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Linked color imaging improves the endoscopic visibility of gastric mucosal cancers.

Kitagawa Y1, Suzuki T1, Hara T2, Nankinzan R1, Takashiro H1, Sugita O1, Imazeki H3, Yamaguchi T3.

Endosc Int Open. 2019 Feb;7(2):E164-E170. doi: 10.1055/a-0733-7086. Epub 2019 Jan 18.

Background and study aims: As a newly developed endoscopy technique, linked color imaging (LCI) provides very bright images with enhanced color tones. With the objective of improving the detection rate of gastric mucosal cancers, which are often difficult to detect, we examined the utility of LCI from the viewpoint of visibility.

Patients and methods: The current study used 100 consecutive gastric mucosal cancers ≤ 20 mm in diameter. For each lesion, we selected one endoscopic image acquired by white-light imaging (WLI), blue-laser imaging (BLI) -bright, and LCI modes. Four endoscopists interpreted the images; using a previously reported scale, we scored the visibility level on a scale of 1 - 4.

Results: The mean (± SD) visibility scores were 2.54 ± 1.10 for WLI, 3.02 ± 1.07 for BLI-bright, and 3.28 ± 0.97 for LCI. The score was significantly higher for BLI-bright compared with WLI ( P  < .001) and again higher for LCI compared with BLI-bright ( P  < .001). For the experts, the scores for BLI-bright and LCI were similar, but both were significantly higher than the score for WLI. For the trainees, there was no significant difference between the WLI and BLI-bright scores, but LCI score was significantly higher than those for WLI and BLI-bright scores. With regard to clinical characteristics, LCI particularly enhanced visibility of normochromic, flat and depressed lesions, which had the lowest visibility scores of all three modalities compared with those of the other lesions.

Conclusion: LCI increased visibility and may contribute to early detection of gastric mucosal cancers.

1 Endoscopy Division, Chiba Cancer Center, Chiba, Japan
2 Hara Clinic, Chiba, Japan
3 Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan


Advanced Treatment and Imaging in Colonoscopy: The Pocket-Creation Method for Complete Resection and Linked Color Imaging for Better Detection of Early Neoplastic Lesions by Colonoscopy.

Yamamoto H1, Shinozaki S2, Hayashi Y1, Miura Y1, Khurelbaatar T1, Osawa H1, Lefor AK3.

Clin Endosc. 2019 Jan 10. doi: 10.5946/ce.2018.189. [Epub ahead of print]

Early detection and resection of neoplastic lesions are key objectives to diminish colorectal cancer mortality. Resection of superficial colorectal neoplasms, cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection have all been developed and used worldwide. The pocket-creation method facilitates the resection of tumors in difficult and routine locations. Early detection is the most important first step to maximize the benefits of recent advancements in endoscopic techniques. However, the detection of small, flat-shaped, or faded color lesions remains difficult. Linked color imaging, a novel multi-light technology, facilitates the recognition of minor differences in tissue by enhancing the color contrast between early colorectal neoplasms and surrounding normal mucosa in a bright field of view. The most striking feature of linked color imaging is its ability to display the color of early neoplastic lesions as distinct from inflammatory changes, both of which have similar “redness” when viewed using white light imaging. To increase the detection rate of neoplasms, linked color imaging should be used from the outset for endoscopic observation. Early detection of superficial colorectal tumors can result in decreased mortality from colorectal cancer and maintain a good quality of life for patients.

1 Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke
2 Shinozaki Medical Clinic, Utsunomiya,
3 Department of Surgery, Jichi Medical University, Shimotsuke, Japan


Spraying l-menthol enhances gastric intestinal metaplasia in linked color imaging.

Ono S1, Ono Y2, Sakamoto N3.

Dig Endosc. 2019 Jan 28. doi: 10.1111/den.13362. [Epub ahead of print]

Recently, there have been some reports that image-enhanced endoscopy (IEE) may be useful for detection of gastric intestinal metaplasia (GIM) (1, 2). Linked color imaging (LCI) enables noninvasive detection of GIM as a lavender color, which is called lavender color sign (LCS) (3). Spraying l-menthol directly onto the gastric antral mucosa is useful for anti-peristalsis. As a secondary effect of spraying l-menthol, Mori et al. reported annular-reticular-like mucosal changes that were mucosal morphologic changes. This article is protected by copyright. All rights reserved.

1 Department of Gastroenterology, Hokkaido University Hospital, Sapporo
2 Department of Gastroenterology, Sapporo City Hospital, Sapporo
3 Department of Gastroenterology and Hepatology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.


Quantitative Comparisons of Linked Color Imaging and White-Light Colonoscopy for Colorectal Polyp Analysis

Xinran Wei 1 , Jiyang Xie 1 , Wenrui He 1 , Min Min 2, Zhanyu Ma 1 and Jun Guo 1

The performance of imaging techniques has an important influence on the clinical diagnostic strategy of colorectal cancer. Linked color imaging (LCI) by laser endoscopy is a recently developed techniques, and its advantage in improving the analysis accuracy of colorectal polyps over white-light (WL) endoscopy has been demonstrated in previous clinical studies. However, there are no objective criteria to evaluate and compare the aforementioned endoscopy methods. This paper presents a new criterion, namely entropy of color gradients image (ECGI), which is based on color gradients distribution and provides a comprehensive and objective evaluating indicator of the performance of colorectal images. Our method extracts the color gradient image pairs of 143 colonoscopy polyps in the LCI-PairedColon database, which are generated with WL and LCI conditions, respectively. Then, we apply the morphological method to fix the deviation of light-reflecting regions, and the ECGI scores of sample pairs are calculated. Experimental results show that the average ECGI scores of LCI images (5.7071) were significantly higher than that of WL (4.6093). This observation is consistent with the clinical studies. Therefore, the effectiveness of the proposed criterion is demonstrated.

1 Pattern Recognition and Intelligent Systems Lab, Beijing University of Posts and Telecommunications, Beijing, China
2 Department of Gastroenterology and Hepatology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, China


Optical diagnosis of colorectal polyps with Blue Light Imaging using a new international classification

Sharmila Subramaniam1, Bu Hayee2, Patrick Aepli3, Erik Schoon4, Milan Stefanovic5, Kesavan Kandiah1, Sreedhari Thayalasekaran1, Asma Alkandari1, Paul Bassett6, Emmanuel Coron7, Oliver Pech8, Cesare Hassan9, Helmut Neumann10, Raf Bisschops11, Alessandro Repici12 and Pradeep Bhandari1

United European Gastroenterology Journal 0(0) 1–10 Received: 1 October 2018; accepted: 21 November 2018

Abstract Background: Blue Light Imaging (BLI) is a new imaging technology that enhances mucosal surface and vessel patterns. A specific BLI classification was recently developed to enable better characterisation of colorectal polyps (BLI Adenoma Serrated International Classification (BASIC)). The aim of this study was to validate the diagnostic performance of BASIC in predicting polyp histology in experienced and trainee endoscopists.

Methods: Five experienced and five trainee endoscopists evaluated high-definition white light (HDWL) and BLI images from 45 small polyps to assess baseline accuracy, sensitivity, specificity, and positive and negative predictive values (NPVs) of polyp histology. Each endoscopist was trained with the BLI classification before repeating the exercise. Results were compared pre- and post-training.

Results: The overall pre-training accuracy improved from 87% to 94%. The sensitivity and NPV of adenoma diagnosis also improved significantly from 79% to 96% and 81% to 95% with BASIC training. This improvement was noted in both groups. The interobserver level of agreement was very good (K=0.90) in the experienced cohort and good (K=0.66) in the trainee group post-training.

Conclusions: BLI is a useful tool for optical diagnosis, and the use of BASIC with adequate training can significantly improve the accuracy, sensitivity and NPV of adenoma diagnosis.

1 Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
2 Department of Gastroenterology, King’s College Hospital NHS Foundation Trust, London, UK
3 Department of Gastroenterology, Luzerner Kantonspittal, Lucerne, Switzerland
4 Department of Gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
5,Department of Gastroenterology, Diagnosticˇni center Bled, Ljubljana, Slovenia
6 StatsConsultancy Limited, Amersham, UK
7 Centre Hospitalier Universitaire and Faculte´ de Me´decine de Nantes, Institut des Maladies de l’Appareil Digestif, Nantes, France
8 Department of Gastroenterology and Interventional Endoscopy, St John of God Hospital, Regensburg, Bavaria, Germany
9 Department of Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy
10 Department of Medicine, University Hospital Erlangen, Germany
11 Department of Gastroenterology and Hepatology, Universitaire Ziekenhuizen Leuven, Belgium
12 Istituto Clinico Humanitas, Rozzano, Lombardia, Italy


Blue Laser Imaging, Blue Light Imaging, and Linked Color Imaging for the Detection and Characterization of Colorectal Tumors.

Yoshida N 1 , Dohi O 1 , Inoue K 1 , Yasuda R 1 , Murakami T 1 , Hirose R 1 , Inoue K 1 , Naito Y 1 , Inada Y 2 , Ogiso K 3 , Morinaga Y 4 , Kishimoto M4 , Rani RA 5 , Itoh Y 1 .

Gut Liver. 2018 Dec 4. doi: 10.5009/gnl18276. [Epub ahead of print]

Abstract:A laser endoscopy system was developed in 2012. The system allows blue laser imaging (BLI), BLI-bright, and linked color imaging (LCI) to be performed as modes of narrow-band light observation; these modes have been reported to be useful for tumor detection and characterization. Furthermore, an innovative endoscopy system using four-light emitting diode (LED) multilight technology was released in 2016 to 2017 in some areas in which laser endoscopes have not been approved for use, including the United States and Europe. This system enables blue light imaging (this is also known as BLI) and LCI with an LED light source instead of a laser light source. Several reports have shown that these modes have improved tumor detection. In this paper, we review the efficacy of BLI and LCI with laser and LED endoscopes in tumor detection and characterization.

1 Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
2 Department of Gastroenterology, Fukuchiyama City Hospital, Kyoto
3 Department of Gastroenterology, Osaka General Hospital of West Japan Railway Company, Osaka
4 Department of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
5 Gastroenterology Unit, Faculty of Medicine, Universiti Teknologi MARA, Shah Alam, Malaysia


Blue-light imaging has an additional value to white-light endoscopy in visualization of early Barrett’s neoplasia. an international multicenter cohort study.

de Groof AJ1, Swager A1, Pouw RE1, Weusten BLAM2, Schoon EJ3, Bisschops R4, Pech O5, Meining A6, Neuhaus H7, Curvers WL3, Bergman JJ1.

Gastrointest Endosc. 2018 Nov 9. pii: S0016-5107(18)33259-0. doi: 10.1016/j.gie.2018.10.046. [Epub ahead of print]

Background and aims: Endoscopic features of early neoplasia in Barrett’s esophagus (BE) are subtle. Blue-light imaging (BLI) may improve visualization of neoplastic lesions. The aim of this study was to evaluate BLI in visualization of Barrett’s neoplasia.

Methods: Corresponding white-light endoscopy (WLE) and BLI images of 40 BE lesions were obtained prospectively and assessed by 6 international experts in 3 assessments. Each assessment consisted of overview and magnification images. Assessments were as follows: Assessment 1: WLE only; Assessment 2: BLI only; and Assessment 3: corresponding WLE and BLI images. Outcome parameters were as follows: (1) appreciation of macroscopic appearance and surface relief (VAS-scores); (2) ability to delineate lesions (VAS-scores); (3) preferred technique for delineation (ordinal scores); and (4) quantitative agreement on delineations (AND/OR scores).

Results: Experts appreciated BLI significantly better than WLE for visualization of macroscopic appearance (median 8.0 vs 7.0, P<0.001) and surface relief (8.0 vs 6.0, P<0.001). For both overview and magnification images, experts appreciated BLI significantly better than WLE for ability to delineate lesions (8.0 vs 6.0, P<0.001 and 8.0 vs 5.0, P<0.001). There was no overall significant difference in AND/OR scores of WLE+BLI when compared with WLE, yet agreement increased significantly with WLE+BLI for cases with a low baseline AND/OR score on WLE, both in overview (mean difference 0.15, P=0.015) and magnification (mean difference 0.10, P=0.01).

Conclusions: BLI has additional value for visualization of BE neoplasia. Experts appreciated BLI better than WLE for visualization and delineation of BE neoplasia. Quantitative agreement increased significantly when BLI was offered next to WLE for lesions that were hard to delineate with WLE alone.

1 Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
2 Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands.
3 Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands.
4 Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
5 Gastroenterology and interventional Endoscopy, Krankenhaus Barmherzige Brüder, Regensburg, Germany.
6 Center of Internal Medicine, Ulm University, Ulm, Germany
7 Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany


Leaving colorectal polyps in place can be achieved with high accuracy using blue light imaging (BLI).

Neumann H1, Neumann Sen H2, Vieth M3, Bisschops R4, Thieringer F1, Rahman KF1, Gamstätter T1, Tontini GE5, Galle PR1.

United European Gastroenterol J. 2018 Aug;6(7):1099-1105. doi: 10.1177/2050640618769731. Epub 2018 May 17.

Objectives: A negative predictive value of more than 90% is proposed by the American Society of Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) statement for a new technology in order to leave distal diminutive colorectal polyps in place without resection. To our knowledge, no prior prospective study has yet evaluated the feasibility of the most recently introduced blue light imaging (BLI) system for real-time endoscopic prediction of polyp histology for the specific endpoint of leaving hyperplastic polyps in place.

Aims: Prospective assessment of real-time prediction of colorectal polyps by using BLI.

Material and methods: In total, 177 consecutive patients undergoing screening or surveillance colonoscopy were included. Colorectal polyps were evaluated in real-time by using high-definition endoscopy and the BLI technology without optical magnification. Before resection, the endoscopist described each polyp according to size, shape and surface characteristics (pit and vascular pattern, colour and depression), and histology was predicted with a level of confidence (high or low).

Results: Histology was predicted with high confidence in 92.5% of polyps. Sensitivity of BLI for prediction of adenomatous histology was 92.68%, with a specificity and accuracy of 94.87 and 93.75%, respectively. Following the recommendation of the PIVI statement, positive and negative predictive values were calculated with values of 95 and 92.5%, respectively. Prediction of surveillance based on both US and European guidelines was correctly predicted in 91% of patients.

Conclusion: The most recently introduced BLI technology is accurate enough to leave distal colorectal polyps in place without resection. BLI also allowed for assignment of postpolypectomy surveillance intervals. This approach therefore has the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps.

1 First Medical Department, Interdisciplinary Endoscopy, University Medical Center Mainz, Mainz, Germany
2 Internistische Schwerpunktpraxis Bad Salzuflen, Germany
3 Institute of Pathology, Klinikum Bayreuth, Germany
4 Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
5 Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy


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


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