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Therapeutic application of linked color imaging for colorectal endoscopic mucosal resection

Goda Y1, Mori H1, Kobara H1, Nishiyama N1, Kobayashi N1, Yachida T1, Masaki T1.

Endoscopy. 2017 Oct 17. doi: 10.1055/s-0043-119984. [Epub ahead of print]

Linked color imaging (LCI; Fujifilm Co., Tokyo, Japan) is a newly developed image- enhanced technique that has shown high diagnostic performance in the field of gastrointestinal endoscopy. LCI enhances color separation of the mucosal layer, making red regions redder and white regions whiter. This contributes to the detection of gastric cancer [1], ulcerative colitis [2], colorectal polyps [3, 4], and other lesions. Although the diagnostic productivity is steadfast, the treatment benefit of LCI remains unclear or limited [5]. We herein introduce an advantage of LCI with respect to increasing the safety of endoscopic mucosal resection (EMR), illustrating the efficacy of LCI in the treatment field.

Compared with white-light imaging, narrow- band imaging, and bright-light imaging, the view of the blood vessels in the superficial layer is much more conspicuous when obtained by LCI. When performing EMR, local injection is the first crucial step and the basis of later procedures such as polyp removal by snaring. However, injury to the superficial vessels invisible with white light sometimes induces hematoma formation, making subsequent snaring difficult (▶Fig. 1 a). LCI can more precisely reveal the running of the superficial vessels around a colorectal polyp than can white light imaging (▶Fig. 1 b) and bright-light imaging (▶Fig. 1 c). LCI enhances the reddish, glaring characteristics of the vessels, pinpointing safe sites for needling (▶Fig. 1 d). Consequently, the clinician can avoid needling blood vessels near the polyp (▶Fig. 1 e) and prevent unnecessary bleeding and hematoma formation (▶Fig. 1 f), leading to secure completion of EMR.

White-light imaging, bright-light imaging, and LCI for EMR local injections are compared in ▶Video 1. Only LCI shows the reddish network pattern of the superficial blood vessels. This leads to sufficient swelling of the submucosal layer and appropriate removal of colorectal polyps.

Fig. 1 Endoscopic images illustrating the advantages of linked color imaging (LCI) during endoscopic mucosal resection. a Improper injection can induce hematoma formation. b Superficial vessels around a colorectal polyp are invisible with white-light imaging. c Superficial vessels are also unclear with bright-light imaging. d LCI shows the orientation of vessels around the polyp. e The injection needle pinpoints a site lacking vessels. f Unnecessary hematoma formation and bleeding can be avoided during mucosal injection.

Video 1 White-light imaging only ambiguously shows the blood vessel routes, whereas linked color imaging (LCI) indicates the vessels clearly as a vivid reddish color. From injection to snaring, LCI allows the clinician to avoid unnecessary bleeding.

1Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan.


BASIC (BLI Adenoma Serrated International Classification) classification study for colorectal polyp characterization with blue light imaging

Raf Bisschops1, Cesare Hassan2,3, Pradeep Bhandari4, Emmanuel Coron5, Helmut Neumann6, Oliver Pech7, Loredana Correale2, Alessandro Repici3

Endoscopy 2018; 50: 1-17 / https://doi.org/10.1055/s-0043-121570

Backgound and study aim: Advanced endoscopic imaging has revolutionized the characterization of lesions during colonoscopy. The aim of this study was to create a new classification for differentiating subcentimetric hyperplastic and adenomatous polyps, and deeply invasive malignant lesions using blue-light imaging (BLI) with high definition, with and without optical magnification, as well as to assess its interobserver concordance.

Methods: A video library consisting of 48 videos/still images (with/without optical magnification) from 24 histologically verified polyps/cancer with BLI was prospectively created. In the first step, seven endoscopists with experience in electronic chromoendoscopy reviewed 12 BLI videos/still images with/without magnification representative of the different histotypes, and individually identified possible descriptors. In the second step, these descriptors were categorized and summarized with a modified Delphi methodology. In the third step, the seven endoscopists independently reviewed the remaining 36 videos/still images with/without optical magnification, and the interobserver agreement for the new descriptors was assessed. The interobserver agreement between endoscopists was assessed using Gwet’s AC1.

Results: By reviewing the initial 12 videos/still images, 43 descriptors were proposed. By a modified Delphi process, the endoscopists eventually agreed on summarizing 12 descriptors into three main domains. The main domains identified were: polyp surface (mucus, yes/no; regular/irregular; [pseudo]depressed, yes/no), pit appearance (featureless, yes/no; round/nonround with/without dark spots; homogeneous/heterogeneous distribution with/without focal loss), and vessels (present/absent, lacy, pericryptal, irregular). Interobserver agreement for the polyp surface domain appeared to be almost perfect for mucus (AC1 0.92 with and 0.88 without optical magnification), substantial for the regular/irregular surface (AC1 0.67 with and 0.66 without optical magnification). For the pit appearance domain, interobserver agreement was good for featureless (AC1 0.9 with and 0.8 without optical magnification), and round/nonround (AC1 0.77 with and 0.69 without optical magnification) descriptors, but less consistent for the homogeneity of distribution (AC1 with/without optical magnification 0.58). Agreement was almost perfect for the vessel domain (AC1 0.81 – 0.85).

Conclusions: The new BASIC classification takes into account both morphological features of the polyp, as well as crypt and vessel characteristics. A high concordance among the observers was shown for most of the summarized descriptors. Optical magnification had a beneficial effect in terms of interobserver agreement for most of the descriptors.

1 Department of Gastroenterology and Hepatology, Catholic University of Leuven (KUL), TARGID, University Hospitals Leuven, Leuven, Belgium.
2 Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy.
3 Digestive Endoscopy Unit, Humanitas University, Milan, Italy.
4 Solent Centre for Digestive Diseases, Portsmouth Hospital, Portsmouth, United Kingdom.
5 Hepatogastroenterology, Centre Hospitalier Universitaire Hotel Dieu, Nantes, France.
6 First Medical Department, University Medical Center Mainz, Mainz, Germany.
7 Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.



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.