscope. In the form of a J so-called the J manoeuvre, flipping and looking downwards.
Sam
OK.
Emilio
Into the rectum. And sometimes some polyps can be removed that way, but it’s not. It’s not easy. And sometimes it’s challenging, sometimes the polyp encroaches into the anal canal, which is not visible. So those cases, I think a video proctoscopy is useful, but the convenience for the patient, convenience for, for the, for the surgeon. So in secondary care is very useful.
Sam
Absolutely. It’s really interesting just finding out how all this stuff works. Being the person who’s normally on the receiving end, if you like, of this sort of procedure, it’s yeah, it’s good to get an insight on it. So I’m just interested. I’m taking this off track a little bit here. I’m just interested in the deeper biopsies and. So when might you need to take a deeper biopsy? What kind of situation would that be?
Emilio
When the, again, when the patient gets an initial… Well, these biopsies, the endoscopic biopsies are usually no larger than two millimetres, so they’re quite small bites and these lesions could be 5-10 centimetres long and not all, they, most of them arise from a polyp. Which is like a wart type growth on the lining. The cancer is not symmetrical. It may happen in a part of the polyp. The invasion could be in one side, not necessarily symmetrical. So if a biopsy is taken from an area which is still a polyp. It will show just some changes and it will not be conclusive. And the biopsy is needed for different analysis and to check for the suitability for certain types of treatment. So it’s important for the oncologist to have tissue diagnosis. So. It is their ultimate confirmation that there is a cancer. That, along with all their tests on it, it’s not just a visualisation, it’s also an MRI scans. CT scans to check for the spread of the of the cancer in the rectum, so deep biopsies are needed for to obtain enough tissue for the pathologists to give us an answer, a definitive diagnosis, a tissue diagnosis, which is what says it is a cancer.
Sam
Right. So I guess, do you sort of always want a deep biopsy?
Emilio
Yeah, but sometimes the biopsy endoscopic biopsy surface for is enough for a tissue diagnosis. Sometimes it isn’t. Particularly when it’s a low, low lesion and it cannot be sampled properly with a long flexible instrument. In those cases the biopsy is can be achieved with LumenEye can be achieved in in the outpatient department.
Sam
- Can we just touch sort of briefly, I know it’s not quite your area because you’re hospital based and we might do an episode later on as well with another guest about the use of LumenEye in CDC’s or community diagnostic centres. But can we just touch on that because I know that that’s somewhere else where that’s being used and what is a community diagnostic centre and can we talk a bit about sort of like the benefits of doing it there as well?
Emilio
Yeah. So there are different. There is an established lower GI cancer pathway where patients get referred to secondary care for investigations to rule out colorectal cancer. Some of these referrals are based on, most of the referrals are based on screening tests. Stool tests, which basically picks up small amounts of blood in the stool, which is often invisible to the patient, to be nanograms of haemoglobin and mixed with this tool that gets picked up by this test and then the patients who has a certain amount of the of blood can be referred to secondary care. For additional investigations, most often the investigation is a colonoscopy if the patient can tolerate it. And essentially. It is a screening tool into the pathway to know who will benefit from an invasive investigation. All the referrals and all parts of the referral patients who are having rectal bleeding. Rectal bleeding that could be clinically bright red could be painless, could be painful. And sometimes is a clinical suspicion of the of the GP. When doing a rectal examination, a digital examination with a finger, checking for masses or lesions in the anus or the rectum. So most of the time these are very basic physical examination findings. And sometimes these referrals are in a way not appropriate, because if there was an additional way of looking at the area or taking pictures then I think the diagnostic accuracy of the GP in the community will be enhanced for this for this pathway. So I think it will it can add an additional way of checking that area. For that particular area of the pathway in the community, I think it will definitely not replace a colonoscopy as a gold standard. For investigation and in some cases, some rectal cancer can be picked up if they are low enough, can be picked up by the LumenEye. If it can be done in the community, those will be picked up. But there might be some rectal cancers that are missed because they’re higher up. Cannot be seen with the with the LumenEye, need to be with the flexi.
Sam
Yeah.
Emilio
So it’s in a particular set of patients with negative or borderline blood in the stool. And particular symptoms which are suggestive of a lesion that’s low in the rectum. Those are the ones that would benefit from the from the rectal examination with the proctosigmoidocopy, a rigid protosigmoidoscopy.
Sam
- So patient has potential bleeding or sort of some of the symptoms that you just talked about and they go to their GP and instead of referring them to the hospital immediately for a colonoscopy, quite an invasive procedure, instead to the GP can send them to the CDC, the Community Diagnostic Centre. Instead they can have LumenEye, it’s less invasive. It’s one less person who’s having to go to the hospital and be added to that waiting list in the endoscopy unit. Yeah, and it could be potentially closer to people’s homes and a little bit more convenient that way as well.
Emilio
Yeah. So, so rectal cancer can be ruled out or lower sigmoid cancer can be ruled out. That’s an investigation that there’s no tumour in the rectum in the sigmoid and the lower sigmoid. And their large haemorrhoids, or any other benign pathology. So that patient can be diverted to the colorectal outpatient clinic and not necessarily to a suspected cancer clinic. So this patient may still need a flexi or a colonoscopy, but it doesn’t need to go straight into the pathway to be diverted to the right on the right pathway, the right route.
Sam
Yeah. Yeah.
Emilio
So that’s essentially I think the advantage given more, given a diagnostic tool. That can be used at the at this community centre, so trained personnel can do these tests because the GPs themselves can do these tests. They can learn and train. They can share the findings, which are videos or pictures. And then fine tune their referral and have more capacity to diagnose. And if they find a big lump or a big cancer. Then that abbreviates the process of referral.
Sam
Yeah. And yeah, as you say, the secondary care or the hospital then has more information from LumenEye than they would have if the patient had just been referred straight from the GP as well. Yeah. Lots of lots of benefits. And yeah, we’ve mentioned no bowel prep needed with the LumenEye as well, which I’ve highlighted in my notes because that as a patient, it’s always a bonus just having to do an enema instead.
Emilio
That there’s no laxative involved, but in this clinic, what I was telling you about the surveillance clinic for rectal cancer. Non oxidative, we routinely give an enema because we need to have a very good look.
Sam
Yeah.
Emilio
And the lining at the side where the tumour is or was burned by radiation, essentially. And then that requires that direction to be very clean. So we routinely give an enema. Which is a way of it’s a rectal preparation. It’s a. The patient gets an enema, opens bowels and the rectum is very clean. So with the LumenEye you can have a look a very close look at the lighting because all depends in all of the scope, any endoscopic procedure. The success of the test is reliant on the bowel preparation. They cannot see anything then the diagnostic capabilities decrease. Essentially, you cannot see anything. You cannot biopsy. You cannot check there. Even with colonoscopy, there are blind spots. There are areas of the bowel is it’s an. It’s a muscular tube and it’s irregular. So there are folds. There are areas that can not be easy to check, there are many bends, so even with colonoscopy. Even with good bowel preparation, there are some issues that that could be missed. It’s tricky and it requires a significant amount of training. On a rigid sigmoidoscopy or LumenEye, the training shouldn’t be that long. It’s a more straight area and there are less bands and the instrument is a bit simpler. Easier to manage. So I think in with regards to training in these centres, healthcare assistance advanced nurse practitioners. GPs. Any person who has basic knowledge of anal rectal examination could do, could do a rigid sigmoidoscopy. Is a combination of radioisotopes and proctoscopy, so it can be done in the community.
Sam
That was going to be my next question actually was the difference for LumenEye for the person who’s actually doing it because yeah, again, sort of being a patient, you don’t really think about how easy is it to drive a colonoscope, how easy it is sort of to navigate sort of the bends and things like that. I don’t know if I might quite like to have a go. Strange things to say.
Emilio
Well, it requires a significant amount of training of the platforms.
Sam
Absolutely, yeah. But I mean is it, you sort of touched on how it’s easier doing a flexi sig or LumenEye with than a colonoscopy because it’s sort of a smaller area. I mean is there a difference in the tools, it’s one more comfortable than the other and that kind of thing or easier to use for a long period of time because I guess you’re if you’re in clinic, you’re doing this over and over and over again.
Emilio
Yeah, so you got significantly if you work in a in a colorectal department as a basic part of the examination of any patient with this type of symptoms. With regards to the endoscopic procedures that is different, it’s more complex, it requires an endoscopy unit anywhere, significant amount of equipment. And assistance. And the procedure basically is technically challenging. It could be even challenging for very expert endoscopists in some cases, so that’s a different, you need to be someone very well trained. Now for assessment in the in the community at the GP surgeries or the CDC the rigid sigmoidoscopy, the proctoscopy it is a great advantage. I don’t think training will take a long time.
Sam
Yeah. And LumenEye actually you said can be done in conjunction with other tests at CDCs as well, can’t it? You mentioned MRI’s and blood tests and that sort of thing. And I believe that some of these centres now you can go and kind of get all of that done at the same time in the same appointments so just one trip instead of, you know, maybe three or whatever for the patient.
Emilio
Yeah. So it’s, it’s a process called staging. So the process is about getting some tissue diagnosis, getting some samples from them, getting a sense of the depth of invasion of the rectal wall. That’s done with an MRI scan of the rectum. Magnetic resonance imaging scan of the rectum. And there’s also need to do a CT scan to check for distant spread. Usually these cancers can spread most to the lymph nodes, can spread to the liver. The lungs. Metastasis. So basically as a cardinal feature of a cancer it can metastasize. It can travel in the lymph nodes, in the lymph glands and then can spread. Via lymph or via the bloodstream. And can seed other distant organs, distant metastasis. So that is very important to do staging if it can be done in one single place. Very quickly, that’s very, very useful.
Sam
Yeah, absolutely. And so in terms of patients who could benefit from this technology and we’ve touched on this already. But again in sort of our previous chats, we’ve said that it’s it might not be appropriate for people with high risk symptoms like weight loss and things like that, can you tell us a bit more about that?
Emilio
Yeah. So there’s there are significant cardinal symptoms of cancer. The patient has had significant changes in the bowel habit, for example. They started, they had. They were perfectly regular and so on, they started having diarrhoea with mucus and then they started noticing blood in the stool themselves intermittently, some abdominal discomfort. That’s unusual, and they lose, unexpectedly start losing weight. And they decide to do the FIT, and then in the FIT test the screening test of the stool. And the FIT test comes back positive or the patient develops a new anaemia, for example. Then that that patient will be better served with the colonoscopy. Whole, the whole bowl. Because there might be a tumour and the tumour could be anywhere. If it can be readily assessed in the outpatient department with a rigid sigi or LumenEye. Right then, that segment is basically clear. So you can say well, there’s no replica. If they found a big lump. This patient has a rectal cancer. They may still have cancer, and they may still need a colonoscopy, but at least the diagnosis of the rectal cancer is done there and there, so that’s something. That is, it’s basically an extra diagnostic tool. So most patients with cardinal symptoms and with strongly positive or very positive screening tests those patients most of the time need a colonoscopy. And LumenEye or a protocol won’t be. Enough to check. It could exclude rectal cancer, anal cancer, but it cannot look anywhere. Anywhere in the rest of the bowel.
Sam
Sure. And it’s the same for people with genetic condition. Isn’t it? Like Lynch syndrome, for example, if people have to go to regular surveillance to check for colon cancer you need to check the entire colon. So again you would want a full colonoscopy for if you had Lynch syndrome or something like that.
Emilio
Exactly and there are also enhanced versions of colonoscopy with dyes to check and pick up small lesions. So I think the colonoscopy in those cases is an absolute requirement. And usually done in referral centres and it enhances the diagnostic capabilities. So there are different, the new colonoscopies had many diagnostic features. Such as dye spray, they can use basically light changes in the light, narrowband imaging to check for superficial lesions that may not be apparent to the naked eye, and they have very, very high resolution. So they’re very, very, very accurate. So I think, uh, in those cases, in cases where you are doing surveillance for Lynch for polyposis, I think would be a good idea to do a colonoscopy.
Sam
So we’ve kind of talked about this already I think, the difference between a flexi sig and the rigid versions. I mean, are there any other differences between the two in terms of like collecting biopsies or do you know the difference for the patients in terms of like going through a flexi sig or LumenEye in terms of…?
Emilio
It’s very similar. It’s very similar. It about the reach. So the flexi will reach higher up that’s essentially the main.
Sam
Yes.
Emilio
The rigid, the LumenEye will reach no longer than 15 centimetres. It will be the lower segment. At the most. It cannot bend. It cannot look sideways, sometimes behind folds, so that’s a limitation. But the procedure itself is very similar. The position of the patient is very similar. The preparation could be done with the retrograde preparation, with enemas for both. And it doesn’t require sedations with similar but. Is about the capacity of endoscopy unit.
Sam
Yeah.
Emilio
To offer high volumes of this. Is something that’s something that’s available in the outpatient department or in a CDC. That’s very, very convenient.
Sam
Yeah, I think it’s, it’s great and yeah, especially sort of all the benefits of going to the CDC and secondary care then having that information when you if you do need to go for colonoscopy and yeah sort of reducing the wait times and all that sort of thing, yeah. It sounds very good and all of the purposes that, that you mentioned before as well for robotic surgery and things like that. Yeah, quite a flexible tool then.
Emilio
Intraoperative checks of the rectum of the joints, anastomosis, very convenient. Also for examination in theatre, when you’re doing a procedure and used to check inside reach up to 25 centimetres. And even under anaesthesia, it can reach even further.
Sam
OK.
Emilio
So that’s also something that can be used in theatre.
Sam
How come it can reach further when you’re under anaesthesia?
Emilio
Yeah, we can. You can reach further because there is less discomfort when you reach.
Sam
Sure.
Emilio
You can press harder without causing discomfort.
Sam
Yep. Excellent. Final question for you then is what are your hopes for the future in terms of how people are referred and tested for bowel conditions? What sort of one takeaway would you like to leave us with?
Emilio
Yeah. So I think well, the video proctoscopy would be a plus for the outpatient. Basically assessment of patients with ordering symptoms, particularly rectal bleeding. It can be done as part of the physical examination before referral. Most of these patients will need a flexi or a colonoscopy. The patients that will end up having a big malignancy, the rectum can be diagnosed straight away. If it’s not clear to the finger or the under digital examination, it can be enhanced by having a look. I think that is something that would be very convenient to have and have that diagnostic accuracy from the start. And then in the community. Again, it will not replace the endoscopic assessment, but is, you know is an extension of your clinical capabilities for clinical exploration. In primary and secondary care, everywhere. With regards to the pathway, I think the pathway need to continue, I think is a very important in order to pick up. We know the survival depends on the stage and then need to pick up cancers. Colorectal cancer early. The main the main take. So in the path we should continue. And the most experienced people in the community can make the pathway more efficient. So the patients that has haemorrhoids or fissures or they don’t have a mass, those patients can be taken off the pathway. Basically get additional endoscopy capacity and patients that don’t really doesn’t really need. It. So that’s something that can be also adjusted by having this available.
Sam
Brilliant. Thank you so much for coming to talk to me about this, Emilio. It’s always really great to hear about sort of new technologies and how they can benefit patients and all of the research that’s being done in that area. So thanks very much for coming to chat to me.
Emilio
Thank you for inviting me, Sam, and thank you for having me.
Sam
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