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Linked color imaging reduces the miss rate of neoplastic lesions in the right colon: a randomized tandem colonoscopy study

Paggi S1, Mogavero G1, Amato A1, Rondonotti E1, Andrealli A1, Imperiali G1, Lenoci N1, Mandelli G1, Terreni N1, Conforti FS1, Conte D1, Spinzi G1, Radaelli F1.

Endoscopy. 2018 Apr;50(4):396-402. doi: 10.1055/a-0580-7405. Epub 2018 Mar 14.

Background:  Linked color imaging (LCI) is a newly developed image-enhancing endoscopy technology that provides bright endoscopic images and increases color contrast. We investigated whether LCI improves the detection of neoplastic lesions in the right colon when compared with high definition white-light imaging (WLI).

Methods: Consecutive patients undergoing colonoscopy were randomized (1:1) after cecal intubation into right colon inspection at first pass by LCI or by WLI. At the hepatic flexure, the scope was reintroduced to the cecum under LCI and a second right colon inspection was performed under WLI in previously LCI-scoped patients (LCI–WLI group) and vice versa (WLI–LCI group). Lesions detected on first- and second-pass examinations were used to calculate detection and miss rates, respectively. The primary outcome was the right colon adenoma miss rate.

Results: Of the 600 patients enrolled, 142 had at least one adenoma in the right colon, with similar right colon adenoma detection rates (r-ADR) in the two groups (22.7 % in LCI–WLI and 24.7 % in WLI–LCI). At per-polyp analysis, double inspection of the right colon in the LCI–WLI and WLI–LCI groups resulted in an 11.8 % and 30.6 % adenoma miss rate, respectively (P < 0.001). No significant difference in miss rate was found for advanced adenomas or sessile serrated lesions. At per-patient analysis, at least one adenoma was identified in the second pass only (incremental ADR) in 2 of 300 patients (0.7 %) in the LCI – WLI group and in 13 of 300 patients (4.3 %) in the WLI – LCI group (P = 0.01).

Conclusions: LCI could reduce the miss rate of neoplastic lesions in the right colon.

1 Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy.
# Contributed equally

Linked color imaging enhances endoscopic detection of sessile serrated adenoma/polyps

Fujimoto D1, Muguruma N1, Okamoto K1, Fujino Y1, Kagemoto K1, Okada Y1, Takaoka Y1, Mitsui Y1, Kitamura S1, Kimura T1, Miyamoto H1, Bando Y2, Sonoda T3, Takayama T1.

Endoscopy International Open 2018 Mar;6(3):E322-E334. doi: 10.1055/s-0043-124469. Epub 2018 Mar 7.

Background and study aims: Although new image-enhanced endoscopy (IEE) technologies such as blue laser imaging (BLI), BLI-bright, and linked color imaging (LCI) have been developed, their utility for the detection of sessile serrated adenoma/polyps (SSA/Ps) is still unclear. This study aimed to evaluate the utility of BLI, BLI-bright, and LCI for SSA/P detection in still image examinations and in a prospective randomized controlled trial (RCT).

Patients and methods: A group of 6 expert and non-expert endoscopists read 200 endoscopic still images containing SSA/P lesions using white light image (WLI), BLI, BLI-bright, and LCI. Color differences were calculated using the color space method. A prospective RCT of tandem colonoscopy with WLI and LCI was performed. Patients with SSA/P and those with a history of SSA/P that had been endoscopically removed were enrolled and randomly allocated to WLI-LCI or LCI-WLI groups. Additional endoscopic detection rates for SSA/P were compared between the 2 groups.

Results: LCI showed the highest SSA/P detection rate among the 4 modes for both expert and non-expert endoscopists. The detection rate with LCI for the 6 expert endoscopists (mean 98.3 ± standard deviation 2.0 %) was significantly higher than that with WLI (86.7 ± 6.0 %, P < 0.01). Likewise, the detection rate with LCI for the 6 non-expert endoscopists (92.3 ± 2.9 %) was significantly higher than that with WLI (72.7 ± 11.5 %, P < 0.01). The color difference of SSA/P with LCI was the highest among the 4 modes, and was significantly higher than with WLI (median 15.9, (interquartile range 13.7 – 20.6) vs. 10.2, (7.6 – 14.2); P < 0.0001). In the RCT, a total of 44 patients (WLI-LCI 22 vs. LCI-WLI 22) underwent colonoscopy. The additional detection rate for SSA/P in the second inspection in the WLI-LCI group (21.6 %, 8/37) was significantly higher than in the LCI-WLI group (3.2 %, 1/31; P = 0.02). The small, flat, non-mucus and isochromatic SSA/Ps in the transverse colon were detected more frequently in the second inspection with LCI.

Conclusions: LCI was the most sensitive mode for SSA/P detection among WLI, BLI, BLI-bright, and LCI in the still image examinations. Our RCT strongly suggests that LCI is superior to conventional WLI for SSA/P detection during colonoscopy. UMIN000017599.

1 Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan.
2 Division of Pathology, Tokushima University Hospital, Tokushima, Japan.
3 Department of Public Health, Sapporo Medical University School of Medicine, Sapporo, Japan.

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.

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.

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.

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.