Validating polyp and instrument segmentation methods in colonoscopy through Medico 2020 and MedAI 2021 Challenges.

Automatic analysis of colonoscopy images has been an active field of research motivated by the importance of early detection of precancerous polyps. However, detecting polyps during the live examination can be challenging due to various factors such as variation of skills and experience among the endoscopists, lack of attentiveness, and fatigue leading to a high polyp miss-rate. Therefore, there is a need for an automated system that can flag missed polyps during the examination and improve patient care. Deep learning has emerged as a promising solution to this challenge as it can assist endoscopists in detecting and classifying overlooked polyps and abnormalities in real time, improving the accuracy of diagnosis and enhancing treatment. In addition to the algorithm's accuracy, transparency and interpretability are crucial to explaining the whys and hows of the algorithm's prediction. Further, conclusions based on incorrect decisions may be fatal, especially in medicine. Despite these pitfalls, most algorithms are developed in private data, closed source, or proprietary software, and methods lack reproducibility. Therefore, to promote the development of efficient and transparent methods, we have organized the "Medico automatic polyp segmentation (Medico 2020)" and "MedAI: Transparency in Medical Image Segmentation (MedAI 2021)" competitions. The Medico 2020 challenge received submissions from 17 teams, while the MedAI 2021 challenge also gathered submissions from another 17 distinct teams in the following year. We present a comprehensive summary and analyze each contribution, highlight the strength of the best-performing methods, and discuss the possibility of clinical translations of such methods into the clinic. Our analysis revealed that the participants improved dice coefficient metrics from 0.8607 in 2020 to 0.8993 in 2021 despite adding diverse and challenging frames (containing irregular, smaller, sessile, or flat polyps), which are frequently missed during a routine clinical examination. For the instrument segmentation task, the best team obtained a mean Intersection over union metric of 0.9364. For the transparency task, a multi-disciplinary team, including expert gastroenterologists, accessed each submission and evaluated the team based on open-source practices, failure case analysis, ablation studies, usability and understandability of evaluations to gain a deeper understanding of the models' credibility for clinical deployment. The best team obtained a final transparency score of 21 out of 25. Through the comprehensive analysis of the challenge, we not only highlight the advancements in polyp and surgical instrument segmentation but also encourage subjective evaluation for building more transparent and understandable AI-based colonoscopy systems. Moreover, we discuss the need for multi-center and out-of-distribution testing to address the current limitations of the methods to reduce the cancer burden and improve patient care.

Domain Generalization with Correlated Style Uncertainty.

Domain generalization (DG) approaches intend to extract domain invariant features that can lead to a more robust deep learning model. In this regard, style augmentation is a strong DG method taking advantage of instance-specific feature statistics containing informative style characteristics to synthetic novel domains. While it is one of the state-of-the-art methods, prior works on style augmentation have either disregarded the interdependence amongst distinct feature channels or have solely constrained style augmentation to linear interpolation. To address these research gaps, in this work, we introduce a novel augmentation approach, named Correlated Style Uncertainty (CSU), surpassing the limitations of linear interpolation in style statistic space and simultaneously preserving vital correlation information. Our method's efficacy is established through extensive experimentation on diverse cross-domain computer vision and medical imaging classification tasks: PACS, Office-Home, and Camelyon17 datasets, and the Duke-Market1501 instance retrieval task. The results showcase a remarkable improvement margin over existing state-of-the-art techniques. The source code is available https://github.com/freshman97/CSU.

RETHINKING INTERMEDIATE LAYERS DESIGN IN KNOWLEDGE DISTILLATION FOR KIDNEY AND LIVER TUMOR SEGMENTATION.

Knowledge distillation (KD) has demonstrated remarkable success across various domains, but its application to medical imaging tasks, such as kidney and liver tumor segmentation, has encountered challenges. Many existing KD methods are not specifically tailored for these tasks. Moreover, prevalent KD methods often lack a careful consideration of 'what' and 'from where' to distill knowledge from the teacher to the student. This oversight may lead to issues like the accumulation of training bias within shallower student layers, potentially compromising the effectiveness of KD. To address these challenges, we propose Hierarchical Layer-selective Feedback Distillation (HLFD). HLFD strategically distills knowledge from a combination of middle layers to earlier layers and transfers final layer knowledge to intermediate layers at both the feature and pixel levels. This design allows the model to learn higher-quality representations from earlier layers, resulting in a robust and compact student model. Extensive quantitative evaluations reveal that HLFD outperforms existing methods by a significant margin. For example, in the kidney segmentation task, HLFD surpasses the student model (without KD) by over 10%, significantly improving its focus on tumor-specific features. From a qualitative standpoint, the student model trained using HLFD excels at suppressing irrelevant information and can focus sharply on tumor-specific details, which opens a new pathway for more efficient and accurate diagnostic tools. Code is available here.

Assessing generalisability of deep learning-based polyp detection and segmentation methods through a computer vision challenge.

Polyps are well-known cancer precursors identified by colonoscopy. However, variability in their size, appearance, and location makes the detection of polyps challenging. Moreover, colonoscopy surveillance and removal of polyps are highly operator-dependent procedures and occur in a highly complex organ topology. There exists a high missed detection rate and incomplete removal of colonic polyps. To assist in clinical procedures and reduce missed rates, automated methods for detecting and segmenting polyps using machine learning have been achieved in past years. However, the major drawback in most of these methods is their ability to generalise to out-of-sample unseen datasets from different centres, populations, modalities, and acquisition systems. To test this hypothesis rigorously, we, together with expert gastroenterologists, curated a multi-centre and multi-population dataset acquired from six different colonoscopy systems and challenged the computational expert teams to develop robust automated detection and segmentation methods in a crowd-sourcing Endoscopic computer vision challenge. This work put forward rigorous generalisability tests and assesses the usability of devised deep learning methods in dynamic and actual clinical colonoscopy procedures. We analyse the results of four top performing teams for the detection task and five top performing teams for the segmentation task. Our analyses demonstrate that the top-ranking teams concentrated mainly on accuracy over the real-time performance required for clinical applicability. We further dissect the devised methods and provide an experiment-based hypothesis that reveals the need for improved generalisability to tackle diversity present in multi-centre datasets and routine clinical procedures.

An Efficient Multi-Scale Fusion Network for 3D Organs at Risk (OARs) Segmentation.

Accurate segmentation of organs-at-risks (OARs) is a precursor for optimizing radiation therapy planning. Existing deep learning-based multi-scale fusion architectures have demonstrated a tremendous capacity for 2D medical image segmentation. The key to their success is aggregating global context and maintaining high resolution representations. However, when translated into 3D segmentation problems, existing multi-scale fusion architectures might underperform due to their heavy computation overhead and substantial data diet. To address this issue, we propose a new OAR segmentation framework, called OARFocalFuseNet, which fuses multi-scale features and employs focal modulation for capturing global-local context across multiple scales. Each resolution stream is enriched with features from different resolution scales, and multi-scale information is aggregated to model diverse contextual ranges. As a result, feature representations are further boosted. The comprehensive comparisons in our experimental setup with OAR segmentation as well as multi-organ segmentation show that our proposed OARFocalFuseNet outperforms the recent state-of-the-art methods on publicly available OpenKBP datasets and Synapse multi-organ segmentation. Both of the proposed methods (3D-MSF and OARFocalFuseNet) showed promising performance in terms of standard evaluation metrics. Our best performing method (OARFocalFuseNet) obtained a dice coefficient of 0.7995 and hausdorff distance of 5.1435 on OpenKBP datasets and dice coefficient of 0.8137 on Synapse multi-organ segmentation dataset. Our code is available at https://github.com/NoviceMAn-prog/OARFocalFuse.

TransResU-Net: A Transformer based ResU-Net for Real-Time Colon Polyp Segmentation.

Colorectal cancer (CRC) is one of the most common causes of cancer and cancer-related mortality worldwide. Performing colon cancer screening in a timely fashion is the key to early detection. Colonoscopy is the primary modality used to diagnose colon cancer. However, the miss rate of polyps, adenomas and advanced adenomas remains significantly high. Early detection of polyps at the precancerous stage can help reduce the mortality rate and the economic burden associated with colorectal cancer. Deep learning-based computer-aided diagnosis (CADx) system may help gastroenterologists to identify polyps that may otherwise be missed, thereby improving the polyp detection rate. Additionally, CADx system could prove to be a cost-effective system that improves long-term colorectal cancer prevention. In this study, we proposed a deep learning-based architecture for automatic polyp segmentation called Transformer ResU-Net (TransResU-Net). Our proposed architecture is built upon residual blocks with ResNet-50 as the backbone and takes advantage of the transformer self-attention mechanism as well as dilated convolution(s). Our experimental results on two publicly available polyp segmentation benchmark datasets showed that TransResU-Net obtained a highly promising dice score and a real-time speed. With high efficacy in our performance metrics, we concluded that TransResU-Net could be a strong benchmark for building a real-time polyp detection system for the early diagnosis, treatment, and prevention of colorectal cancer. The source code of the proposed TransResU-Net is publicly available at https://github.com/nikhilroxtomar/TransResUNet.

A multi-centre polyp detection and segmentation dataset for generalisability assessment.

Polyps in the colon are widely known cancer precursors identified by colonoscopy. Whilst most polyps are benign, the polyp's number, size and surface structure are linked to the risk of colon cancer. Several methods have been developed to automate polyp detection and segmentation. However, the main issue is that they are not tested rigorously on a large multicentre purpose-built dataset, one reason being the lack of a comprehensive public dataset. As a result, the developed methods may not generalise to different population datasets. To this extent, we have curated a dataset from six unique centres incorporating more than 300 patients. The dataset includes both single frame and sequence data with 3762 annotated polyp labels with precise delineation of polyp boundaries verified by six senior gastroenterologists. To our knowledge, this is the most comprehensive detection and pixel-level segmentation dataset (referred to as PolypGen) curated by a team of computational scientists and expert gastroenterologists. The paper provides insight into data construction and annotation strategies, quality assurance, and technical validation.

FANet: A Feedback Attention Network for Improved Biomedical Image Segmentation.

The increase of available large clinical and experimental datasets has contributed to a substantial amount of important contributions in the area of biomedical image analysis. Image segmentation, which is crucial for any quantitative analysis, has especially attracted attention. Recent hardware advancement has led to the success of deep learning approaches. However, although deep learning models are being trained on large datasets, existing methods do not use the information from different learning epochs effectively. In this work, we leverage the information of each training epoch to prune the prediction maps of the subsequent epochs. We propose a novel architecture called feedback attention network (FANet) that unifies the previous epoch mask with the feature map of the current training epoch. The previous epoch mask is then used to provide hard attention to the learned feature maps at different convolutional layers. The network also allows rectifying the predictions in an iterative fashion during the test time. We show that our proposed feedback attention model provides a substantial improvement on most segmentation metrics tested on seven publicly available biomedical imaging datasets demonstrating the effectiveness of FANet. The source code is available at https://github.com/nikhilroxtomar/FANet.

Meta-learning with implicit gradients in a few-shot setting for medical image segmentation.

Widely used traditional supervised deep learning methods require a large number of training samples but often fail to generalize on unseen datasets. Therefore, a more general application of any trained model is quite limited for medical imaging for clinical practice. Using separately trained models for each unique lesion category or a unique patient population will require sufficiently large curated datasets, which is not practical to use in a real-world clinical set-up. Few-shot learning approaches can not only minimize the need for an enormous number of reliable ground truth labels that are labour-intensive and expensive, but can also be used to model on a dataset coming from a new population. To this end, we propose to exploit an optimization-based implicit model agnostic meta-learning (iMAML) algorithm under few-shot settings for medical image segmentation. Our approach can leverage the learned weights from diverse but small training samples to perform analysis on unseen datasets with high accuracy. We show that, unlike classical few-shot learning approaches, our method improves generalization capability. To our knowledge, this is the first work that exploits iMAML for medical image segmentation and explores the strength of the model on scenarios such as meta-training on unique and mixed instances of lesion datasets. Our quantitative results on publicly available skin and polyp datasets show that the proposed method outperforms the naive supervised baseline model and two recent few-shot segmentation approaches by large margins. In addition, our iMAML approach shows an improvement of 2%-4% in dice score compared to its counterpart MAML for most experiments.

MSRF-Net: A Multi-Scale Residual Fusion Network for Biomedical Image Segmentation.

Methods based on convolutional neural networks have improved the performance of biomedical image segmentation. However, most of these methods cannot efficiently segment objects of variable sizes and train on small and biased datasets, which are common for biomedical use cases. While methods exist that incorporate multi-scale fusion approaches to address the challenges arising with variable sizes, they usually use complex models that are more suitable for general semantic segmentation problems. In this paper, we propose a novel architecture called Multi-Scale Residual Fusion Network (MSRF-Net), which is specially designed for medical image segmentation. The proposed MSRF-Net is able to exchange multi-scale features of varying receptive fields using a Dual-Scale Dense Fusion (DSDF) block. Our DSDF block can exchange information rigorously across two different resolution scales, and our MSRF sub-network uses multiple DSDF blocks in sequence to perform multi-scale fusion. This allows the preservation of resolution, improved information flow and propagation of both high- and low-level features to obtain accurate segmentation maps. The proposed MSRF-Net allows to capture object variabilities and provides improved results on different biomedical datasets. Extensive experiments on MSRF-Net demonstrate that the proposed method outperforms the cutting-edge medical image segmentation methods on four publicly available datasets. We achieve the Dice Coefficient (DSC) of 0.9217, 0.9420, and 0.9224, 0.8824 on Kvasir-SEG, CVC-ClinicDB, 2018 Data Science Bowl dataset, and ISIC-2018 skin lesion segmentation challenge dataset respectively. We further conducted generalizability tests and achieved DSC of 0.7921 and 0.7575 on CVC-ClinicDB and Kvasir-SEG, respectively.

Video Analytics in Elite Soccer: A Distributed Computing Perspective.

Ubiquitous sensors and Internet of Things (IoT) technologies have revolutionized the sports industry, providing new methodologies for planning, effective coordination of training, and match analysis post game. New methods, including machine learning, image and video processing, have been developed for performance evaluation, allowing the analyst to track the performance of a player in real-time. Following FIFA's 2015 approval of electronics performance and tracking system during games, performance data of a single player or the entire team is allowed to be collected using GPS-based wearables. Data from practice sessions outside the sporting arena is being collected in greater numbers than ever before. Realizing the significance of data in professional soccer, this paper presents video analytics, examines recent state-of-the-art literature in elite soccer, and summarizes existing real-time video analytics algorithms. We also discuss real-time crowdsourcing of the obtained data, tactical and technical performance, distributed computing and its importance in video analytics and propose a future research perspective.

Transformer based Generative Adversarial Network for Liver Segmentation.

Automated liver segmentation from radiology scans (CT, MRI) can improve surgery and therapy planning and follow-up assessment in addition to conventional use for diagnosis and prognosis. Although convolutional neural networks (CNNs) have became the standard image segmentation tasks, more recently this has started to change towards Transformers based architectures because Transformers are taking advantage of capturing long range dependence modeling capability in signals, so called attention mechanism. In this study, we propose a new segmentation approach using a hybrid approach combining the Transformer(s) with the Generative Adversarial Network (GAN) approach. The premise behind this choice is that the self-attention mechanism of the Transformers allows the network to aggregate the high dimensional feature and provide global information modeling. This mechanism provides better segmentation performance compared with traditional methods. Furthermore, we encode this generator into the GAN based architecture so that the discriminator network in the GAN can classify the credibility of the generated segmentation masks compared with the real masks coming from human (expert) annotations. This allows us to extract the high dimensional topology information in the mask for biomedical image segmentation and provide more reliable segmentation results. Our model achieved a high dice coefficient of 0.9433, recall of 0.9515, and precision of 0.9376 and outperformed other Transformer based approaches. The implementation details of the proposed architecture can be found at https://github.com/UgurDemir/tranformer_liver_segmentation.

Automatic Polyp Segmentation with Multiple Kernel Dilated Convolution Network.

The detection and removal of precancerous polyps through colonoscopy is the primary technique for the prevention of colorectal cancer worldwide. However, the miss rate of colorectal polyp varies significantly among the endoscopists. It is well known that a computer-aided diagnosis (CAD) system can assist endoscopists in detecting colon polyps and minimize the variation among endoscopists. In this study, we introduce a novel deep learning architecture, named MKDCNet, for automatic polyp segmentation robust to significant changes in polyp data distribution. MKDCNet is simply an encoder-decoder neural network that uses the pre-trained ResNet50 as the encoder and novel multiple kernel dilated convolution (MKDC) block that expands the field of view to learn more robust and heterogeneous representation. Extensive experiments on four publicly available polyp datasets and cell nuclei dataset show that the proposed MKDCNet outperforms the state-of-the-art methods when trained and tested on the same dataset as well when tested on unseen polyp datasets from different distributions. With rich results, we demonstrated the robustness of the proposed architecture. From an efficiency perspective, our algorithm can process at (≈ 45) frames per second on RTX 3090 GPU. MKDCNet can be a strong benchmark for building real-time systems for clinical colonoscopies. The code of the proposed MKDCNet is available at https://github.com/nikhilroxtomar/MKDCNet.

Video Capsule Endoscopy Classification using Focal Modulation Guided Convolutional Neural Network.

Video capsule endoscopy is a hot topic in computer vision and medicine. Deep learning can have a positive impact on the future of video capsule endoscopy technology. It can improve the anomaly detection rate, reduce physicians' time for screening, and aid in real-world clinical analysis. Computer-Aided diagnosis (CADx) classification system for video capsule endoscopy has shown a great promise for further improvement. For example, detection of cancerous polyp and bleeding can lead to swift medical response and improve the survival rate of the patients. To this end, an automated CADx system must have high throughput and decent accuracy. In this study, we propose FocalConvNet, a focal modulation network integrated with lightweight convolutional layers for the classification of small bowel anatomical landmarks and luminal findings. FocalConvNet leverages focal modulation to attain global context and allows global-local spatial interactions throughout the forward pass. Moreover, the convolutional block with its intrinsic inductive/learning bias and capacity to extract hierarchical features allows our FocalConvNet to achieve favourable results with high throughput. We compare our FocalConvNet with other state-of-the-art (SOTA) on Kvasir-Capsule, a large-scale VCE dataset with 44,228 frames with 13 classes of different anomalies. We achieved the weighted F1-score, recall and Matthews correlation coefficient (MCC) of 0.6734, 0.6373 and 0.2974, respectively, outperforming SOTA methodologies. Further, we obtained the highest throughput of 148.02 images/second rate to establish the potential of FocalConvNet in a real-time clinical environment. The code of the proposed FocalConvNet is available at https://github.com/NoviceMAn-prog/FocalConvNet.

TGANet: Text-guided attention for improved polyp segmentation.

Colonoscopy is a gold standard procedure but is highly operator-dependent. Automated polyp segmentation, a precancerous precursor, can minimize missed rates and timely treatment of colon cancer at an early stage. Even though there are deep learning methods developed for this task, variability in polyp size can impact model training, thereby limiting it to the size attribute of the majority of samples in the training dataset that may provide sub-optimal results to differently sized polyps. In this work, we exploit size-related and polyp number-related features in the form of text attention during training. We introduce an auxiliary classification task to weight the text-based embedding that allows network to learn additional feature representations that can distinctly adapt to differently sized polyps and can adapt to cases with multiple polyps. Our experimental results demonstrate that these added text embeddings improve the overall performance of the model compared to state-of-the-art segmentation methods. We explore four different datasets and provide insights for size-specific improvements. Our proposed text-guided attention network (TGANet) can generalize well to variable-sized polyps in different datasets. Codes are available at https://github.com/nikhilroxtomar/TGANet.

Kvasir-Capsule, a video capsule endoscopy dataset.

Artificial intelligence (AI) is predicted to have profound effects on the future of video capsule endoscopy (VCE) technology. The potential lies in improving anomaly detection while reducing manual labour. Existing work demonstrates the promising benefits of AI-based computer-assisted diagnosis systems for VCE. They also show great potential for improvements to achieve even better results. Also, medical data is often sparse and unavailable to the research community, and qualified medical personnel rarely have time for the tedious labelling work. We present Kvasir-Capsule, a large VCE dataset collected from examinations at a Norwegian Hospital. Kvasir-Capsule consists of 117 videos which can be used to extract a total of 4,741,504 image frames. We have labelled and medically verified 47,238 frames with a bounding box around findings from 14 different classes. In addition to these labelled images, there are 4,694,266 unlabelled frames included in the dataset. The Kvasir-Capsule dataset can play a valuable role in developing better algorithms in order to reach true potential of VCE technology.

Comparative validation of multi-instance instrument segmentation in endoscopy: Results of the ROBUST-MIS 2019 challenge.

Intraoperative tracking of laparoscopic instruments is often a prerequisite for computer and robotic-assisted interventions. While numerous methods for detecting, segmenting and tracking of medical instruments based on endoscopic video images have been proposed in the literature, key limitations remain to be addressed: Firstly, robustness, that is, the reliable performance of state-of-the-art methods when run on challenging images (e.g. in the presence of blood, smoke or motion artifacts). Secondly, generalization; algorithms trained for a specific intervention in a specific hospital should generalize to other interventions or institutions. In an effort to promote solutions for these limitations, we organized the Robust Medical Instrument Segmentation (ROBUST-MIS) challenge as an international benchmarking competition with a specific focus on the robustness and generalization capabilities of algorithms. For the first time in the field of endoscopic image processing, our challenge included a task on binary segmentation and also addressed multi-instance detection and segmentation. The challenge was based on a surgical data set comprising 10,040 annotated images acquired from a total of 30 surgical procedures from three different types of surgery. The validation of the competing methods for the three tasks (binary segmentation, multi-instance detection and multi-instance segmentation) was performed in three different stages with an increasing domain gap between the training and the test data. The results confirm the initial hypothesis, namely that algorithm performance degrades with an increasing domain gap. While the average detection and segmentation quality of the best-performing algorithms is high, future research should concentrate on detection and segmentation of small, crossing, moving and transparent instrument(s) (parts).

A comprehensive analysis of classification methods in gastrointestinal endoscopy imaging.

Gastrointestinal (GI) endoscopy has been an active field of research motivated by the large number of highly lethal GI cancers. Early GI cancer precursors are often missed during the endoscopic surveillance. The high missed rate of such abnormalities during endoscopy is thus a critical bottleneck. Lack of attentiveness due to tiring procedures, and requirement of training are few contributing factors. An automatic GI disease classification system can help reduce such risks by flagging suspicious frames and lesions. GI endoscopy consists of several multi-organ surveillance, therefore, there is need to develop methods that can generalize to various endoscopic findings. In this realm, we present a comprehensive analysis of the Medico GI challenges: Medical Multimedia Task at MediaEval 2017, Medico Multimedia Task at MediaEval 2018, and BioMedia ACM MM Grand Challenge 2019. These challenges are initiative to set-up a benchmark for different computer vision methods applied to the multi-class endoscopic images and promote to build new approaches that could reliably be used in clinics. We report the performance of 21 participating teams over a period of three consecutive years and provide a detailed analysis of the methods used by the participants, highlighting the challenges and shortcomings of the current approaches and dissect their credibility for the use in clinical settings. Our analysis revealed that the participants achieved an improvement on maximum Mathew correlation coefficient (MCC) from 82.68% in 2017 to 93.98% in 2018 and 95.20% in 2019 challenges, and a significant increase in computational speed over consecutive years.

Real-Time Polyp Detection, Localization and Segmentation in Colonoscopy Using Deep Learning.

Computer-aided detection, localisation, and segmentation methods can help improve colonoscopy procedures. Even though many methods have been built to tackle automatic detection and segmentation of polyps, benchmarking of state-of-the-art methods still remains an open problem. This is due to the increasing number of researched computer vision methods that can be applied to polyp datasets. Benchmarking of novel methods can provide a direction to the development of automated polyp detection and segmentation tasks. Furthermore, it ensures that the produced results in the community are reproducible and provide a fair comparison of developed methods. In this paper, we benchmark several recent state-of-the-art methods using Kvasir-SEG, an open-access dataset of colonoscopy images for polyp detection, localisation, and segmentation evaluating both method accuracy and speed. Whilst, most methods in literature have competitive performance over accuracy, we show that the proposed ColonSegNet achieved a better trade-off between an average precision of 0.8000 and mean IoU of 0.8100, and the fastest speed of 180 frames per second for the detection and localisation task. Likewise, the proposed ColonSegNet achieved a competitive dice coefficient of 0.8206 and the best average speed of 182.38 frames per second for the segmentation task. Our comprehensive comparison with various state-of-the-art methods reveals the importance of benchmarking the deep learning methods for automated real-time polyp identification and delineations that can potentially transform current clinical practices and minimise miss-detection rates.

A Comprehensive Study on Colorectal Polyp Segmentation With ResUNet++, Conditional Random Field and Test-Time Augmentation.

Colonoscopy is considered the gold standard for detection of colorectal cancer and its precursors. Existing examination methods are, however, hampered by high overall miss-rate, and many abnormalities are left undetected. Computer-Aided Diagnosis systems based on advanced machine learning algorithms are touted as a game-changer that can identify regions in the colon overlooked by the physicians during endoscopic examinations, and help detect and characterize lesions. In previous work, we have proposed the ResUNet++ architecture and demonstrated that it produces more efficient results compared with its counterparts U-Net and ResUNet. In this paper, we demonstrate that further improvements to the overall prediction performance of the ResUNet++ architecture can be achieved by using Conditional Random Field (CRF) and Test-Time Augmentation (TTA). We have performed extensive evaluations and validated the improvements using six publicly available datasets: Kvasir-SEG, CVC-ClinicDB, CVC-ColonDB, ETIS-Larib Polyp DB, ASU-Mayo Clinic Colonoscopy Video Database, and CVC-VideoClinicDB. Moreover, we compare our proposed architecture and resulting model with other state-of-the-art methods. To explore the generalization capability of ResUNet++ on different publicly available polyp datasets, so that it could be used in a real-world setting, we performed an extensive cross-dataset evaluation. The experimental results show that applying CRF and TTA improves the performance on various polyp segmentation datasets both on the same dataset and cross-dataset. To check the model's performance on difficult to detect polyps, we selected, with the help of an expert gastroenterologist, 196 sessile or flat polyps that are less than ten millimeters in size. This additional data has been made available as a subset of Kvasir-SEG. Our approaches showed good results for flat or sessile and smaller polyps, which are known to be one of the major reasons for high polyp miss-rates. This is one of the significant strengths of our work and indicates that our methods should be investigated further for use in clinical practice.