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Linked color imaging improves visibility of reflux esophagitis

Tsutomu Takeda1, Daisuke Asaoka2, Daiki Abe1, Maiko Suzuki2, Yuta Nakagawa2, Hitoshi Sasaki2, Yoshihiro Inami2, Muneo Ikemura1, Hisanori Utsunomiya1, Shotaro Oki1, Nobuyuki Suzuki1, Atsushi Ikeda1, Noboru Yatagai1, Hiroyuki Komori1, Yoichi Akazawa1, Kohei Matsumoto1, Kumiko Ueda1, Hiroya Ueyama1, Yuji Shimada1, Kenshi Matsumoto1, Mariko Hojo1, Taro Osada1, Shuko Nojiri3, Akihito Nagahara1

BMC Gastroenterol. 2020 Oct 27;20(1):356. doi: 10.1186/s12876-020-01511-9.

Background: With more prevalent gastroesophageal reflux disease comes increased cases of Barrett’s esophagus and esophageal adenocarcinoma. Image-enhanced endoscopy using linked-color imaging (LCI) differentiates between mucosal colors. We compared LCI, white light imaging (WLI), and blue LASER imaging (BLI) in diagnosing reflux esophagitis (RE).

Methods: Consecutive RE patients (modified Los Angeles [LA] classification system) who underwent esophagogastroduodenoscopy using WLI, LCI, and BLI between April 2017 and March 2019 were selected retrospectively. Ten endoscopists compared WLI with LCI or BLI using 142 images from 142 patients. Visibility changes were scored by endoscopists as follows: 5, improved; 4, somewhat improved; 3, equivalent; 2, somewhat decreased; and 1, decreased. For total scores, 40 points was considered improved visibility, 21-39 points was comparable to white light, and < 20 points equaled decreased visibility. Inter- and intra-rater reliabilities (Intra-class Correlation Coefficient [ICC]) were also evaluated. Images showing color differences (ΔE) and L a* b* color values in RE and adjacent esophageal mucosae were assessed using CIELAB, a color space system.

Results: The mean age of patients was 67.1 years (range: 27-89; 63 males, 79 females). RE LA grades observed included 52 M, 52 A, 24 B, 11 C, and 3 D. Compared with WLI, all RE cases showed improved visibility: 28.2% (40/142), LA grade M: 19.2% (10/52), LA grade A: 34.6% (18/52), LA grade B: 37.5% (9/24), LA grade C: 27.3% (3/11), and LA grade D: 0% (0/3) in LCI, and for all RE cases: 0% in BLI. LCI was not associated with decreased visibility. The LCI inter-rater reliability was “moderate” for LA grade M and “substantial” for erosive RE. The LCI intra-rater reliability was “moderate-substantial” for trainees and experts. Color differences were WLI: 12.3, LCI: 22.7 in LA grade M; and WLI: 18.2, LCI: 31.9 in erosive RE (P < 0.001 for WLI vs. LCI).

Conclusion: LCI versus WLI and BLI led to improved visibility for RE after subjective and objective evaluations. Visibility and the ICC for minimal change esophagitis were lower than for erosive RE for LCI. With LCI, RE images contrasting better with the surrounding esophageal mucosa were more clearly viewed.

1 Department of Gastroenterology, Juntendo University School of Medicine,2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
2 Department of Gastroenterology, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan.
3 Department of Medical Technology Innovation Center, Juntendo University School of Medicine, Tokyo, Japan.

Detection of early stage gastric cancers in screening laser endoscopy using linked color imaging for patients with atrophic gastritis

Minoru Yamaoka1, Hiroyuki Imaeda2, Kazuya Miyaguchi1, Keigo Ashitani1, Yoshikazu Tsuzuki2, Hideki Ohgo2, Hiromitsu Soma2, Nobutaka Hirooka1, Hidetomo Nakamoto1

J Gastroenterol Hepatol. 2020 Oct 30. doi: 10.1111/jgh.15312. Online ahead of print.

Background and aims: Laser endoscopy involves blue laser imaging in bright mode (BLI-bright). Linked color imaging (LCI) is superior to white light imaging (WLI) for detecting gastric cancers. This study aimed to detect gastric cancers on screening endoscopy using not only WLI but also BLI-bright and LCI in patients with atrophic gastritis.

Patients and methods: A total of 500 patients with atrophic gastritis undergoing screening esophagogastroduodenoscopy were included. The gastric lumen was observed in the WLI mode, followed by the LCI and BLI-bright modes. When gastric neoplasms were suspected, the mode was changed to WLI, and we sprayed indigo carmine. Finally, biopsy specimens were taken for those lesions and pathological diagnosis was made. We compared the size, morphology, and color of gastric neoplasms found by the first WLI mode and those detected by only the LCI mode or BLI-bright mode.

Results: We detected 16 gastric neoplasms (3.2%), of which 13 were early gastric cancers (EGCs) and three were gastric adenomas. Ten EGCs and two gastric adenomas (75%) were detected by the first WLI mode; three EGCs and one gastric adenoma (25%) were missed by the first WLI mode and were detected by the LCI mode or BLI-bright mode. All were less than 1 cm in diameter and were reddish. Mean diameter of the lesions was significantly less for LCI-detected or BLI-bright-detected lesions than for WLI-detected lesions (7.8 vs 21.2 mm).

Conclusions: Laser endoscopy is useful for detecting EGCs by LCI for patients with atrophic gastritis.

1 Department of General Internal Medicine, Saitama Medical University, Saitama, Japan
2 Departement of Gastroenterology, Saitama Medical University, Saitama, Japan

Linked Color Imaging Focused on Neoplasm Detection in the Upper Gastrointestinal Tract

Shinji Kitamura, Tomoyuki Koike, Shinichiro Hori, Hiromitsu Kanzaki, Takahisa Murao, Nobuaki Yagi, Fumisato Sasaki, Keiichi Hashiguchi, Shiro Oka, Kazuhiro Katada, Ryo Shimoda, Kazuhiro Mizukami, Mitsuhiko Suehiro, Toshihisa Takeuchi, Shinichi Katsuki, Momoko Tsuda, Yuji Naito, Tatsuyuki Kawano, Ken Haruma, Hideki Ishikawa, Keita Mori, Mototsugu Kato

Annals of Internal Medicine 2020 Oct

Background: Linked color imaging (LCI) is a new image-enhanced endoscopy technique that allows users to recognize slight differences in mucosal color.

Objective: To compare the performance of LCI with white light imaging (WLI) in detecting neoplastic lesions in the upper gastrointestinal tract.
Design:A controlled, multicenter trial with randomization using minimization. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000023863)
Setting:16 university hospitals and 3 tertiary care hospitals in Japan.
Patients:1502 patients with known previous or current cancer of the gastrointestinal tract and undergoing surveillance for gastrointestinal cancer.

Measurements: Diagnosis of 1 or more neoplastic lesions in the pharynx, esophagus, or stomach in the first examination (primary outcome) and 1 or more neoplastic lesions overlooked in the first examination (secondary outcome).

Results: 752 patients were assigned to the WLI group and 750 to the LCI group. The percentage of patients with 1 or more neoplastic lesions diagnosed in the first examination was higher with LCI than with WLI (60 of 750 patients or 8.0% [95% CI, 6.2% to 10.2%] vs. 36 of 752 patients or 4.8% [CI, 3.4% to 6.6%]; risk ratio, 1.67 [CI, 1.12 to 2.50; P = 0.011]). The proportion with overlooked neoplasms was lower in the LCI group than in the WLI group (5 of 750 patients or 0.67% [CI, 0.2% to 1.6%] vs. 26 of 752 patients or 3.5% [CI, 2.3% to 5.0%]; risk ratio, 0.19 [CI, 0.07 to 0.50]).

Conclusion: LCI is more effective than WLI for detecting neoplastic lesions in the pharynx, esophagus, and stomach.

1 Hokkaido University Hospital, Sapporo, Japan (S.O., M.T.)
2 Tokyo Medical and Dental University, Tokyo, Japan (K.K.)
3 Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan (O.D., Y.N.)
4 Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan (S.K.)
5 Tohoku University Graduate School of Medicine, Sendai, Japan (T.K.)
6 National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan (S.H.)
7 Okayama University Graduate School of Medicine Dentistry, and Pharmaceutical Sciences, Okayama, Japan (H.K.)
8 Kawasaki Medical School, Okayama, Japan (T.M.)
9 Asahi University Hospital, Gifu, Japan (N.Y.)
10 Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan (F.S.)
11 Nagasaki University Hospital, Nagasaki, Japan (K.H.)
12 Hiroshima University Hospital, Hiroshima, Japan (S.O.)
13 North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan (K.K.)
14 Saga University, Saga, Japan (R.S.)
15 Oita University, Oita, Japan (K.M.)
16 Kawasaki Medical School General Medical Center, Okayama, Japan (M.S.,K.H.)
17 Osaka Medical College, Osaka, Japan (T.T.)
18 Otaru Ekisaikai Hospital, Otaru, Japan (S.K.)
19 Soka Municipal Hospital, Soka,Japan (T.K.)
20 Kyoto Prefectural University of Medicine, Osaka, Japan (H.I.)
21 Shizuoka Cancer Center, Shizuoka, Japan (K.M.)
22 National Hospital Organization Hakodate National Hospital, Hakodate, Japan (M.K.).

Optical effect of spraying l-menthol on gastric intestinal metaplasia visualized by linked color imaging

Ono, Shokoa1; Shimoda, Yoshihikob2; Tanaka, Ikkob2; Kinowaki, Sayokob2; Inoue, Masakib2; Ono, Masayoshib2; Yamamoto, Keikoc3; Shimizu, Yuichic3; Sakamoto, Naoya2

European Journal of Gastroenterology & Hepatology: September 9, 2020 – Volume Publish Ahead of Print – Issue –

Objective: Linked color imaging (LCI) enables noninvasive detection of gastric intestinal metaplasia (GIM) as a lavender color sign (LCS), and there has been a recent report that l-menthol enhanced GIM with LCI. We measured color values of GIM and surrounding mucosa with white light imaging (WLI), LCI and LCI after spraying l-menthol (Mint-LCI) and investigated the effect of l-menthol on gastric mucosa.

Methods: Endoscopic images of the antrum with WLI, LCI and Mint-LCI from 18 patients were prepared. Each of six regions of interest (three points of GIM and three points of surrounding mucosa) was selected for each modality, and CIE1976 (Lab) color space was used to measure the color values. The primary endpoint was color differences (ΔE) between GIM and surrounding mucosa in each modality. Results For surrounding mucosa, the mean a value with Mint-LCI was significantly higher than the mean values with WLI and LCI (P < 0.01). The mean b* value of GIM with LCI was significantly lower than that of surrounding mucosa, and spraying l-menthol decreased the b* values of GIM with a change to a deeper lavender color (LCI: 10.0 ± 5.8, Mint-LCI: 3.7 ± 6.1, P < 0.01). However, there was no significant difference in mean ΔE values between LCI and Mint LCI (LCI: 21.1 ± 6.6, Mint-LCI: 22.7 ± 5.4, NS). After spraying l-menthol, the microstructure of GIM changed to translucent and microvessels were obscured.

Conclusions: As shown by LCI, spraying l-menthol optically enhances the color of GIM in the antrum.

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

Comparison of the diagnostic efficacy of blue laser imaging with narrow band imaging for gastric cancer and precancerous lesions: a meta-analysis

Jingyuan Zhou1, Huijie Wu1, Chenglong Fan1 , Songda Chen1 , Aiqun Liu1

Rev Esp Enferm Dig. 2020 Aug;112(8):649-658. doi: 10.17235/reed.2020.6591/2019.

Background and aims: novel endoscopic techniques including narrowband imaging (NBI) and blue laser imaging (BLI) have led to the improved detection of early stage gastric cancer and precancerous lesions. However, these techniques are not generally thought to be equivalent at present and BLI is generally considered as superior to NBI. Therefore, this comprehensive meta-analysis aimed to definitively compare the diagnostic efficacy of NBI and BLI for the diagnosis of gastric cancer and precancerous lesions.

Methods: relevant articles were identified via searches of the PubMed, Web of Science, Embase and Cochrane Library databases from their inception until October 2019. In total, 28 relevant studies were identified and incorporated into the meta-analysis. RevMan5.3 was used to assess the relative diagnostic efficacy of these two imaging modalities in these studies. The threshold was assessed using Meta-DiSc 1.4 and STATA 14.0 for bivariate regression modeling of pooled studies.

Results: the pooled sensitivity of BLI for gastric cancer was 0.89 (0.80, 0.95) and the specificity was 0.92 (0.76, 0.98). The pooled sensitivity of NBI for gastric cancer was 0.83 (0.75, 0.89) and the specificity was 0.95 (0.91, 0.97). The pooled sensitivity of BLI for precancerous lesions was 0.81 (0.71, 0.87) and the specificity was 0.90 (0.80, 0.96). The pooled sensitivity of NBI for precancerous lesions was 0.80 (0.75, 0.85) and the specificity was 0.88 (0.77, 0.94).

Conclusions: this study showed that both BLI and NBI have a very high diagnostic efficacy for the detection of gastric cancer and precancerous lesions, the sensitivity and specificity of these two approaches were similar.

1 Department of Endoscopy. Affiliated Tumor Hospital of Guangxi Medical University. Nanning, Guangxi. China

Diagnostic performance of magnifying blue laser imaging versus magnifying narrow-band imaging for identifying the depth of invasion of superficial esophageal squamous cell carcinoma

Tomohiro Ueda1,2, Osamu Dohi1, Yuji Naito1, Takuma Yoshida1, Yuka Azuma1, Tsugitaka Ishida1, Shinya Matsumura1, Hiroaki Kitae1, Shun Takayama1, Naoki Mizuno1, Takahiro Nakano1,3, Naoto Iwai1,4, Ryohei Hirose1, Ken Inoue1, Naohisa Yoshida1, Kazuhiro Kamada1, Kazuhiko Uchiyama1, Takeshi Ishikawa1, Tomohisa Takagi1, Hideyuki Konishi1, Ayako Nishimura5, Mitsuo Kishimoto5, Yoshito Itoh1

Dis Esophagus. 2020 Jul 21;doaa078. doi: 10.1093/dote/doaa078. Online ahead of print.

Identifying the depth of invasion (DOI) of superficial esophageal squamous cell carcinoma (SESCC) is crucial to determine the indication for endoscopic resection. This retrospective, single-center study aimed to evaluate the diagnostic efficacy of magnifying blue laser imaging (M-BLI) compared with white-light imaging (WLI) or magnifying narrow-band imaging (M-NBI) for identifying the DOI of SESCC. A total of 160 consecutive patients with SESCCs who underwent endoscopic submucosal dissection were enrolled in this study. Still images of the lesion were obtained using WLI, M-BLI and M-NBI prior to endoscopic submucosal dissection. Three endoscopists retrospectively evaluated the DOI using WLI according to non-magnifying findings and using M-BLI and M-NBI images according to the magnifying endoscopic classification of the Japan Esophageal Society. The diagnostic accuracy of each modality was compared using the chi-square test. The DOIs in 160 SESCCs evaluated pathologically were as follows: invasion to the epithelium or lamina propria mucosa in 130, invasion to the lamina muscularis mucosa or submucosa to a depth ≤ 200 μm in 18, and invasion to the submucosa to a depth > 200 μm in 12. The overall diagnostic accuracy rates of WLI, M-BLI, M-NBI, WLI with M-BLI (WLI + M-BLI), and WLI with M-NBI (WLI + M-NBI) were 86.9, 91.2, 90.6, 95.6 and 94.4%, respectively. Significant differences were found between WLI and WLI + M-BLI or WLI + M-NBI (P = 0.006 and P = 0.021, respectively). The concordance of intrapapillary capillary loops between M-BLI and M-NBI was 91.2%. The kappa coefficients for interobserver variability of the three endoscopists for M-BLI and M-NBI were 0.728/0.649/0.792 and 0.729/0.666/0.791, respectively, while those for intraobserver variability were 0.919/0.746/0.778 and 0.736/0.720/0.745, respectively. Similar to M-NBI, M-BLI was useful in predicting the DOI of SESCCs.

1 Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
2 Departement of Gastroenterology and Hepatology, Kyoto Chubu Medical Center, Nantan, Japan
3 Departement of Gastroenterology, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
4 Departement of Gastroenterology and Hepatology, Fukuchiyama City Hospital, Fukuchiyama, Japan
5 Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan