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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.


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.


Magnified endoscopic observation of small depressed gastric lesions using linked color imaging with indigo carmine dye.

Kitagawa Y, Hara T, Yamaguchi T, Suzuki T. et al.

Endoscopy. 2017 Sep 27. doi: 10.1055/s-0043-119212. Epub ahead of print

Background and study aims: Magnifying linked color imaging with indigo carmine dye (M-Chromo-LCI) enables sterically enhanced and color image-magnified observation of the superficial gastric mucosa. This study investigated the usefulness of M-Chromo-LCI for the differential diagnosis of gastric lesions.

Patients and methods: 100 consecutive small depressed lesions were examined with conventional white-light imaging (C-WLI), magnifying blue-laser imaging (M-BLI), and M-Chromo-LCI. Endoscopic images were reviewed by three experts and three non-experts. Diagnostic accuracy and interobserver agreement were compared among the modalities.

Results: For experts, M-BLI showed a significantly higher diagnostic accuracy than C-WLI (82.7 % vs. 67.0 %; P < 0.001). The diagnostic accuracy of M-Chromo-LCI was not different from M-BLI (87.7 % vs. 82.7 %; P = 0.31). For non-experts, M-BLI showed a significantly higher diagnostic accuracy than C-WLI (69.3 % vs. 52.3 %; P < 0.001). M-Chromo-LCI additionally showed a significantly higher diagnostic accuracy than M-BLI (79.7 % vs. 69.3 %; P = 0.005). M-Chromo-LCI had the highest interobserver agreement for each group.

Conclusions: M-Chromo-LCI is expected to become a useful modality for the accurate diagnosis of gastric lesions.


Evaluation of image-enhanced endoscopic technology using advanced diagnostic endoscopy for the detection of early gastric cancer: a pilot study

Daisuke Yamaguchi, Mitsuhiro Fujishiro, Kazuhiko Koike, et al.

Endosc Int Open. 2017 Sep; 5(9): E825–E833.

Background and study aims: Image-enhanced endoscopy (IEE) plays an important role in early detection and detailed examination of early gastric cancer (EGC). The current study aimed to clarify the efficacy of IEE using advanced diagnostic endoscopy for EGC detection without magnification.

Patients and methods: We performed endoscopic examinations without magnification in patients referred to our hospital with a diagnosis of upper gastrointestinal tumor detected through routine screening endoscopy. In this study, we used three IEE technologies: narrow-band imaging; blue laser imaging; and i-scan optical enhancement. The detection rates for EGC between IEE and white-light imaging (WLI) were compared.

Results: Between July 2013 and June 2014, 156 patients were enrolled. Among upper gastrointestinal tumors, we analyzed endoscopic examination results of 119 lesions that were histologically diagnosed as EGC in 109 patients. The EGC detection rate in the IEE plus WLI groups was 77.3 %. Although the EGC detection rate in the IEE group was higher than that in the WLI group (80.0 % vs. 70.3 %), there was no significant difference between these two modalities. An important detection factor using IEE was tumor circumference, where the rate of detection in the anterior wall and lesser curvature was significantly higher than that in the posterior wall and greater curvature ( P  = 0.046). An important detection factor using WLI was color variation, where the rate of occurrence of a reddened or pale tumor was significantly higher than that of normal colored tumors ( P  = 0.030).

Coclusions: The detection rate of EGC without magnification was similar between the IEE group and the WLI group. Important detection factors differed between IEE and WLI; therefore, the IEE and WLI modalities have different characteristics regarding EGC detection. Consequently, we propose to use both IEE and WLI in the evaluation of EGC.


Magnifying Blue Laser Imaging versus Magnifying Narrow-Band Imaging for the Diagnosis of Early Gastric Cancer: A Prospective, Multicenter, Comparative Study.

Dohi O1, Yagi N, Yoshida S, Ono S, Sanomura Y, Tanaka S, Naito Y, Kato M.

Digestion. 2017 Aug 26;96(3):127-134. doi: 10.1159/000479553.

Background/Aims: The diagnostic efficacy of magnifying blue laser imaging (M-BLI) and M-BLI in bright mode (M-BLI-bright) in the identification of early gastric cancer (EGC) was evaluated for comparison to that of magnifying narrow-band imaging (M-NBI).

Methods: This prospective, multicenter study evaluated 114 gastric lesions examined using M-BLI, M-BLI-bright, and M-NBI between May 2012 and November 2012; 104 EGCs were evaluated by each modality. The vessel plus surface classification system was used to evaluate the demarcation line (DL), microvascular pattern (MVP), and microsurface pattern (MSP).

Results: M-BLI, M-BLI-bright, and M-NBI revealed a DL for 96.1, 98.1, and 98.1% and irregular MVP for 95.1, 95.1, and 96.2% of lesions, respectively, with no significant difference. Irregular MSP was observed by M-BLI, M-BLI-bright, and M-NBI in 97.1, 90.4, and 78.8% of lesions, respectively, with significant differences (p < 0.001). The proportion of moderately differentiated adenocarcinoma with irregular MSP on M-BLI and absent MSP on M-NBI was significantly higher than that with irregular MSP on M-BLI and M-NBI (35.0 and 9.9%, respectively; p = 0.002).

Conclusion: M-BLI and M-BLI-bright provided excellent visualization of microstructures and microvessels similar to M-NBI. Irregular MSP in a moderately differentiated adenocarcinoma might be frequently visualized using M-BLI and M-BLI-bright compared with using M-NBI.


Magnifying Endoscopy with Blue Laser Imaging improves the Microstructure Visualization in Early Gastric Cancer: Comparison of Magnifying Endoscopy with Narrow-Band Imaging

Reiko Kimura-Tsuchiya, Osamu Dohi, Yoshito Itoh. et al.

Gastroenterol Res Pract. 2017;2017:8303046. doi: 10.1155/2017/8303046. Epub 2017 Aug 30.

Backgrounds: Magnifying endoscopy with blue laser imaging (ME-BLI) for diagnosis of early gastric cancer (EGC) is as effective as magnifying endoscopy with narrow-band imaging (ME-NBI). However, there are different EGCs in microstructure visualization between ME-BLI and ME-NBI. This study aimed to clarify the pathological features of the EGCs, in which microstructure visualization was different between ME-NBI and ME-BLI.

Methods: EGCs were classified into groups A (irregular microsurface pattern (MSP) in ME-BLI and absent MSP in ME-NBI), B (irregular MSP in two modalities), or C (absent MSP in two modalities), according to the vessel plus surface classification. We compared the pathological features of EGCs between the three groups.

Results: 17, four, and five lesions could be evaluated in detail in groups A, B and C, respectively. Well-differentiated adenocarcinomas with shallow crypts were more frequent in group A than in group B (58.8 and 0%, resp.). The mean crypt depth of group A was significantly shallower than that of group B (56 ± 20, 265 ± 64 μm, resp., P = 0.0002).

Conclusions: ME-BLI could better visualize the microstructures of the EGCs with shallow crypts compared with ME-NBI. Therefore, ME-BLI could enable a more accurate diagnosis of EGC with shallow crypts.


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.

Purpose: Linked color imaging (LCI) by laser endoscopy is a novel narrow band light observation. In this study, we analyzed the efficacy of LCI for improving the various featured colorectal polyp’s visibility utilizing a subjective endoscopist’s visibility scoring and objective color difference (CD) value.

Methods: We retrospectively reviewed two pictures both with white light (WL) and LCI for 54 consecutive neoplastic polyps 2-20 mm in size. All pictures were evaluated by four endoscopists according to a published polyp visibility score from four (excellent visibility) to one (poor visibility). Additionally, we calculated CD value between each polyp and surrounding mucosa in LCI and WL using an original software.

Results: The mean polyp visibility scores of LCI (3.11 ± 1.05) were significantly higher than those of WL (2.50 ± 1.09, P < 0.001). The ratio of an endoscopist’s poor visibility (polyp visibility scores 1 and 2) was significantly lower in LCI (27.9%) than WL (55.6%, P < 0.001). With respect to the CD analysis, the CD value of LCI was significantly higher than that of WL (33.3 ± 13.9 vs. 20.7 ± 13.6, P < 0.001). In a subgroup analysis, the polyp visibility scores and CD values of LCI about 24 diminutive polyps (≤5 mm) were higher than those of WL (3.29 ± 0.99 vs. 2.12 ± 0.99, P < 0.001; 31.6 ± 12.8 vs. 14.7 ± 7.6, P < 0.001). Additionally, the polyp visibility scores and CD values of LCI for polyps with any location, size, histology, and morphology were significantly higher than those of WL.

Conclusions: LCI improved the various featured polyp’s visibility compared to WL in both polyp visibility scores and CD value.


Advances in image enhancement in colonoscopy for detection of adenomas.

Matsuda T, Ono A, Sekiguchi M, Fujii T, Saito Y

Nat Rev Gastroenterol Hepatol. 2017 May;14(5):305-314

High-quality colonoscopy is mandatory to prevent adenoma recurrence and colorectal cancer. In the past few years, technical advances have been developed with the purpose of improving adenoma detection rate (ADR), one of the most important validated colonoscopy quality benchmarks. Several techniques or devices are used to optimize visualization: observation techniques; add-on devices; auxiliary imaging devices; colonoscopes with increased field of view; and colonoscopes with an integrated inflatable reusable balloon. Image-enhanced endoscopy (IEE) facilitates the detection and characterization of polyps and especially nonpolypoid colorectal neoplasms. Indigo carmine is the most frequently used dye in colonoscopy as it deposits in depressed areas, improving detection of flat and depressed lesions. Virtual chromoendoscopy has emerged as an effective contrast enhancement technology without the limitation of preparing dyes and applying them through the colonoscope working channel. Narrow-band imaging (NBI) enhances the capillary pattern and surface of the mucosa using optical filters, and second-generation NBI provides a twofold brighter image than the previous system, yielding promising ADR results. Moreover, a second-generation blue laser imaging system, LASEREO, has been reported to improve not only polyp detection rate but also ADR, becoming a promising IEE modality. Herein, we describe technical advances in colonoscopy imaging and their effect on ADR.


Linked color imaging improves the visibility of colorectal polyps: a video study

Naohisa Yoshida1, Yuji Naito1, Takaaki Murakami1, Ryohei Hirose1, Kiyoshi Ogiso1, Yutaka Inada1, etc

Endoscopy International Open 2017; 05: E518–E525 Impact factor 5.196

Background and study aim: Linked color imaging (LCI) by a laser endoscope (Fujifilm Co, Tokyo, Japan) is a novel narrow band light observation. In this study, we aimed to investigate whether LCI could improve the visibility of colorectal polyps using endoscopic videos.

Patients and methods: We prospectively recorded videos of consecutive polyps 2 – 20 mm in size diagnosed as neoplastic polyps. Three videos, white light (WL), blue laser imaging (BLI)-bright, and LCI, were recorded for each polyp by one expert. After excluding inappropriate videos, all videos were evaluated in random order by two experts and two non-experts according to a published polyp visibility score from four (excellent visibility) to one (poor visibility). Additionally, the relationship between polyp visibility scores in LCI and various clinical characteristics including location, size, histology, morphology, and preparation were analyzed compared to WL and BLI-bright.

Results: We analyzed 101 colorectal polyps (94 neoplastic) in 66 patients (303 videos). The mean polyp size was 9.0 ± 8.1 mm and 54 polyps were non-polypoid. The mean polyp visibility scores for LCI (2.86 ±1.08) were significantly higher than for WL and BLI-bright (2.53 ±1.15, P < 0.001; 2.73 ± 1.47, P <0.041). The ratio of poor visibility (score 1 and 2) was significantly lower in LCI for experts and non-experts (35.6 %, 33.6 %) compared with WL (49.6 %, P = 0.015, 50.5 %, P = 0.046). The polyp visibility scores for LCI were significantly higher than those for WL for all of the factors. With respect to the comparison between BLI-bright and WL, the polyp visibility scores for BLI-bright were not higher than WL for right-sided location, < 10 mm size, sessile serrated adenoma and polyp histology, and poor preparation. For those characteristics, LCI improved the lesions with right-sided location, SSA/P histology, and poor preparation significantly better than BLI.

Conclusions: LCI improved polyp visibility compared to WL for both expert and non-expert endoscopists. It is useful for improving polyp visibility in any location, any size, any morphology, any histology, and any preparation level.


Endoscopic Submucosal Dissection of a Rectal Neuroendocrine Tumor Using Linked Color Imaging Technique.

Xiao-Tian Sun1, Min Min2, Yi-Liang Bi2, Yang Xu2, Yan Liu2

Chin Med J (Engl). 2017 May 5 Impact factor 0.957

Endoscopic submucosal dissection (ESD) has been widely applied in clinical practice for resecting gastrointestinal mucosal lesions. However, the risk of post-ESD complications is relatively high, and the bleeding is one of the most common complications after ESD, which needs timely detection and treatment. At recent, several new endoscopic imaging techniques have been developed to improve the diagnostic efficiency. Linked color imaging (LCI), which is a newly developed endoscopic technique,[1],[2] could enhance the color contrast and thus have advantage of identifying bleeding points during ESD. So far, whether the application of LCI in ESD procedure is feasible and safe has not been ever explored. In this report, we described a patient with rectal neuroendocrine tumor who was successfully treated by ESD using LCI.

The dissection was completed under WLE mode, which could clearly observe the mucosa and submucosal vessels. If the bleeding was suspected, LCI mode was used, which was easier to detect the bleeding point located in superficial submucosa [Supplementary Video 2]. The postoperative wound should be observed combining WLE and LCI mode, which could effectively handle the superficial and deep vessels and prevent postoperative bleeding.

This report demonstrated that LCI technique could be safe and effective in the application of ESD for rectal neuroendocrine tumor. LCI is a new endoscopic technique, which has a high diagnostic field. The report rarely demonstrated that the application of LCI during ESD was feasible and safe. Furthermore, the observation under LCI mode could identify the bleeding points, enabling the complete hemostasis. LCI mode is quite efficient in detecting the bleeding points during ESD, while WLE mode is recommended for the dissection procedure to avoid vascular damage. The clinical application of LCI might be further examined in future clinical trial.