Frontiers of Robotic Gastroscopy: A Comprehensive Review of Robotic Gastroscopes and Technologies

A review of potential mechanisms and treatments of gastric intestinal metaplasia

Gastric intestinal metaplasia (GIM) is a pathological process where gastric mucosal epithelial cells are replaced by intestinal-type cells, serving as a precursor lesion for gastric cancer. This transformation involves various genetic and environmental factors, affecting key genes and signaling pathways. Recent research has revealed complex mechanisms, including changes in gene expression, abnormal signaling pathway activation, and altered cell behavior. This review summarizes the latest research on GIM, discussing its pathogenesis, current treatment strategies, and potential efficacy of emerging approaches like gene editing, microbiome interventions, and integrative medicine. By exploring these strategies, we aim to provide more effective treatments for GIM and reduce gastric cancer incidence. The review also highlights the importance of interdisciplinary studies in understanding GIM mechanisms and improving treatment strategies.

Robotics in interventional endoscopy-evolution and the way forward

The integration of robotics into gastrointestinal (GI) endoscopy represents a transformative advancement and bears the potential to bridge the gap between traditional limitations by offering unprecedented precision and control in diagnostic and therapeutic procedures. This review explores the historical progression, current applications and future potential of robotic platforms in GI endoscopy. Originally designed for surgical applications, robotic systems have expanded their reach into endoscopy, potentially enhancing procedural accuracy and reducing ergonomic strain on practitioners. Natural Orifice Transluminal Endoscopic Surgery (NOTES) emerged as a promising technique, leveraging natural orifices to perform minimally invasive surgeries. Despite its initial potential, several factors, including limitations of the available instrumentations and lack of reliable closure techniques, hindered its widespread adoption and progress. Conventional endoscopic tools often fall short in terms of triangulation, traction and degrees of freedom, necessitating the adoption of robotic interventions. Over recent decades, robotic endoscopy has significantly evolved, focusing on both diagnostic and complex therapeutic procedures such as endoscopic sub-mucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). Various robotic platforms demonstrate enhanced safety and efficiency in GI procedures. As the field progresses, the emphasis on clinical validation, advanced training and the exploration of new applications remains crucial. Continuous innovation in robotic technology and endoscopic techniques promises to overcome existing limitations, further revolutionizing the management of GI diseases and improving patient outcomes.

Endoluminal Procedures and Devices for Esophageal Tract Investigation: A Critical Review

Diseases of the esophageal tract represent a heterogeneous class of pathological conditions for which diagnostic paradigms continue to emerge. In the last few decades, innovative diagnostic devices have been developed, and several attempts have been made to advance and standardize diagnostic algorithms to be compliant with medical procedures. To the best of our knowledge, a comprehensive review of the procedures and available technologies to investigate the esophageal tract was missing in the literature. Therefore, the proposed review aims to provide a comprehensive analysis of available endoluminal technologies and procedures to investigate esophagus health conditions. The proposed systematic review was performed using PubMed, Scopus, and Web of Science databases. Studies have been divided into categories based on the type of evaluation and measurement that the investigated technology provides. In detail, three main categories have been identified, i.e., endoluminal technologies for the (i) morphological, (ii) bio-mechanical, and (iii) electro-chemical evaluation of the esophagus.

A variable stiffness manipulator with multifunctional channels for endoscopic submucosal dissection

PURPOSE

Endoscopic submucosal dissection (ESD) has become the main treatment for early esophageal and gastric cancers, but the insufficient stiffness and large diameter of current devices increase the difficulty in operation. To address the above problems, this study proposes a variable stiffness manipulator with multifunctional channels for ESD.

METHODS

The proposed manipulator has a diameter of just 10 mm and highly integrates a CCD camera, two optical fibers, two channels for instruments, and one channel for water and gas. Additionally, a compact wire-driven variable stiffness mechanism is also integrated. The drive system of the manipulator is designed, and the kinematics and workspace are analyzed. The variable stiffness and practical application performance of the robotic system are tested.

RESULTS

The motion tests verify that the manipulator has sufficient workspace and motion accuracy. The variable stiffness tests show that the manipulator achieves 3.55 times of stiffness variation instantly. Further insertion tests and operation test demonstrates that the robotic system is safe and can satisfy the needs in motion, stiffness, channels, image, illumination, and injection.

CONCLUSION

The manipulator proposed in this study highly integrates six functional channels and a variable stiffness mechanism in a 10 mm diameter. After kinematic analysis and testing, the performance and application prospect of the manipulator are verified. The proposed manipulator can promote the stability and accuracy of ESD operation.

Burnout in healthcare - the Emperor's New Clothes

Burnout is common among physicians; it severely alters their health and has a negative impact on functioning of healthcare systems. Hypertension, increased cortisol levels, maladaptive behaviors with negative social consequences, and suboptimal quality of care have been associated with healthcare providers' burnout. As the number of patients with cancers, psychiatric and neurodegenerative disorders will rise, we need new solutions to maintain physicians' health and, therefore, quality of care. Coping strategies before the COVID-19 pandemic seem ineffective in scaling all the deficits of the global healthcare systems. Examples of new initiatives include new collaborative projects, such as COH-FIT (The Collaborative Outcomes study on Health and Functioning during Infection Times - https://www.coh-fit.com), which aims to collect global data and understand the impact of the COVID-19 pandemic on physical and mental health in order to identify various coping strategies for patients and healthcare workers during infection times, or MEMO (Minimizing Error, Maximizing Outcome), funded by the Agency of Healthcare Research and Quality (AHRQ). Others: i) Rome Foundation GastroPsych undertake efforts dedicated to the science and practice of psychogastroenterology, a burgeoning field with roots in behavioral intervention, cognitive science and experimental psychology focused on fostering the professional growth and collaboration of those engaged in medical practices, or ii) World Gastroenterology Organisation (WGO), Train The Trainers (TTT) program including a new topic of the impact of burnout on career longevity in order to foster strategies for staying healthy and increasing career satisfaction. There is a need for continuous development of digital technologies (e.g. training simulators, telemedicine, robots and artificial intelligence). Their implementation into medical practice is inevitable. Now more than ever, there is a need for a new spirit in healthcare. Together with others in the field, we believe this article is a desperate call for maximizing the use of novel technologies supported by collaborative interactions among healthcare providers and medical professionals of diverse medical fields.

Flexible robotic endoscopy for treating gastrointestinal neoplasms

Therapeutic flexible endoscopic robotic systems have been developed primarily as a platform for endoscopic submucosal dissection (ESD) in the treatment of early-stage gastrointestinal cancer. Since ESD can only be performed by highly skilled endoscopists, the goal is to lower the technical hurdles to ESD by introducing a robot. In some cases, such robots have already been used clinically, but they are still in the research and development stage. This paper outlined the current status of development, including a system by the author’s group, and discussed future challenges.

Actuation and design innovations in earthworm-inspired soft robots: A review

Currently, soft robotics technologies are creating the means of robotic abilities and are required for the development of biomimetic robotics. In recent years, earthworm-inspired soft robot has garnered increasing attention as a major branch of bionic robots. The major studies on earthworm-inspired soft robots focuses on the deformation of the earthworm body segment. Consequently, various actuation methods have been proposed to conduct the expansion and contraction of the robot's segments for locomotion simulation. This review article aims to act as a reference guide for researchers interested in the field of earthworm-inspired soft robot, and to present the current state of research, summarize current design innovations, compare the advantages and disadvantages of different actuation methods with the purpose of inspiring future innovative orientations for researchers. Herein, earthworm-inspired soft robots are classified into single- and multi-segment types, and the characteristics of various actuation methods are introduced and compared according to the number of matching segments. Moreover, various promising application instances of the different actuation methods are detailed along with their main features. Finally, motion performances of the robots are compared by two normalized metrics-speed compared by body length and speed compared by body diameter, and future developments in this research direction are presented.

Magnetic controlled capsule endoscope (MCCE)'s diagnostic performance for H. pylori infection status based on the Kyoto classification of gastritis

BACKGROUND

Previous studies have shown that the Kyoto classification of gastritis can accurately predict H. pylori infection status on conventional gastroscopy. The aim of this study was to test whether the Kyoto classification of gastritis applies well to magnetic controlled capsule endoscopy (MCCE).

METHODS

We consecutively recruited 227 participants who underwent both MCCE and urea breath tests (UBTs). Two physicians who were blinded to the UBT results independently made the diagnosis of H. pylori infection status according to 10 findings listed in the Kyoto classification of gastritis after reviewing MCCE images. We also developed 2 predictive models to assess H. pylori infection status by combining these 10 findings.

RESULTS

The MCCE's overall diagnostic accuracy for H. pylori infection status was 80.2%. The sensitivity, specificity and diagnostic odds ratio (DOR) for current infection were 89.4%, 90.1% and 77.1, respectively. Major specific findings were mucosal swelling and spotty redness for current infection, regular arrangement of collecting venules (RAC), streak redness, fundic gland polyp (FGP) for noninfection, and map-like redness for past-infection. In the two prediction models, the area under the curve (AUC) values for predicting noninfection and current infection were 84.7 and 84.9, respectively.

CONCLUSIONS

The Kyoto classification of gastritis applied well to MCCE. H. pylori infection status could be accurately assessed on MCCE according to the Kyoto classification of gastritis.

Endoscopic Features of Gastric Epithelial Neoplasm of Fundic Gland Mucosa Lineage

The endoscopic features of gastric epithelial neoplasms of fundic gland mucosa lineage (GEN-FGML) have not been well investigated. We aimed to clarify the endoscopic features of GEN-FGML and differences between gastric adenocarcinoma of the fundic gland type (GA-FG) and fundic gland mucosa type (GA-FGM). A total of 62 GEN-FGML lesions, including 52 GA-FG and 10 GA-FGM, were retrospectively analyzed using endoscopic and clinicopathological findings to provide information of diagnostic value using white light imaging (WLI) and magnifying endoscopy with narrow-band imaging (M-NBI). GA-FG frequently presented with a whitish, submucosal tumor (SMT) shape with dilated vessels with branching architecture and background mucosa without atrophic change in WLI, an indistinct demarcation line (DL), dilatation of the crypt opening and intervening part (IP), and microvessels without distinct irregularity in M-NBI. GA-FGM frequently presented as a reddish, elevated lesion in WLI, with a distinct DL, dilatation of the IP, and an irregular microvascular pattern in M-NBI. As for an M-NBI diagnosis, five GA-FGM lesions met the diagnostic criteria for cancer, whereas none of the GA-FG lesions met the same criteria. We highlight the endoscopic features of GEN-FGML, and the differentiation between GA-FG and GA-FGM might be possible by combination of lesion color and morphology in WLI and M-NBI diagnoses.

Advances in the application of robotic surgical systems in gastric cancer: A narrative review

Gastric cancer is one of the common malignant tumors in the gastrointestinal tract, and surgery is currently an important treatment for progressive gastric cancer. With the development of technology, the simultaneous maturation of artificial intelligence (AI), fifth-generation (5G) telecommunication networks and the internet of things (IOT) has brought significant efficacy and new opportunities for the surgical treatment of gastric malignancies. The combination of 5G network and remote surgical robotic system is the future trend of radical gastric cancer surgery, and the "unmanned" treatment mode of fully automated robotic gastric cancer radical surgery will be realized soon.

Robotics in therapeutic endoscopy (with video)

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

A Novel Biopsy Capsule Robot Based on High-Speed Cutting Tissue

The capsule robot (CR) is a promising endoscopic method in gastrointestinal diagnosis because of its low discomfort to users. Most CRs are used to acquire image information only and lack the ability to collect samples. Although some biopsy capsule robots (BCRs) have been developed, it remains challenging to acquire the intestinal tissue while avoiding tearing and adhesion due to the flexibility of colonic tissue. In this study, we develop a BCR with a novel sampling strategy in which soft tissue is scratched with sharp blades rotating at high speed to avoid tissue tearing. In the BCR design, a spiral spring with prestored energy is used to release high energy within a short period of time, which is difficult for a motor or magnet to perform within a small capacity installation space. The energy of the tightened spiral spring is transmitted to drive sharp blades to rotate quickly via a designed gear mechanism. To guarantee reliable sampling, a Bowden cable is used to transmit the user's manipulation to trigger the rotation of the blades, and the triggering force transmitted by the cable can be monitored in real time by a force sensor installed at the manipulating end. A prototype of the proposed BCR is designed and fabricated, and its performance is tested through in vitro experiments. The results show that the proposed BCR is effective and the size of its acquired samples satisfies clinical requirements.

Gastric Cancer Screening Methods: A Comparative Study of the Chinese New Gastric Cancer Screening Score and Kyoto Classification of Gastritis

Objective

To evaluate the Chinese new gastric cancer screening score (i.e., Li's score) and Kyoto Classification of Gastritis for screening gastric cancer.

Methods

A total of 702 patients were scored using the two scoring methods. Gastric atrophy, intestinal metaplasia, and gastric cancer (including early gastric cancer) were compared between the two scoring methods. The area under the ROC curve, sensitivity, and specificity of the two scoring methods were evaluated.

Results

Both of the two scoring methods found that gastric atrophy, intestinal metaplasia, and gastric cancer (including early gastric cancer) were all significantly higher in the medium-risk and high-risk group patients than those in the low-risk group patients. According to the Kyoto Classification of Gastritis, patients in the high-risk group had more gastric atrophy, intestinal metaplasia, and gastric cancer than those in the medium-risk group patients. Gastric atrophy, intestinal metaplasia, and gastric cancer in the low-risk and medium-risk group patients evaluated by the Li score were all significantly higher than those in patients with corresponding risk level evaluated by Kyoto Classification of Gastritis, respectively. The area under the ROC curve of the Li score was 0.702, and the sensitivity and specificity were 57.6% and 85.3%, respectively. The area under the ROC curve of the Kyoto Classification of Gastritis was 0.826, and the sensitivity and specificity were 75.4% and 83.6%, respectively.

Conclusion

Both Li's score and Kyoto Classification of Gastritis showed good screening value for gastric cancer, but Kyoto Classification of Gastritis was more sensitive than the Li score.

Interventional cardiac magnetic resonance imaging: current applications, technology readiness level, and future perspectives

BACKGROUND

Cardiac magnetic resonance (CMR) provides excellent temporal and spatial resolution, tissue characterization, and flow measurements. This enables major advantages when guiding cardiac invasive procedures compared with X-ray fluoroscopy or ultrasound guidance. However, clinical implementation is limited due to limited availability of technological advancements in magnetic resonance imaging (MRI) compatible equipment. A systematic review of the available literature on past and present applications of interventional MR and its technology readiness level (TRL) was performed, also suggesting future applications.

METHODS

A structured literature search was performed using PubMed. Search terms were focused on interventional CMR, cardiac catheterization, and other cardiac invasive procedures. All search results were screened for relevance by language, title, and abstract. TRL was adjusted for use in this article, level 1 being in a hypothetical stage and level 9 being widespread clinical translation. The papers were categorized by the type of procedure and the TRL was estimated.

RESULTS

Of 466 papers, 117 papers met the inclusion criteria. TRL was most frequently estimated at level 5 meaning only applicable to in vivo animal studies. Diagnostic right heart catheterization and cavotricuspid isthmus ablation had the highest TRL of 8, meaning proven feasibility and efficacy in a series of humans.

CONCLUSION

This article shows that interventional CMR has a potential widespread application although clinical translation is at a modest level with TRL usually at 5. Future development should be directed toward availability of MR-compatible equipment and further improvement of the CMR techniques. This could lead to increased TRL of interventional CMR providing better treatment.

Unsedated Transnasal Endoscopy: A Safe, Well-Tolerated and Accurate Alternative to Standard Diagnostic Peroral Endoscopy

Diagnostic unsedated transnasal endoscopy (uTNE) has been proven to be a safe and well-tolerated procedure. Although its utilization in the United Kingdom (UK) is increasing, it is currently available in only a few centers. Through consideration of recent studies, we aimed to perform an updated review of the technological advances in uTNE, consider their impact on diagnostic accuracy, and to determine the role of uTNE in the COVID-19 era. Current literature has shown that the diagnostic accuracy of uTNE for identification of esophageal pathology is equivalent to conventional esophagogastroduodenoscopy (cEGD). Concerns regarding suction and biopsy size have been addressed by the introduction of TNE scopes with working channels of 2.4 mm. Advances in imaging have improved detection of early gastric cancers. The procedure is associated with less cardiac stress and reduced aerosol production; when combined with no need for sedation and improved rates of patient turnover, uTNE is an efficient and safe alternative to cEGD in the COVID-19 era. We conclude that advances in technology have improved the diagnostic accuracy of uTNE to the point where it could be considered the first line diagnostic endoscopic investigation in the majority of patients. It could also play a central role in the recovery of diagnostic endoscopic services during the COVID-19 pandemic.

Small bowel to closest human body surface distance calculation through a custom-made software using CT-based datasets

Screening of the gastrointestinal tract is imperative for the detection and treatment of physiological and pathological disorders in humans. Ingestible devices (e.g., magnetic capsule endoscopes) represent an alternative to conventional flexible endoscopy for reducing the invasiveness of the procedure and the related patient's discomforts. However, to properly design localization and navigation strategies for capsule endoscopes, the knowledge of anatomical features is paramount. Therefore, authors developed a semi-automatic software for measuring the distance between the small bowel and the closest human external body surface, using CT colonography images. In this study, volumetric datasets of 30 patients were processed by gastrointestinal endoscopists with the dedicated custom-made software and results showed an average distance of 79.29 ± 23.85 mm.

Comparison of Magnifying Endoscopy with Blue Light Imaging and Narrow Band Imaging for Determining the Invasion Depth of Superficial Esophageal Squamous Cell Carcinoma by the Japanese Esophageal Society's Intrapapillary Capillary Loop Classification

Blue light imaging (BLI) and narrow-band imaging (NBI) are two modalities that enable narrow-band light observation. We aimed to compare the diagnostic ability of magnifying endoscopy with BLI (ME-BLI) and NBI (ME-NBI) for determining the invasion depth of superficial esophageal squamous cell carcinoma (SESCC) by the Japanese Esophageal Society's intrapapillary capillary loop (IPCL) classification. We enrolled 81 patients between 2014 and 2018, and the still endoscopic images for diagnosing the invasion depth at the same part in ME-BLI and ME-NBI were registered. Two blinded investigators reviewed them and diagnosed the invasion depth by the IPCL classification. Subsequently, the diagnostic yields in two modalities were compared. The overall accuracies for the invasion depth by the IPCL classification in ME-BLI and ME-NBI did not differ significantly (67.9-71.6% vs. 72.8-74.1%). In the analysis based on the invasion depth, the sensitivities and positive predictive values in tumors invading the muscularis mucosa or submucosa ≤200 µm were low (23.1-30.8% and 16.7-25.0%, respectively) in both modalities. In conclusion, the diagnostic ability for determining the invasion depth of SESCC by the IPCL classification was relatively similar in ME-BLI and ME-NBI, but diagnosis by magnifying endoscopy alone might not be satisfactory.

A Wi-Fi-Based Mask-Type Laryngoscope for Telediagnosis During the COVID-19 Pandemic: Instrument Validation Study

Background

Owing to the COVID-19 pandemic, social distancing has become mandatory. Wireless endoscopy in contactless examinations promises to protect health care workers and reduce viral spread.

Objective

This study aimed to introduce a contactless endoscopic diagnosis system using a wireless endoscope resembling a mask.

Methods

The Wi-Fi–based contactless mask endoscopy system comprises a disposable endoscope and a controller. First, the effective force applied by the tip during insertion was evaluated in a simple transoral model consisting of a force sensor on a simulated oropharynx wall. Second, the delay in video streaming was evaluated by comparing the frame rate and delays between a movement and its image over direct and Wi-Fi connections. Third, the system was applied to a detailed laryngopharyngeal tract phantom.

Results

The smartphone-controlled wireless endoscopy system was successfully evaluated. The mean, maximum, and minimum collision forces against the wall of the transoral model were 296 mN (30 gf), 363 mN (37 gf), and 235 mN (24 gf), respectively. The delay resulting from the wireless connection was 0.72 seconds. Using the phantom, an inexperienced user took around 1 minute to orient the endoscope to a desired area via the app.

Conclusions

Device articulation does not pose a significant risk of laryngopharyngeal wall penetration, and latency does not significantly impede its use. Contactless wireless video streaming was successful within the access point range regardless of the presence of walls. The mask endoscope can be controlled and articulated wirelessly, minimizing contact between patients and device operators. By minimizing contact, the device can protect health care workers from infectious viruses like the coronavirus.

Design of Low-Cost Endoscope Based on Novel Wire-Driven Rotary Valve and Water-Jet Mechanism

To improve the prevalence of screening for gastric cancer in low-income areas, a low-cost endoscope based on a novel wire-driven rotary valve and water-jet mechanism is proposed. The primary component of this endoscope is a rotary valve whose core is driven by a stepper motor through a flexible wire, which controls the direction of the water jet. This enables it to reach any point in the workspace by controlling the valve core angle and water-jet intensity. The envelope surface of the endoscope tip trajectory is likely a hemisphere. The horizontal diameter of the working space projection is approximately 350 mm, which is sufficient to observe most parts of the greater curvature of the stomach. The image-acquisition performance of the designed endoscope was satisfactory in a phantom experiment. The introduction of the novel rotary valve greatly simplifies the structure and reduces the cost of the proposed endoscope. With low cost and high portability, this endoscope provides a good alternative for early gastric cancer screening in low- and middle-income areas.

An Origami-Based Soft Robotic Actuator for Upper Gastrointestinal Endoscopic Applications

Soft pneumatic actuators have been explored for endoscopic applications, but challenges in fabricating complex geometry with desirable dimensions and compliance remain. The addition of an endoscopic camera or tool channel is generally not possible without significant change in the diameter of the actuator. Radial expansion and ballooning of actuator walls during bending is undesirable for endoscopic applications. The inclusion of strain limiting methods like, wound fibre, mesh, or multi-material molding have been explored, but the integration of these design approaches with endoscopic requirements drastically increases fabrication complexity, precluding reliable translation into functional endoscopes. For the first time in soft robotics, we present a multi-channel, single material elastomeric actuator with a fully corrugated design (inspired by origami); offering specific functionality for endoscopic applications. The features introduced in this design include i) fabrication of multi-channel monolithic structure of 8.5 mm diameter, ii) incorporation of the benefits of corrugated design in a single material (i.e., limited radial expansion and improved bending efficiency), iii) design scalability (length and diameter), and iv) incorporation of a central hollow channel for the inclusion of an endoscopic camera. Two variants of the actuator are fabricated which have different corrugated or origami length, i.e., 30 mm and 40 mm respectively). Each of the three actuator channels is evaluated under varying volumetric (0.5 mls-1 and 1.5 mls-1 feed rate) and pressurized control to achieve a similar bending profile with the maximum bending angle of 150°. With the intended use for single use upper gastrointestinal endoscopic application, it is desirable to have linear relationships between actuation and angular position in soft pneumatic actuators with high bending response at low pressures; this is where the origami actuator offers contribution. The soft pneumatic actuator has been demonstrated to achieve a maximum bending angle of 200° when integrated with manually driven endoscope. The simple 3-step fabrication technique produces a complex origami pattern in a soft robotic structure, which promotes low pressure bending through the opening of the corrugation while retaining a small diameter and a central lumen, required for successful endoscope integration.

Training Simulators for Gastrointestinal Endoscopy: Current and Future Perspectives

Simple Summary

Over the last decades, visual endoscopy has become a gold standard for the detection and treatment of gastrointestinal cancers. However, mastering endoscopic procedures is complex and requires long hours of practice. In this context, simulation-based training represents a valuable opportunity for acquiring technical and cognitive skills, suiting the different trainees’ learning pace and limiting the risks for the patients. In this regard, the present contribution aims to present a critical and comprehensive review of the current technology for gastrointestinal (GI) endoscopy training, including both commercial products and platforms at a research stage. Not limited to it, the recent revolution played by the technological advancements in the fields of robotics, artificial intelligence, virtual/augmented reality, and computational tools on simulation-based learning is documented and discussed. Finally, considerations on the future trend of this application field are drawn, highlighting the impact of the most recent pandemic and the current demographic trends.

Abstract

Gastrointestinal (GI) endoscopy is the gold standard in the detection and treatment of early and advanced GI cancers. However, conventional endoscopic techniques are technically demanding and require visual-spatial skills and significant hands-on experience. GI endoscopy simulators represent a valid solution to allow doctors to practice in a pre-clinical scenario. From the first endoscopy mannequin, developed in 1969, several simulation platforms have been developed, ranging from purely mechanical systems to more complex mechatronic devices and animal-based models. Considering the recent advancement of technologies (e.g., artificial intelligence, augmented reality, robotics), simulation platforms can now reach high levels of realism, representing a valid and smart alternative to standard trainee/mentor learning programs. This is particularly true nowadays, when the current demographic trend and the most recent pandemic demand, more than ever, the ability to cope with many patients. This review offers a broad view of the technology available for GI endoscopy training, including platforms currently in the market and the relevant advancements in this research and application field. Additionally, new training needs and new emerging technologies are discussed to understand where medical education is heading.