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Improved Visibility of Barrett’s Esophagus with Linked Color Imaging: Inter- and Intra-Rater Reliability and Quantitative Analysis.

Takeda T1, Nagahara A2, Ishizuka K1, Okubo S1, Haga K1, Suzuki M1, Nakajima A1, Komori H1, Akazawa Y1, Izumi K1, Matsumoto K1, Ueyama H1, Shimada Y1, Matsumoto K1, Asaoka D1, Shibuya T1, Sakamoto N1, Osada T1, Hojo M1, Nojiri S3, Watanabe S1.

Digestion. 2018 Jan 10;97(2):183-194. doi: 10.1159/000485459. [Epub ahead of print]

Background/Aims: To evaluate the usefulness of linked color imaging (LCI) and blue LASER imaging (BLI) in Barrett’s esophagus (BE) compared with white light imaging (WLI).

Methods: Five expert and trainee endoscopists compared WLI, LCI, and BLI images obtained from 63 patients with short-segment BE. Physicians assessed visibility as follows: 5 (improved), 4 (somewhat improved), 3 (equivalent), 2 (somewhat decreased), and one (decreased). Scores were evaluated to assess visibility. The inter- and intra-rater reliability (intra-class correlation coefficient) of image assessments were also evaluated. Images were objectively evaluated based on L* a* b* color values and color differences (ΔE*) in a CIELAB color space system.

Results: Improved visibility compared with WLI was achieved for LCI: 44.4%, BLI: 0% for all endoscopists; LCI: 55.6%, BLI: 1.6% for trainees; and LCI: 47.6%, BLI: 0% for experts. The visibility score of trainees compared with experts was significantly higher for LCI (p = 0.02). Intra- and inter-rater reliability ratings for LCI compared with WLI were “moderate” for trainees, and “moderate-substantial” for experts. The ΔE* revealed statistically significant differences between WLI and LCI.

Conclusion: LCI improved the visibility of short-segment BE compared with WLI, especially for trainees, when evaluated both subjectively and objectively.


1 Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan.
2 Department of Gastroenterology, Juntendo Sizuoka Hospital, Sizuoka, Japan.
3 Department of Medical Technology Innovation Center, Juntendo University School of Medicine, Tokyo, Japan.

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Objective Endoscopic Analysis with Linked Color Imaging regarding Gastric Mucosal Atrophy: A Pilot Study.

Mizukami K1, Ogawa R1, Okamoto K1, Shuto M1, Fukuda K1, Sonoda A1, Matsunari O1, Hirashita Y1, Okimoto T1, Kodama M1, Murakami K1.

Gastroenterol Res Pract. 2017; 2017:5054237. Epub 2017 Nov 15.

Objectives: We aimed to determine whether linked color imaging (LCI), a new image-enhanced endoscopy that enhances subtle differences in mucosal colors, can distinguish the border of endoscopic mucosal atrophy.

Methods: This study included 30 patients with atrophic gastritis. In endoscopy, we continuously took images in the same composition with both LCI and white light imaging (WLI). In each image, the color values of atrophic and nonatrophic mucosae were quantified using the International Commission on Illumination 1976 (L∗, a∗, b∗) color space. Color differences at the atrophic border, defined as Euclidean distances of color values between the atrophic and nonatrophic mucosae, were compared between WLI and LCI for the overall cohort and separately for patients with Helicobacter pylori infection status.

Results: We found that the color difference became significantly higher with LCI than with WLI in the overall samples of 90 points in 30 patients. LCI was 14.79 ± 6.68, and WLI was 11.06 ± 5.44 (P < 0.00001). LCI was also more effective in both of the Helicobacter pylori-infected group (P = 0.00003) and the Helicobacter pylori-eradicated group (P = 0.00002).

Conclusions: LCI allows clear endoscopic visualization of the atrophic border under various conditions of gastritis, regardless of Helicobacter pylori infection status.


1 Department of Gastroenterology, Oita University, Japan.

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Evaluation of the visibility of early gastric cancer using linked color imaging and blue laser imaging.

Yoshifuku Y1, Sanomura Y2, Oka S1, Kurihara M1, Mizumoto T1, Miwata T1, Urabe Y1, Hiyama T3, Tanaka S4, Chayama K1.

BMC Gastroenterol. 2017 Dec 8;17(1):150.

Background: Blue laser imaging (BLI) and linked color imaging (LCI) are the color enhancement features of the LASEREO endoscopic system, which provide a narrow band light observation function and expansion and reduction of the color information, respectively.

Methods: We examined 82 patients with early gastric cancer (EGC) diagnosed between April 2014 and August 2015. Five expert and 5 non-expert endoscopists retrospectively compared images obtained on non-magnifying BLI bright mode (BLI-BRT) and LCI with those obtained via conventional white light imaging (WLI). Interobserver agreement was also assessed.

Results: In experts’ evaluation of the images, an improvement in visibility was observed in 73% (60/82) and 20% (16/82) of cases under LCI and BLI-BRT, respectively. In non-experts’ evaluation of the images, an improvement in visibility was observed in 76.8% (63/82) and 24.3% (20/82) of cases under LCI and BLI-BRT, respectively. There were no significant differences between experts and non-experts in the evaluation of the images. The improvement in visibility was significantly higher with LCI than with BLI-BRT in experts and non-experts (p < 0.01). With regard to tumor color on WLI, the improvement in the visibility of reddish and whitish tumors was significantly higher than that of isochromatic tumors when LCI was used. The improvement in visibility with LCI was observed in 71% (12/17) and 74% (48/65) of patients with and without Helicobacter pylori (Hp) eradication, respectively; no significant difference in improvement was observed between these groups. The interobserver agreement was good to satisfactory at ≥ 0.62.

Conclusions: In conclusion, our study showed that LCI improved the visibility of EGC, regardless of the level of endoscopists’ experience or Hp eradication in patients, particularly for EGCs with a reddish or whitish color. The improvement in visibility was significantly higher with LCI than that with BLI.


1 Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Japan.
2 Department of Endoscopy, Hiroshima University Hospital, Japan.
3 Health Service Center, Hiroshima University, Japan.
4 Department of Endoscopy, Hiroshima University Hospital, Japan.

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Linked Color Imaging identified UC Associated Colorectal Cancer. A case report.

Hisamatsu T1, Ohno A1, Chiba T2.

Dig Endosc. 2017 Nov 27. doi: 10.1111/den.12992. [Epub ahead of print]

Ulcerative colitis (UC) associated colorectal cancer (CRC) is an important issue in long-term management of patients with UC. Lesions with chronic inflammatory mucosa as background may often be difficult to identify even by endoscopic observation. Traditionally, a random biopsy strategy was recommended, but problems with patient compliance, increased burden on endoscopic staff and pathologists, were left. This article is protected by copyright. All rights reserved.

1 Third Department of Internal Medicine, Kyorin University School of Medicine.
2 Department of Pathology, Kyorin University School of Medicine.

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Linked-color imaging combined with the NICE classification system for optical diagnosis of colon polyps: new image-enhanced endoscopic technology for pathological prediction.

Wu CH1,2, Chen TH1,2,3, Hsu CM1,2, Su MY1,2, Chiu CT1,2, Wu RC4, Lai CC5.

Ther Clin Risk Manag. 2017 Oct 3;13:1317-1321.

Introduction: Linked-color imaging (LCI) is a recently developed system used in endoscopy. It creates clear and bright endoscopic images using short-wavelength, narrow-band laser light combined with white laser light. The illuminating light and signal processing emphasize slight color differences in abnormal regions that approximate the normal color of the mucosa. As a result, regions initially appearing red become a deeper shade of red, while regions originally appearing white become brighter, yet with natural tones. This process facilitates recognition of slight differences in the color of the mucosa and clarifies the boundaries of the mucosal pit.

Aim: To determine whether LCI of the colon can improve the correlation between endoscopic findings and pathological diagnosis.

Methods: Consecutive patients who underwent colonoscopy requiring polypectomy or removal by biopsy forceps if possible were recruited. Probable polyp histology was assessed by two endoscopists using the Narrow-band imaging International Colorectal Endoscopic (NICE) classification and LCI data. All detected polyps were sent to the pathology department for pathological diagnosis by two pathologists.

Results: In total, 94 polyps were found in 43 patients. The sensitivity, specificity, positive predictive value, and negative predictive value for neoplastic lesion prediction (NICE type2/3) were 96.5%, 83.8%, 90.2%, and 93.9%, respectively.

Conclusion: LCI combined with the NICE classification system is a powerful tool for predicting probable histology of colon polyps.

1 Department of Gastroenterology and Hepatology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan.
2 Chang Gung University, College of Medicine, Taoyuan.
3 Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan.
4 Department of Pathology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan.
5 Department of Colon and Rectal Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.

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Linked color imaging improves the visibility of various featured colorectal polyps in an endoscopist’s visibility and color difference value.

Yoshida N, Naito Y,  Itoh Y. et al.

Int J Colorectal Dis. 2017 Jul 19. doi: 10.1007/s00384-017-2855-z.

Background and study aims: Linked color imaging (LCI) and blue laser imaging (BLI) are novel image-enhanced endoscopy technologies with strong, unique color enhancement. We investigated the efficacy of LCI and BLI-bright compared to conventional white light imaging (WLI) by measuring the color difference between early gastric cancer lesions and the surrounding mucosa.

Patients and methods: Images of early gastric cancer scheduled for endoscopic submucosal dissection were captured by LCI, BLI-bright, and WLI under the same conditions. Color values of the lesion and surrounding mucosa were defined as the average of the color value in each region of interest. Color differences between the lesion and surrounding mucosa (ΔE) were examined in each mode. The color value was assessed using the CIE L*a*b* color space (CIE: Commission Internationale d’Eclairage).

Results: We collected images of 43 lesions from 42 patients. Average ΔE values with LCI, BLI-bright, and WLI were 11.02, 5.04, and 5.99, respectively. The ΔE was significantly higher with LCI than with WLI ( P  < 0.001). Limited to cases of small ΔE with WLI, the ΔE was approximately 3 times higher with LCI than with WLI (7.18 vs. 2.25). The ΔE with LCI was larger when the surrounding mucosa had severe intestinal metaplasia ( P  = 0.04). The average color value of a lesion and the surrounding mucosa differed. This value did not have a sufficient cut-off point between the lesion and surrounding mucosa to distinguish them, even with LCI.

Conclusion: LCI had a larger ΔE than WLI. It may allow easy recognition and early detection of gastric cancer, even for inexperienced endoscopists.

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Therapeutic application of linked color imaging for colorectal endoscopic mucosal resection

Goda Y1, Mori H1, Kobara H1, Nishiyama N1, Kobayashi N1, Yachida T1, Masaki T1.

Endoscopy. 2017 Oct 17. doi: 10.1055/s-0043-119984. [Epub ahead of print]

Linked color imaging (LCI; Fujifilm Co., Tokyo, Japan) is a newly developed image- enhanced technique that has shown high diagnostic performance in the field of gastrointestinal endoscopy. LCI enhances color separation of the mucosal layer, making red regions redder and white regions whiter. This contributes to the detection of gastric cancer [1], ulcerative colitis [2], colorectal polyps [3, 4], and other lesions. Although the diagnostic productivity is steadfast, the treatment benefit of LCI remains unclear or limited [5]. We herein introduce an advantage of LCI with respect to increasing the safety of endoscopic mucosal resection (EMR), illustrating the efficacy of LCI in the treatment field.

Compared with white-light imaging, narrow- band imaging, and bright-light imaging, the view of the blood vessels in the superficial layer is much more conspicuous when obtained by LCI. When performing EMR, local injection is the first crucial step and the basis of later procedures such as polyp removal by snaring. However, injury to the superficial vessels invisible with white light sometimes induces hematoma formation, making subsequent snaring difficult (▶Fig. 1 a). LCI can more precisely reveal the running of the superficial vessels around a colorectal polyp than can white light imaging (▶Fig. 1 b) and bright-light imaging (▶Fig. 1 c). LCI enhances the reddish, glaring characteristics of the vessels, pinpointing safe sites for needling (▶Fig. 1 d). Consequently, the clinician can avoid needling blood vessels near the polyp (▶Fig. 1 e) and prevent unnecessary bleeding and hematoma formation (▶Fig. 1 f), leading to secure completion of EMR.

White-light imaging, bright-light imaging, and LCI for EMR local injections are compared in ▶Video 1. Only LCI shows the reddish network pattern of the superficial blood vessels. This leads to sufficient swelling of the submucosal layer and appropriate removal of colorectal polyps.

Fig. 1 Endoscopic images illustrating the advantages of linked color imaging (LCI) during endoscopic mucosal resection. a Improper injection can induce hematoma formation. b Superficial vessels around a colorectal polyp are invisible with white-light imaging. c Superficial vessels are also unclear with bright-light imaging. d LCI shows the orientation of vessels around the polyp. e The injection needle pinpoints a site lacking vessels. f Unnecessary hematoma formation and bleeding can be avoided during mucosal injection.

Video 1 White-light imaging only ambiguously shows the blood vessel routes, whereas linked color imaging (LCI) indicates the vessels clearly as a vivid reddish color. From injection to snaring, LCI allows the clinician to avoid unnecessary bleeding.

1Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan.

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BASIC (BLI Adenoma Serrated International Classification) classification study for colorectal polyp characterization with blue light imaging

Raf Bisschops1, Cesare Hassan2,3, Pradeep Bhandari4, Emmanuel Coron5, Helmut Neumann6, Oliver Pech7, Loredana Correale2, Alessandro Repici3

Endoscopy 2018; 50: 1-17 / https://doi.org/10.1055/s-0043-121570

Backgound and study aim: Advanced endoscopic imaging has revolutionized the characterization of lesions during colonoscopy. The aim of this study was to create a new classification for differentiating subcentimetric hyperplastic and adenomatous polyps, and deeply invasive malignant lesions using blue-light imaging (BLI) with high definition, with and without optical magnification, as well as to assess its interobserver concordance.

Methods: A video library consisting of 48 videos/still images (with/without optical magnification) from 24 histologically verified polyps/cancer with BLI was prospectively created. In the first step, seven endoscopists with experience in electronic chromoendoscopy reviewed 12 BLI videos/still images with/without magnification representative of the different histotypes, and individually identified possible descriptors. In the second step, these descriptors were categorized and summarized with a modified Delphi methodology. In the third step, the seven endoscopists independently reviewed the remaining 36 videos/still images with/without optical magnification, and the interobserver agreement for the new descriptors was assessed. The interobserver agreement between endoscopists was assessed using Gwet’s AC1.

Results: By reviewing the initial 12 videos/still images, 43 descriptors were proposed. By a modified Delphi process, the endoscopists eventually agreed on summarizing 12 descriptors into three main domains. The main domains identified were: polyp surface (mucus, yes/no; regular/irregular; [pseudo]depressed, yes/no), pit appearance (featureless, yes/no; round/nonround with/without dark spots; homogeneous/heterogeneous distribution with/without focal loss), and vessels (present/absent, lacy, pericryptal, irregular). Interobserver agreement for the polyp surface domain appeared to be almost perfect for mucus (AC1 0.92 with and 0.88 without optical magnification), substantial for the regular/irregular surface (AC1 0.67 with and 0.66 without optical magnification). For the pit appearance domain, interobserver agreement was good for featureless (AC1 0.9 with and 0.8 without optical magnification), and round/nonround (AC1 0.77 with and 0.69 without optical magnification) descriptors, but less consistent for the homogeneity of distribution (AC1 with/without optical magnification 0.58). Agreement was almost perfect for the vessel domain (AC1 0.81 – 0.85).

Conclusions: The new BASIC classification takes into account both morphological features of the polyp, as well as crypt and vessel characteristics. A high concordance among the observers was shown for most of the summarized descriptors. Optical magnification had a beneficial effect in terms of interobserver agreement for most of the descriptors.

1 Department of Gastroenterology and Hepatology, Catholic University of Leuven (KUL), TARGID, University Hospitals Leuven, Leuven, Belgium.
2 Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy.
3 Digestive Endoscopy Unit, Humanitas University, Milan, Italy.
4 Solent Centre for Digestive Diseases, Portsmouth Hospital, Portsmouth, United Kingdom.
5 Hepatogastroenterology, Centre Hospitalier Universitaire Hotel Dieu, Nantes, France.
6 First Medical Department, University Medical Center Mainz, Mainz, Germany.
7 Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.

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The Combination Use of an Acetic Acid Indigo Carmine Mixture and Linked-Color Imaging to Detect Early Gastric Cancer.

Kono Y1, Kawahara Y2, Okada H1.

Clin Gastroenterol Hepatol. 2017 Sep 1. pii: S1542-3565(17)31045-5.

Chromoendoscopy (CE) and image-enhanced endoscopy are useful for accurately diagnosing gastric neoplasms. However, unclear lesions, such as those with a flat morphology or normochromic color, sometimes can be missed. We herein present a case in which CE was performed with the combined use of an acetic acid indigo carmine mixture (AIM) and linked-color imaging (LCI), and this method was effective for detecting early gastric cancer. A Japanese man in his 70s underwent esophagogastroduodenoscopy for screening purposes. It was difficult to identify any lesions by white-light imaging (Figure A).

However, when performing image-enhanced endoscopy with LCI, a shallow depressed lesion was identified in the prepyloric area and this modality made it easier to detect the lesion, but the visibility was insufficient to distinguish clearly between the lesion and the surrounding area (Figure B). CE using an AIM with LCI enhanced not only the surface color, but also the demarcation line of the lesion (Figure C). A histologic examination of a biopsy specimen showed differentiated-type adenocarcinoma, and endoscopic submucosal dissection thereafter was performed.

The pathologic diagnosis of the resected specimen showed well-differentiated adenocarcinoma of the stomach (Figure D). Performing CE using an AIM and LCI is useful for detecting gastric neoplasms.

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Linked Color Imaging Technology for Diagnosis of Gastric Mucosa-associated Lymphoid Tissue Lymphoma.

Deng P1, Min M2, Ma CY1, Liu Y1.

Chin Med J (Engl). 2017 Sep 7. doi: 10.4103/0366-6999.214137. Epub ahead of print

Mucosa‑associated lymphoid tissue (MALT) lymphoma has previously been diagnosed only by a histological examination of gastric specimens, which made the diagnosis of MALT lymphoma very difficult. Endoscopic findings of gastric MALT lymphoma are variable, and current conventional white‑light endoscopy cannot distinguish the cancerous tissue of MALT lymphoma from inflammation due to its histomorphological similarities. A new endoscopic modality known as linked color imaging (LCI) has been developed that may help in the diagnosis of gastric MALT lymphoma. Here, we reported a case of MALT lymphoma diagnosed by LCI.