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Linked Color Imaging and Blue Laser Imaging for Upper Gastrointestinal Screening.

Osawa H1, Miura Y1, Takezawa T1, Ino Y1, Khurelbaatar T1, Sagara Y1, Lefor AK2, Yamamoto H1.

Clin Endosc. 2018 Nov 2. doi: 10.5946/ce.2018.132. [Epub ahead of print]

White light imaging (WLI) may not reveal early upper gastrointestinal cancers. Linked color imaging (LCI) produces bright images in the distant view and is performed for the same screening indications as WLI. LCI and blue laser imaging (BLI) provide excellent visibility of gastric cancers in high color contrast with respect to the surrounding tissue. The characteristic purple and green color of metaplasias on LCI and BLI, respectively, serve to increase the contrast while visualizing gastric cancers regardless of a history of Helicobacter pylori eradication.
LCI facilitates color-based recognition of early gastric cancers of all morphological types, including flat lesions or those in an H. pylori-negative normal background mucosa as well as the diagnosis of inflamed mucosae including erosions. LCI reveals changes in mucosal color before the appearance of morphological changes in various gastric lesions. BLI is superior to LCI in the detection of early esophageal cancers and abnormal findings of microstructure and microvasculature in close-up views of upper gastrointestinal cancers. Excellent images can also be obtained with transnasal endoscopy. Using a combination of these modalities allows one to obtain images useful for establishing a diagnosis. It is important to observe esophageal cancers (brown) using BLI and gastric cancers (orange) surrounded by intestinal metaplasia (purple) and duodenal cancers (orange) by LCI.

1 Division of Gastroenterology, Department of Medicine
2 Department of Surgery, Jichi Medical University, Shimotsuke, Japan

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Linked color imaging improves detection of minimal change esophagitis in non-erosive reflux esophagitis patients.

Deng P1, Min M1, Dong T1, Bi Y1, Tang A1, Liu Y1

Endosc Int Open. 2018 Oct;6(10):E1177-E1183. doi: 10.1055/a-0602-3997. Epub 2018 Oct 8.

Background and study aims: Non-erosive reflux disease (NERD) includes minimal change esophagitis (MCE) and no endoscopic abnormalities. However, for most endoscopists, it is difficult to detect MCE with conventional white-light endoscopy (WLE). Linked color imaging (LCI) technology is the most recently developed image-enhancing technology and improves detection and differentiation of subtle mucosal changes using a color contrast method. This study assessed the efficacy of WLE combined with LCI for diagnosing MCE compared with WLE.

Patients and methods: Between February and May 2017, 44 NERD patients and 40 healthy subjects were enrolled in our study. First, the distal esophagus was examined using WLE followed by LCI. Second, three experienced endoscopists observed all the patients’ white-light (WL) images and corresponding images of WL and LCI and then recorded presence or absence of minimal change esophagitis (MCE +/-). The proportion of minimal change between the two groups was then compared. Third, five blinded endoscopists with different levels of endoscopic experience assessed whether MCE was present. Intraobserver reproducibility and interobserver agreement were described using the kappa value.

Results: The proportion of MCE in the NERD group (70.8 %, 35/48) was higher than that in the control group (22.5 %, 9/40, P  < 0.001) when diagnosed by the three experienced endoscopists. Detection rates for MCE using WLE combined with LCI were higher than those using WLE (43/88, 48.9 % vs. 29/88, 33.0 %, P  < 0.001). With WLE combined with LCI, intraobserver reproducibility significantly improved, indicating that the combined approach can improve interobserver agreement compared with using WLE alone.

Conclusions:  Endoscopic diagnosis of MCE using WLE combined with LCI images is effective. Intraobserver reproducibility and interobserver agreement in MCE can be improved when LCI is applied with conventional imaging.

1 Department of Gastroenterology and Hepatology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, China

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Blue laser imaging: a new image-enhanced endoscopy for the diagnosis of colorectal lesions.

Dos Santos CEO1, Malaman D1, Yoshida N2, Pereira-Lima JC3, Onófrio FQ3, Furlan RG1, Tabushi FI4, Malafaia O4 .

Eur J Gastroenterol Hepatol. 2018 Oct 2. doi: 10.1097/MEG.0000000000001278. [Epub ahead of print]

Background: Image-enhanced endoscopy enables real-time differential diagnosis of colorectal lesions through the observation of microvascular architecture.

Purpose: To evaluate the efficacy of using blue laser imaging (BLI) for capillary pattern analysis in the differential diagnosis of neoplastic and non-neoplastic lesions.

Patients and methods: This prospective study included 920 consecutive superficial lesions diagnosed in 457 patients. The capillary pattern was analysed using BLI-bright magnification on the basis of the Teixeira classification. Histopathology was used as the reference standard.

Results: The adenoma detection rate was 42.3%, with a mean of 0.95 adenomas per patient. Neoplastic lesions were predominant (70.3%), of which 33 (5.1%) had advanced histology. Neoplastic progression was significantly increased in patients aged at least 50 years, in lesions at least 10 mm and in lesions located in the right colon (P<0.01). BLI-based capillary pattern analysis showed 95.5% accuracy, 95.7% sensitivity, 95.2% specificity, 97.9% positive predictive value and 90.3% negative predictive value in the diagnosis of neoplastic lesions. For 672 diminutive lesions (≤5 mm), BLI-based capillary pattern analysis showed 95.7% accuracy, 96.6% sensitivity, 93.6% specificity, 97.2% positive predictive value and 92.2% negative predictive value. Analysing only lesions up to 5 mm in the rectum and sigmoid colon, the values were 95.2, 93.9, 96.5, 95.8 and 94.8%, respectively.

Conclusion: BLI associated with magnification yielded excellent results for the real-time predictive histological diagnosis of colorectal lesions.

1 Department of Endoscopy and Gastroenterology, Santa Casa de Caridade hospital, Bagé
2 Department of Gastroenterology and Endoscopy, Santa Casa Hospital, Porto Alegre
3 department of Surgery, Faculdade Evangélica do Paraná, Curitiba, Brazil
4 Department of Molecular Gastroenterology and Hepatology, Graduate School of Mecdical Science, Koyo Prefectural University of Medicine, Kyoto, Japan

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Linked color imaging can enhance recognition of early gastric cancer by high color contrast to surrounding gastric intestinal metaplasia.

Fukuda H1, Miura Y1, Osawa H2, Takezawa T1, Ino Y1, Okada M1, Khurelbaatar T1, Lefor AK1, Yamamoto H1.

J Gastroenterol. 2018 Oct 5. doi: 10.1007/s00535-018-1515-6. [Epub ahead of print]

Background: Linked color imaging (LCI) increases the visibility of early gastric cancers, which may be associated with characteristic findings including background purple mucosae. These lesions are found in areas of chronic gastritis and surrounding mucosa. The aim of this study is to objectively characterize these lesions by color differences and color component values using LCI.

Methods: Fifty-two patients with early gastric cancer were enrolled. Color differences were calculated prospectively in malignant lesions and adjacent mucosa and compared with histological findings in resected specimens. Color component values of L, a, and b* were compared between purple and non-purple mucosae in areas of chronic gastritis. Based on histological findings, the accuracy of identifying gastric intestinal metaplasia was calculated.

Results: Cancers and surrounding mucosa in 74% of lesions had similar colors using white light imaging (WLI), whereas purple mucosa surrounded part or all of cancers appearing orange-red, orange or orange-white using LCI. Greater color differences were seen using LCI compared to WLI, including flat-type cancers, leading to higher contrast. The surrounding purple mucosa corresponded histologically to intestinal metaplasia, facilitating the identification of malignant lesions. Forty lesions (83%) with purple mucosa and eight lesions (17%) with non-purple mucosa in areas of chronic gastritis were diagnosed as intestinal metaplasia by biopsy (83% accuracy). Color component values of purple mucosa differ significantly from those of non-purple mucosae.

Conclusions: LCI images have higher color contrast between early gastric cancers and surrounding mucosa compared to WLI. A characteristic purple color around gastric cancers using LCI represents intestinal metaplasia.

1 Division of Gastroenterology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan
2 Department of Surgery, Jichi Medical University, Shimotsuke, Japan

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Blue-light imaging compared with high-definition white light for real-time histology prediction of subcentimetric colorectal polyps: a prospective randomized study.

Rondonotti E1, Paggi S1, Amato A1, Mogavero G1,2, Andrealli A1, Conforti FS1,3, Conte D1, Spinzi G1, Radaelli F1.

Gastrointest Endosc. 2018 Sep 28. pii: S0016-5107(18)33137-7. doi: 10.1016/j.gie.2018.09.027. [Epub ahead of print]

Background and aims: Blue light imaging (BLI) is a new chromoendoscopy technology, potentially useful for differentiating neoplastic from non-neoplastic lesions. Present study was aimed at comparing BLI with high-definition white light (HDWL) in the real-time histology prediction of subcentimetric (<10 mm) colonic polyps.

Methods: Consecutive outpatients undergoing colonoscopy with ELUXEO 7000 endoscopy platform and 760 series videocolonscopes (Fujifilm Co, Tokyo, Japan) having at least one polyp <10 mm, were randomized to BLI or HDWL for polyp characterization. The accuracy of high-confidence real-time histology prediction (adenoma vs. non-adenoma) by either BLI or HDWL for subcentrimentic (primary end-point) and diminutive (<5mm) polyps was calculated, along with sensitivity, specificity, positive and negative predictive values, with histopathology as the reference standard.

Results: A total of 483 polyps were detected in 245 randomized patients (125 and 120 in the BLI and HDWL arms, respectively); 358 were diminutive and 283 adenomas. Overall, 222 (85.7%) and 193 (86.1%) polyps were characterized with high-confidence by BLI and HDWL, respectively (p=0.887), with an overall accuracy of 92% and 84%, respectively (p=0.011). The accuracy was significantly higher by BLI than HDWL also for diminutive polyps (92% vs. 83%; p=0.008). When BLI was used, the negative predictive value for diminutive rectosigmoid polyps was 88% and the post-polypectomy surveillance interval was correctly attributed in 85.7% and 93.7% of patients, according to U.S. and European guidelines respectively.

Conclusions: The BLI was superior to HDWL for the real-time prediction of subcentimetric polyp histology. A BLI-dedicated classification might further improve the endoscopists’ performances.

1 Gastroenterology Unit, Valduce Hospital, Como, Italy.
2 Gastroenterology Unit, Biomedical Department of Internal and Specialized Medicine (Di.Bi.M.I.S.), University of Palermo, Palermo, Italy.
3 Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.

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Diffuse redness in linked color imaging is useful for diagnosing current Helicobacter pylori infection in the stomach.

Masaya Iwamuro 2, Hiroyuki Sakae 1, Hiromitsu Kanzaki 1, PhD Hiroyuki Okada 2

Journal of General and Family Medicine

Abstract: Esophagogastroduodenoscopic examination shows diffuse redness of the mucosa of the gastric body, which can be identified as a deep reddish color. The present case underscores the importance of diffuse redness as a key endoscopic feature that enables prompt diagnosis of current Helicobacter pylori infection.

1 Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry
2 Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

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Blue laser imaging with acetic acid enhancement improved the detection rate of gastric intestinal metaplasia.

Chen H1, Wu X2, Liu Y1, Wu Q1, Lu Y1, Li C1.

Lasers Med Sci. 2018 Sep 6. doi: 10.1007/s10103-018-2629-z. [Epub ahead of print]

Abstract: Our aim was to evaluate the ability of blue laser imaging (BLI) combined with acetic acid (BLI-AA) to detect gastric intestinal metaplasia (GIM). Participants undergoing gastroscopy from July 2017 to February 2018 in our hospital were enrolled prospectively. The abilities of white light imaging endoscopy, BLI endoscopy, and BLI-AA to detect GIM were compared. One hundred six patients undergoing gastroscopy met the inclusion criteria. GIM was diagnosed in 41 patients. For BLI-AA, the sensitivity, specificity, positive predictive, and negative predictive values were 85.4%, 84.6%, 77.8%, and 90.2% respectively. The diagnostic accuracy rate for BLI-AA was 84.9%, which was higher than that of white light imaging endoscopy and BLI endoscopy. For target biopsy, the GIM detection rate for the BLI-AA mode was significantly higher (77.8%, 105/135) than that for the BLI mode (58.3%, 84/144) or the white light endoscopy mode (40.4%, 57/141) (p < 0.05). BLI-AA is an efficient and simple method for the detection of GIM.

1 Department of Gastrointestinal Endoscopy, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, No.26 Yuancun Er Heng Rd, Tianhe District, Guangzhou 510655, Guangdong Province. People´s Republic of China
2 Department of Gastrointestinal Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, No.26 Yuancun Er Heng Rd, Tianhe District, Guangzhou 510655,
Guangdong Province. People´s Republic of China

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Blue laser imaging-bright improves real-time detection rate of early gastric cancer: a randomized controlled study.

Dohi O1, Yagi N2, Naito Y1, Fukui A4, Gen Y4, Iwai N1, Ueda T1, Yoshida N1, Kamada K1, Uchiyama K1, Takagi T1, Konishi H1, Yanagisawa A4, Itoh Y1.

Gastrointest Endosc. 2018 Sep 3. pii: S0016-5107(18)33008-6. doi: 10.1016/j.gie.2018.08.049. [Epub ahead of print]

Background and aims: Blue laser imaging (BLI)-bright (BLI-bright) has shown promise as a more useful tool for detection of early gastric cancer (EGC) than white-light imaging (WLI). However, the diagnostic performance of BLI-bright in the detection of EGC has not been investigated. We aimed to compare real-time detection rates of WLI with that of BLI-bright for EGC.

Methods: This was a prospective, randomized, controlled study in 2 Japanese academic centers. We investigated 629 patients undergoing follow-up endoscopy for atrophic gastritis with intestinal metaplasia or surveillance after endoscopic resection of EGC. Patients were randomly assigned to receive primary WLI followed by BLI-bright or primary BLI-bright followed by WLI. The real-time detection rates of EGC were compared between primary WLI and primary BLI-bright.

Results: Of 298 patients in each group, the real-time detection rate of EGC with primary BLI-bright was significantly greater than that with primary WLI (93.1% vs 50.0%; p = 0.001). Primary BLI-bright had a significantly greater ability to detect EGCs in patients with a history of endoscopic resection for EGC, an HP-negative stomach after eradication therapy, lesions with an open-type atrophic border, lesions in the lower third of the stomach, depressed-type lesions, small lesions measuring <10 mm and 10 to 20 mm in diameter, reddish lesions, well-differentiated adenocarcinomas, and lesions with a depth of invasion of T1a.

Conclusions: BLI-bright has a higher real-time EGC detection rate than WLI. BLI-bright should be performed during surveillance endoscopy in patients at high risk for EGC.

1 Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
2 Department of Gastroenterology and Hepatology, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
3 Department of Gastroenterology, Murakami Memorial Hospital, Asahi University, Gifu, Japan
4 Department of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan

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Blue Laser Imaging with a Small-Caliber Endoscope Facilitates Detection of Early Gastric Cancer.

Takahashi H1, Miura Y1, Osawa H1, Takezawa T1, Ino Y1, Okada M1, Lefor AK2, Yamamoto H1.

Clin Endosc. 2018 Aug 14. doi: 10.5946/ce.2018.100. [Epub ahead of print]

Abstract: Conventional endoscopy often misses early gastric cancers with minimal red discoloration because they cannot be distinguished from inflamed mucosa. We treated a patient with a small early gastric cancer that was difficult to diagnose using conventional endoscopy. Conventional endoscopy using a small-caliber endoscope showed only subtle red discoloration of the gastric mucosa. However, blue laser imaging showed a clearly discolored area measuring 10 mm in diameter around the red lesion, which was distinct from the surrounding inflamed mucosa. Irregular vessels on the tumor surface (suspicious for early gastric cancer) were observed even with small-caliber endoscopy. Biopsy revealed a well-moderately differentiated tubular adenocarcinoma, and endoscopic submucosal dissection was performed. Histopathological examination of the specimen confirmed well-moderately differentiated adenocarcinoma localized to the mucosa with slight depression compared to the surrounding mucosa, consistent with the endoscopic findings. This small early gastric cancer became clearly visible with blue laser imaging using small-caliber endoscopy.

1 Division of Gastroenterology, Department of Medicine
2 Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan

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Additional Thirty Seconds Observation with Linked Color Imaging Improves Detection of Missed Polyps in the Right-Sided Colon.

Yoshida N1, Inada Y2, Yasuda R1, Murakami T1, Hirose R1, Inoue K1, Dohi O1, Naito Y1, Ogiso K3, Morinaga Y4, Kishimoto M4, Konishi E4, Itoh Y1.

Gastroenterol Res Pract. 2018 Jul 8;2018:5059834. doi: 10.1155/2018/5059834. eCollection 2018.

Background and aims: Missed polyps are a pitfall of colonoscopy. In this study, we analyzed the efficacy of an additional 30 seconds observation using linked color imaging (LCI) for detecting adenoma and sessile serrated adenoma/polyp (SSA/P).

Materials and methods: We enrolled patients undergoing colonoscopy from February to October 2017 in two institutions. In all patients, the cecum and ascending colon were observed with white light imaging (WLI) first. The colonoscope was inserted again, and the cecum and ascending colon were observed for an additional 30 seconds using either LCI or WLI. The method for the 30 sec observation was to insufflate the cecum and ascending colon sufficiently and observe them in a distant view, because the length of the second observation was determined to be precisely 30 sec. For the second observation, LCI was performed for the first 65 patients and WLI for the next 65. Adenoma and SSA/P detection rate (ASDR) in the second observation were examined in both groups. According to a pilot study, the sample size was estimated 65.

Results: In the first observation, ASDR were 30.7% in the LCI group and 32.2% in the WLI group (p = 0.85). For the second observation, 13 polyps were detected in the LCI group and 5 polyps in the WLI group (p = 0.04). Additionally, ASDR for the second observation were 18.5% and 6.1%, respectively (p = 0.03). There were no significant differences between the LCI and WLI groups with respect to morphology (ratio of polypoid) (38.5% versus 60.0%, p = 0.52) and histology (ratio of adenoma) (92.3% versus 100.0%, p = 0.91). Total adenoma and SSA/P number were 48 in the LCI group and 36 in the WLI group (p = 0.02).

Conclusion: The 30 seconds additional observation with LCI improved the detection of adenoma and SSA/P in the right-sided colon.

1 Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
2 Department of Gastroenterology, Fukuchiyama City Hospital, Kyoto, Japan
3 Department of Gastroenterology, Osaka General Hospital of West Japan Railway Company, Osaka, Japan
4 Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan