Comparison of computed virtual chromoendoscopy and conventional chromoendoscopy with acetic acid for detection of neoplasia in Barrett's esophagus

Endoscopic Diagnosis and Management of Barrett's Esophagus with Low-Grade Dysplasia

Barrett’s Esophagus is a common condition associated with chronic gastroesophageal reflux disease. It is well known that it has an association with a higher incidence of esophageal adenocarcinoma, but this neoplastic transformation is first preceded by the onset of low and high-grade dysplasia. The evaluation of low grade dysplastic esophageal mucosa is still controversial; although endoscopic surveillance is preferred, several minimally invasive endoscopic therapeutic approaches are available. Endoscopic mucosal resection and radiofrequency ablation are the most used endoscopic treatments for the eradication of low-grade dysplasia, respectively, for nodular and flat dysplasia. Novel endoscopic treatments are cryotherapy ablation and argon plasma coagulation, that have good rates of eradication with less complications and post-procedural pain.

Image-Enhanced Capsule Endoscopy Improves the Identification of Small Intestinal Lesions

Image-enhanced endoscopy is useful for diagnosing and identifying lesions in the gastrointestinal tract. Recently, image-enhanced endoscopy has become a breakthrough technology that has attracted significant attention. This image enhancing technology is available for capsule endoscopy, which is an effective tool for small intestinal lesions and has been applied in flexible spectral color enhancement technology and in contrast capsule like narrow-band imaging. In this field, most researchers focus on improving the visibility and detection of small intestinal lesions. This review summarizes previous studies on image-enhanced capsule endoscopy and aims to evaluate the efficacy of this technology.

Current Status of Image-Enhanced Endoscopy for Early Identification of Esophageal Neoplasms

Advanced esophageal cancer is known to have a poor prognosis. The early detection of esophageal neoplasms, including esophageal dysplasia and early esophageal cancer, is highly important for the accurate treatment of the disease. However, esophageal dysplasia and early esophageal cancer are usually subtle and can be easily missed. In addition to the early detection, proper pretreatment evaluation of the depth of invasion of esophageal cancer is very important for curative treatment. The progression of non-invasive diagnosis via image-enhanced endoscopy techniques has been shown to aid the early detection and estimate the depth of invasion of early esophageal cancer and, as a result, may provide additional opportunities for curative treatment. Here, we review the advancement of image-enhanced endoscopy-related technologies and their role in the early identification of esophageal neoplasms.

Serum iron and vitamin B 12 deficiency could indicate celiac disease by flexible spectral imaging color enhancement

INTRODUCTION Celiac disease (CeD) is an autoimmune disease that can be delayed in diagnosis due to the presence of atypical and asymptomatic cases in adulthood. Herein we aimed to study the frequency of CeD and evaluate whether magnified endoscopy and magnified/FICE (flexible spectral imaging color enhancement) techniques contribute to the diagnosis in patients with serum iron and vitamin B12 deficiency. METHODS We evaluated 50 adult patients (10 males and 40 females) who had serum iron and vitamin B12 deficiency, prospectively. All the patients had undergone upper gastrointestinal system endoscopy by the same endoscopist. The second part of the duodenum was evaluated with white light, magnified, and magnified/FICE endoscopy. Biopsy specimens were evaluated by the same pathologist. The specimens diagnosed as CeD were classified according to the Modified Marsh-Oberhuber criteria. RESULTS 10 of 50 patients (20%) were diagnosed as CeD. The average age was 41±11 years (20-67 years). Thirty percent of CeD diagnosed patients had typical CeD symptoms. Six of 10 patients (60%) who were diagnosed as CeD had typical endoscopic images under white lighted endoscopy. All of these 10 patients (100%) showed villous irregularity, partial villous atrophy, or total villous atrophy consistent with CeD with magnified and magnified/FICE endoscopy. CONCLUSION The practical use of magnified/FICE endoscopy allows us to differentiate mucosal abnormalities of the duodenum and minimize false-negative results that indicate normal mucosal findings with conventional endoscopy.

Optical enhancement imaging versus acetic acid for detecting gastric intestinal metaplasia: A randomized, comparative trial

BACKGROUND AND AIMS

The diagnosis of gastric intestinal metaplasia (GIM) is still challenging. Optical Enhancement technology (OE) may improve the detection of GIM. We compared detection of GIM with OE, acetic acid and the Sydney biopsy protocol in a surveillance population.

METHODS

Consecutive patients with atrophic gastritis or known GIM were prospectively included. The stomach was examined with high definition whitelight endoscopy, followed by OE or acetic acid with targeted biopsies (1:1 randomisation). Subsequently, five random biopsies were taken according to the updated Sydney system.

RESULTS

A total of 154 patients were randomized. Higher proportions of patients with GIM were detected by OE and acetic acid versus random biopsy (60.5% vs 35.5%, 67.1% vs 31.5%, respectively; P < 0.0001 for both comparisons). The combined use of targeted biopsies and random biopsies provides high diagnostic yields for GIM (78.9% in OE group and 83.6% in acetic acid group). In addition, the proportion of extensive GIM was significantly increased when image enhanced endoscopy was used instead of white light endoscopy (P = 0.029, P = 0.048, respectively).

CONCLUSIONS

OE and acetic acid showed comparable results diagnosing GIM in the study. Targeted biopsies plus random biopsies should be used complementary in high risk populations.

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

The Japan Gastroenterological Endoscopy Society has developed endoscopic submucosal dissection/endoscopic mucosal resection guidelines. These guidelines present recommendations in response to 18 clinical questions concerning the preoperative diagnosis, indications, resection methods, curability assessment, and surveillance of patients undergoing endoscopic resection for esophageal cancers based on a systematic review of the scientific literature.

Advanced imaging in surveillance of Barrett’s esophagus: Is the juice worth the squeeze?

Esophageal cancer is on the rise. The known precursor lesion is Barrett’s esophagus (BE). Patients with dysplasia are at higher risk of developing esophageal cancer. Currently the gold standard for surveillance endoscopy involves taking targeted biopsies of abnormal areas as well as random biopsies every 1-2 cm of the length of the Barrett’s. Unfortunately studies have shown that this surveillance can miss dysplasia and cancer. Advanced imaging technologies have been developed that may help detect dysplasia in BE. This opinion review discusses advanced imaging in BE surveillance endoscopy and its utility in clinical practice.

International development and validation of a classification system for the identification of Barrett's neoplasia using acetic acid chromoendoscopy: the Portsmouth acetic acid classification (PREDICT)

BACKGROUND

Barrett's oesophagus is an established risk factor for developing oesophageal adenocarcinoma. However, Barrett's neoplasia can be subtle and difficult to identify. Acetic acid chromoendoscopy (AAC) is a simple technique that has been demonstrated to highlight neoplastic areas but lesion recognition with AAC remains a challenge, thereby hampering its widespread use.

OBJECTIVE

To develop and validate a simple classification system to identify Barrett's neoplasia using AAC.

DESIGN

The study was conducted in four phases: phase 1-development of component descriptive criteria; phase 2-development of a classification system; phase 3-validation of the classification system by endoscopists; and phase 4-validation of the classification system by non-endoscopists.

RESULTS

Phases 1 and 2 led to the development of a simplified AAC classification system based on two criteria: focal loss of acetowhitening and surface patterns of Barrett's mucosa. In phase 3, the application of PREDICT (Portsmouth acetic acid classification) by endoscopists improved the sensitivity and negative predictive value (NPV) from 79.3% and 80.2% to 98.1% and 97.4%, respectively (p<0.001). In phase 4, the application of PREDICT by non-endoscopists improved the sensitivity and NPV from 69.6% and 75.5% to 95.9% and 96.0%, respectively (p<0.001).

CONCLUSION

We developed and validated a classification system known as PREDICT for the diagnosis of Barrett's neoplasia using AAC. The improvement seen in the sensitivity and NPV for detection of Barrett's neoplasia in phase 3 demonstrates the clinical value of PREDICT and the similar improvement seen among non-endoscopists demonstrates the potential for generalisation of PREDICT once proven in real time.

Machine Learning Creates a Simple Endoscopic Classification System that Improves Dysplasia Detection in Barrett's Oesophagus amongst Non-expert Endoscopists

Introduction

Barrett's oesophagus (BE) is a precursor to oesophageal adenocarcinoma (OAC). Endoscopic surveillance is performed to detect dysplasia arising in BE as it is likely to be amenable to curative treatment. At present, there are no guidelines on who should perform surveillance endoscopy in BE. Machine learning (ML) is a branch of artificial intelligence (AI) that generates simple rules, known as decision trees (DTs). We hypothesised that a DT generated from recognised expert endoscopists could be used to improve dysplasia detection in non-expert endoscopists. To our knowledge, ML has never been applied in this manner.

Methods

Video recordings were collected from patients with non-dysplastic (ND-BE) and dysplastic Barrett's oesophagus (D-BE) undergoing high-definition endoscopy with i-Scan enhancement (PENTAX®). A strict protocol was used to record areas of interest after which a corresponding biopsy was taken to confirm the histological diagnosis. In a blinded manner, videos were shown to 3 experts who were asked to interpret them based on their mucosal and microvasculature patterns and presence of nodularity and ulceration as well as overall suspected diagnosis. Data generated were entered into the WEKA package to construct a DT for dysplasia prediction. Non-expert endoscopists (gastroenterology specialist registrars in training with variable experience and undergraduate medical students with no experience) were asked to score these same videos both before and after web-based training using the DT constructed from the expert opinion. Accuracy, sensitivity, and specificity values were calculated before and after training where p < 0.05 was statistically significant.

Results

Videos from 40 patients were collected including 12 both before and after acetic acid (ACA) application. Experts' average accuracy for dysplasia prediction was 88%. When experts' answers were entered into a DT, the resultant decision model had a 92% accuracy with a mean sensitivity and specificity of 97% and 88%, respectively. Addition of ACA did not improve dysplasia detection. Untrained medical students tended to have a high sensitivity but poor specificity as they "overcalled" normal areas. Gastroenterology trainees did the opposite with overall low sensitivity but high specificity. Detection improved significantly and accuracy rose in both groups after formal web-based training although it did it reach the accuracy generated by experts. For trainees, sensitivity rose significantly from 71% to 83% with minimal loss of specificity. Specificity rose sharply in students from 31% to 49% with no loss of sensitivity.

Conclusion

ML is able to define rules learnt from expert opinion. These generate a simple algorithm to accurately predict dysplasia. Once taught to non-experts, the algorithm significantly improves their rate of dysplasia detection. This opens the door to standardised training and assessment of competence for those who perform endoscopy in BE. It may shorten the learning curve and might also be used to compare competence of trainees with recognised experts as part of their accreditation process.

How Should We Report Endoscopic Results in Patient's with Barrett's Esophagus?

Barrett's esophagus is the only known pre-cancerous lesion for esophageal adenocarcinoma and is diagnosed by high-definition white light endoscopy demonstrating a columnar-lined esophagus along with biopsy evidence of intestinal metaplasia. With accurate performance and reporting of the endoscopic procedure, an evidence-based management strategy can be developed for treatment of Barrett's dysplasia. However, cross-sectional data demonstrate that there is still inconsistency among gastroenterologists in performance and reporting of endoscopic findings in patients with Barrett's esophagus. Here, we present an evidence-based review of how to report endoscopic findings in Barrett's esophagus.

Emerging optical methods for endoscopic surveillance of Barrett's oesophagus

Barrett's oesophagus is an acquired metaplastic condition that predisposes patients to the development of oesophageal adenocarcinoma, prompting the use of surveillance regimes to detect early malignancy for endoscopic therapy with curative intent. The currently accepted surveillance regime uses white light endoscopy together with random biopsies, but has poor sensitivity and discards information from numerous light-tissue interactions that could be exploited to probe structural, functional, and molecular changes in the tissue. Advanced optical methods are now emerging that are highly sensitive to these changes and hold potential to improve surveillance of Barrett's oesophagus if they can be applied endoscopically. The next decade will see some of these exciting new methods applied to surveillance of Barrett's oesophagus in new device architectures for the first time, potentially leading to a long-awaited improvement in the standard of care.

White light-emitting contrast image capsule endoscopy for visualization of small intestine lesions: a pilot study

BACKGROUND AND STUDY AIMS

 Capsule endoscopy (CE) has become a routine means of diagnosing obscure gastrointestinal bleeding (OGIB) in the small intestine. Capsules using novel blue-enhanced white light-emitting diodes are expected to acquire clearer contrast images (CIs) of the small bowel vasculature. We conducted a pilot study to examine whether CIs facilitate visualization of small bowel erosions, ulcers, and areas of angioectasia compared with standard white light images (WLIs).

PATIENTS AND METHODS

 A total of 24 patients with OGIB were recruited in this study. The main outcome measure was visibility of lesions on CIs compared with WLIs. We also examined the color difference between lesions and normal mucosa (ΔE) with each imaging modality.

RESULTS

 Three experienced physicians retrospectively evaluated 138 images of small bowel lesions (107 erosions, or ulcers, and 31 areas of angioectasia) obtained from 24 CE examinations. The endoscopists judged that compared with WLIs, CIs afforded easier identification of erosions or ulcers in 29 of 107 cases (27.1 %), were non-inferior in 68 of 107 cases (63.6 %), and were inferior in 10 of 107 cases (9.3 %). Identification of angioectasia was judged to be easier with CIs in 15 of 31 cases (48.4 %), non-inferior in 13 of 31 cases (41.9 %), and inferior in 3 of 31 cases (9.7 %). ΔE was significantly higher for CIs than WLIs, especially for angioectasia, potentially explaining why lesions were easier to visualize.

CONCLUSIONS

 CIs obtained by CE appear to facilitate identification of small bowel erosions, ulcers, and areas of angioectasia compared with WLIs.

Applications of acetic acid spray combined with narrow band imaging in diagnosis of early gastrointestinal cancers and precancerous lesions

Many new endoscopic techniques have been used for the diagnosis of early gastrointestinal cancers and precancerous lesions, such as magnifying endoscopy, narrow-band imaging (NBI), Fuji intelligent chromoendiscopy, i-scan imaging, confocal laser endomicroscopy, and chromoendoscopy (Lugol's iodine, indigo carmine, methylene blue, acetic acid, and crystal violet). Each technique has its own advantages and disadvantages (e.g., being expensive and prolonged examination duration). Spraying acetic acid onto the mucosal surface can enhance the recognition of mucosal surface architecture, and NBI has the advantage to display the microvascular morphology. Thus, acetic acid spray combined with NBI endoscopy can greatly improve the diagnosis of early gastrointestinal cancers and precancerous lesions. Since this combination has low cost and no adverse reactions, they can be used in primary hospitals without magnification endoscopy.

Barrett’s oesophagus: Current controversies

Oesophageal adenocarcinoma is rapidly increasing in Western countries. This tumour frequently presents late in its course with metastatic disease and has a very poor prognosis. Barrett’s oesophagus is an acquired condition whereby the native squamous mucosa of the lower oesophagus is replaced by columnar epithelium following prolonged gastro-oesophageal reflux and is the recognised precursor lesion for oesophageal adenocarcinoma. There are multiple national and society guidelines regarding screening, surveillance and management of Barrett’s oesophagus, however all are limited regarding a clear evidence base for a well-demonstrated benefit and cost-effectiveness of surveillance, and robust risk stratification for patients to best use resources. Currently the accepted risk factors upon which surveillance intervals and interventions are based are Barrett’s segment length and histological interpretation of the systematic biopsies. Further patient risk factors including other demographic features, smoking, gender, obesity, ethnicity, patient age, biomarkers and endoscopic adjuncts remain under consideration and are discussed in full. Recent evidence has been published to support earlier endoscopic intervention by means of ablation of the metaplastic Barrett’s segment when the earliest signs of dysplasia are detected. Further work should concentrate on establishing better risk stratification and primary and secondary preventative strategies to reduce the risk of adenocarcinoma of the oesophagus.

The Role of Adjunct Imaging in Endoscopic Detection of Dysplasia in Barrett's Esophagus

Advances in imaging technologies have demonstrated promise in early detection of dysplasia and cancer in Barrett's esophagus (BE). Optical chromoendoscopy, dye-based chromoendoscopy, and novel technologies have provided the opportunity to visualize the cellular and subcellular structures. Only narrow-band imaging and acetic acid chromoendoscopy have reached benchmarks for clinical use. Volumetric laser endomicroscopy and molecular imaging are not established for routine use. Best practice in management of BE should be focused on careful endoscopic examination, resection, or ablation of the entire abnormal lesion, as well as the use of available imaging technique that has good diagnostic accuracy.

Meta-analysis: The diagnostic efficacy of chromoendoscopy for early gastric cancer and premalignant gastric lesions

BACKGROUND AND AIM

Chromoendoscopy (CE) is widely used in the diagnosis of early gastric cancer (EGC) and premalignant gastric lesions (PGLs). We conducted a meta-analysis to evaluate the diagnostic efficacy of CE for EGC and PGLs.

METHODS

We searched PubMed/MEDLINE, EMBASE, and the Cochrane library to identify all eligible studies according to inclusion and exclusion standards. Publication bias was tested using Funnel plots and Egger's test. The possible sources of the heterogeneity were explored by performing a meta-regression analysis. Heterogeneity was assessed by the Q test and I(2) statistic.

RESULTS

Ten studies met the inclusion standards, including a total of 699 patients and 902 lesions. The pooled sensitivity, specificity, and area under the curve of CE were 0.90 (95% confidence interval, 0.87-0.92), 0.82 (95% confidence interval, 0.79-0.86), and 0.9464, respectively. In subgroup analysis of diagnostic accuracy, CE showed higher accuracy versus standard white light endoscopy for EGC (P = 0.005) and PGLs (P = 0.001).

CONCLUSION

Chromoendoscopy seems to have a high diagnostic efficacy and improve the detection of EGC and PGLs compared with standard white light endoscopy.

Acetic acid chromoendoscopy: Improving neoplasia detection in Barrett's esophagus

Barrett’s esophagus (BE) is an important condition given its significant premalignant potential and dismal five-year survival outcomes of advanced esophageal adenocarcinoma. It is therefore suggested that patients with a diagnosis of BE undergo regular surveillance in order to pick up dysplasia at an earlier stage to improve survival. Current “gold-standard” surveillance protocols suggest targeted biopsy of visible lesions followed by four quadrant random biopsies every 2 cm. However, this method of Barrett’s surveillance is fraught with poor endoscopist compliance as the procedures are time consuming and poorly tolerated by patients. There are also significant miss-rates with this technique for the detection of neoplasia as only 13% of early neoplastic lesions appear as visible nodules. Despite improvements in endoscope resolution these problems persist. Chromoendoscopy is an extremely useful adjunct to enhance mucosal visualization and characterization of Barrett’s mucosa. Acetic acid chromoendoscopy (AAC) is a simple, non-proprietary technique that can significantly improve neoplasia detection rates. This topic highlight summarizes the current evidence base behind AAC for the detection of neoplasia in BE and provides an insight into the direction of travel for further research in this area.

Digital chromoendoscopy utilization in clinical practice: A survey of gastroenterologists in Connecticut

AIM: To use a survey to characterize and identify potential barriers to the use of digital chromoendoscopy (DC) by practicing gastroenterologists.

METHODS: An anonymous, internet-based survey was sent to gastroenterologists in Connecticut who were members of one of three national gastrointestinal organizations. The survey collected demographic information, frequency of DC use, types of procedures that the respondent performs, setting of practice (academic vs community), years out of training, amount of training in DC, desire to have DC training and perceived barriers to DC use. Responses were collected anonymously. The primary endpoint was the proportion of endoscopists utilizing DC. Associations between the various data collected were analyzed using χ² test.

RESULTS: One hundred and twenty-four gastroenterologists (48%) of 261 who received the online survey responded. Seventy-eight percent of surveyed gastroenterologists have used DC during the performance of upper endoscopy and 81% with lower endoscopy. DC was used in more than half of procedures by only 14% of gastroenterologists during upper endoscopy and 12% during lower endoscopy. Twenty-three percent (upper) and 21% (lower) used DC more than one quarter of the time. DC was used for 10% or less of endoscopies by 60% (upper) and 53% (lower) of respondents. Endoscopists reported lack of training as the leading deterrent to DC use with 36% reporting it as their primary deterrent. Eighty-nine percent of endoscopists never received formal training in DC. Lack of time (30% of respondents), lack of evidence (24%) and lack of reimbursement (10%) were additional deterrents. There were no differences in DC use relative to academic vs community practice setting or years out of training.

CONCLUSION: DC is used infrequently by most endoscopists, primarily due to a lack of training. Training opportunities should be expanded to meet the interest expressed by the majority of endoscopists.

Endoscopic Therapy of Early Carcinoma of the Oesophagus

Background

Oesophageal cancer is a comparatively rare disease in the Western world. Prognosis is highly dependent on the choice of treatment. Early stages can be treated by endoscopic resection, whereas surgery needs to be performed in the case of advanced carcinomas. Technical progress has enabled high-definition endoscopes and technical add-ons which help the endoscopist in finding fine irregularities in the oesophageal mucosa, though interpretation still remains challenging.

Methods

In this review, we discuss both novel and old diagnostic procedures and their value, as well as the current recommendations for the diagnosis and treatment of early oesophageal carcinomas. The database of PubMed and Medline was searched and analysed to provide all relevant literature for this review.

Results and Conclusion

Endoscopic resection is the therapy of choice in early oesophageal cancer. In case of adenocarcinoma it is mandatory to perform subsequent ablation of all residual Barrett's mucosa to avoid metachronous lesions.

Endoscopic imaging of Barrett’s esophagus

The incidence of esophageal adenocarcinoma (EAC) has dramatically increased in the United States as well as Western European countries. The majority of esophageal adenocarcinomas arise from a backdrop of Barrett’s esophagus (BE), a premalignant lesion that can lead to dysplasia and cancer. Because of the increased risk of EAC, GI society guidelines recommend endoscopic surveillance of patients with BE. The emphasis on early detection of dysplasia in BE through surveillance endoscopy has led to the development of advanced endoscopic imaging technologies. These techniques have the potential to both improve mucosal visualization and characterization and to detect small mucosal abnormalities which are difficult to identify with standard endoscopy. This review summarizes the advanced imaging technologies used in evaluation of BE.

Virtual chromoendoscopy improves the diagnostic yield of small bowel capsule endoscopy in obscure gastrointestinal bleeding

BACKGROUND

Small bowel capsule endoscopy represents the initial investigation for obscure gastrointestinal bleeding. Flexible spectral imaging colour enhancement (FICE) is a virtual chromoendoscopy technique designed to enhance mucosal lesions, available in different settings according to light wavelength-- FICE1, 2 and 3.

AIMS

To compare the diagnostic yield of FICE1 and white light during capsule endoscopy in patients with obscure gastrointestinal bleeding.

METHODS

Retrospective single-centre study including 60 consecutive patients referred for small bowel capsule endoscopy for obscure gastrointestinal bleeding. Endoscopies were independently reviewed in FICE1 and white light; findings were then reviewed by another researcher, establishing a gold standard. Diagnostic yield was defined as the presence of lesions with high bleeding potential (P2) angioectasias, ulcers or tumours.

RESULTS

Diagnostic yield using FICE1 was significantly higher than white light (55% vs. 42%, p=0.021). A superior number of P2 lesions was detected with FICE1 (74 vs. 44, p=0.003), particularly angioectasias (54 vs. 26, p=0.002), but not ulcers or tumours.

CONCLUSIONS

FICE1 was significantly superior to white light, resulting in a 13% improvement in diagnostic yield, and potentially bleeding lesions particularly angioectasias were more often observed. Our results support the use of FICE1 while reviewing small bowel capsule endoscopy for obscure gastrointestinal bleeding.

Acetic acid chromoendoscopy for the diagnosis of early neoplasia and specialized intestinal metaplasia in Barrett's esophagus: a meta-analysis

BACKGROUND AND AIMS

Barrett's esophagus (BE) surveillance with random biopsies is time-consuming, invasive, and can lead to sampling error. Acetic acid chromoendoscopy (AAC) with targeted biopsies has been proposed as an effective alternative. The aim of this study was to assess the diagnostic accuracy of AAC for the detection of early neoplasia (high-grade dysplasia [HGD] or early cancer [EC]) and specialized intestinal metaplasia (SIM) in patients with BE.

METHODS

We performed a meta-analysis of all primary studies that compared AAC-based diagnoses (index test) with histopathology as the reference standard. The data were extracted on a per-patient, per-area, and per-procedure basis whenever available.

RESULTS

Thirteen prospective studies met the inclusion criteria. For the diagnosis of HGD/EC, the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for all included studies (9 studies, 1379 patients) were 0.92 (95% confidence interval [CI], 0.83-0.97), 0.96 (95% CI, 0.85-0.99), 25.0 (95% CI, 5.9-105.3), and 0.08 (95% CI, 0.04-0.18), respectively. Results were not significantly different when considering only studies with a per-patient analysis. For the characterization of SIM, the pooled sensitivity, specificity, LR+, and LR- for all the included studies (8 studies, 516 patients) were 0.96 (95% CI, 0.83-0.99), 0.69 (95% CI, 0.54-0.81), 3.0 (95% CI, 2.0-4.7), and 0.06 (95% CI, 0.01-0.26), respectively. No significant sources of heterogeneity were identified on subgroup analysis.

CONCLUSION

AAC has an overall high diagnostic accuracy for detecting HGD/EC in patients with BE. For SIM characterization, AAC sensitivity is very high but has poor specificity, suggesting that histological confirmation is necessary when AAC is positive.

Efficacy of repeat review with flexible spectral imaging color enhancement in patients with no findings by capsule endoscopy

BACKGROUND/AIM

The efficacy of flexible spectral imaging color enhancement (FICE) ch. 1 (F1) for the detection of ulcerative lesions and angioectasias in the small intestine with capsule endoscopy (CE) has been reported. In the present study, we evaluated whether F1 could detect incremental findings in patients with no findings in a standard review mode.

PATIENTS AND METHODS

In total, 52 patients (age: 60.1 ± 15.3 years; 30 males) with obscure gastrointestinal bleeding (OGIB) who underwent CE and in whom no lesion was detected in the small intestine in the standard mode (first review) were enrolled. Two experienced endoscopists independently reviewed CE videos again by F1 (second review). The following findings were defined to be significant: Ulcers, erosions, aphthas, angioectasias, tumors, and bleeding. Incremental findings at the second review were checked at F1 and in standard mode by the two reviewers (third review). Finally, the findings were confirmed by the agreement of the two reviewers at the third review.

RESULTS

F1 detected five significant lesions in three patients with overt OGIB; three erosions, one aphtha, and one angioectasia. For nonsignificant lesions, F1 detected 12 red mucosas and 16 red spots. Moreover, 29 patients with 71 findings were considered false positives.

CONCLUSION

F1 detected incremental significant findings in a small percentage of patients with no findings in the standard review mode. In addition, F1 showed many false-positive findings. The incremental effect of a repeated review by F1 in patients with no findings in the first review is limited.

Diagnostics and Early Diagnosis of Esophageal Cancer

In the esophagus two different kinds of primary neoplasias may arise: squamocellular carcinomas (SCC) and esophageal adenocarcinomas (EAC). Although both types of carcinoma are rare diseases, especially the incidence of EAC rose in the last years. The management of esophageal cancer is challenging. There are no specific symptoms of early esophageal cancers. Due to this fact, most of the esophageal cancers are found incidentally, and only 12.5% of esophageal tumors are endoscopically resectable. Gastroscopy is the gold standard for the diagnosis of esophageal cancer. The sensitivity of detecting early-stage carcinoma may be improved by adjunct techniques such as chromoendoscopy, virtual chromoendoscopy, magnification endoscopy, and other advanced endoscopic imaging techniques. The diagnosis of esophageal cancer can be verified with targeted biopsies. Accurate staging information is crucial for establishing appropriate treatment choices for esophageal cancer, while the depth of the tumor determines the feasibility of therapy. In terms of staging, endosonography, abdominal ultrasound, and computed tomography scan of the thorax and abdomen should thus be performed before initiation of therapy.

Image-enhanced endoscopy technology in the gastrointestinal tract: what is available?

Gastrointestinal malignancy accounts for approximately a fifth of all cancer deaths in the United Kingdom. By the time patients are symptomatic, lesions are often advanced, with limited treatment options available. The development of effective endoscopic therapies means that neoplastic lesions can now be treated with improved patient outcomes. This has led to a paradigm shift, whereby the aim of digestive endoscopy is to identify premalignant conditions or early neoplastic change, in order to make an impact on their natural history. This has necessitated an improvement in imaging techniques in order to identify subtle mucosal changes that may harbour precancerous cells. At present there is an array of available imaging modalities, each with implications on cost, training and lesion detection. Here we describe the scientific rationale behind the major commercially available techniques as well as offering a glimpse at possible future directions.

Red flag imaging in Barrett's esophagus: does it help to find the needle in the haystack?

Esophageal Adenocarcinoma (EAC) has suffered a sharp increase on its incidence for the last decades, and it is associated with a poor prognosis. Barrett's Esophagus (BE) is the most important identifiable risk factor for the progression to esophageal adenocarcinoma. The key to prevent and provide a curative treatment of esophageal adenocarcinoma is the detection and eradication of early neoplasia in patients with esophagus. Endoscopic surveillance is evolving from a blind or random four quadrant biopsies protocol (Seattle protocol) to a more targeted approach. A detailed white light examination with high-resolution endoscopy is the cornerstone for recognition of early neoplastic lesions in BE. Additional imaging modalities may enhance targeting of lesions or provide more information at a focused level. There are emerging data that some of these new modalities can increase the yield of detecting dysplasia, although its routine use has yet to be validated.

Improvement over time in outcomes for patients undergoing endoscopic therapy for Barrett's oesophagus-related neoplasia: 6-year experience from the first 500 patients treated in the UK patient registry

BACKGROUND

Barrett's oesophagus (BE) is a pre-malignant condition leading to oesophageal adenocarcinoma (OAC). Treatment of neoplasia at an early stage is desirable. Combined endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is an alternative to surgery for patients with BE-related neoplasia.

METHODS

We examined prospective data from the UK registry of patients undergoing RFA/EMR for BE-related neoplasia from 2008 to 2013. Before RFA, visible lesions were removed by EMR. Thereafter, patients had RFA 3-monthly until all BE was ablated or cancer developed (endpoints). End of treatment biopsies were recommended at around 12 months from first RFA treatment or when endpoints were reached. Outcomes for clearance of dysplasia (CR-D) and BE (CR-IM) at end of treatment were assessed over two time periods (2008-2010 and 2011-2013). Durability of successful treatment and progression to OAC were also evaluated.

RESULTS

508 patients have completed treatment. CR-D and CR-IM improved significantly between the former and later time periods, from 77% and 56% to 92% and 83%, respectively (p<0.0001). EMR for visible lesions prior to RFA increased from 48% to 60% (p=0.013). Rescue EMR after RFA decreased from 13% to 2% (p<0.0001). Progression to OAC at 12 months is not significantly different (3.6% vs 2.1%, p=0.51).

CONCLUSIONS

Clinical outcomes for BE neoplasia have improved significantly over the past 6 years with improved lesion recognition and aggressive resection of visible lesions before RFA. Despite advances in technique, the rate of cancer progression remains 2-4% at 1 year in these high-risk patients.

TRIAL REGISTRATION NUMBER

ISRCTN93069556.

Endoscopic therapy in early adenocarcinomas (Barrett's cancer) of the esophagus

The incidence of early esophageal adenocarcinoma has been increasing significantly in recent decades. Prognosis depends greatly on the choice of treatment. Early cancers can be treated by endoscopic resection, whereas advanced carcinomas have to be sent for surgery. Esophageal resection is associated with high perioperative mortality (1-5%) even in specialized centers. Early diagnosis enables curative endoscopic treatment option. Patients with gastrointestinal symptoms and a familial risk for esophageal cancer should undergo upper gastrointestinal endoscopy. High-definition endoscopes have been developed with technical add-on that helps endoscopists to find fine irregularities in the esophageal mucosa, but interpreting the findings remains challenging. In this review we discussed novel and old diagnostic procedures and their values, as well as our own recommendations and those of the authors discussed for the diagnosis and treatment of early Barrett's carcinoma. Endoscopic resection is the therapy of choice in early esophageal adenocarcinoma. It is mandatory to perform a subsequent ablation of all residual Barrett's mucosa to avoid metachronous lesions.

The role of acetic acid in the management of Barrett's oesophagus

Barrett's oesophagus is of significant importance due to its premalignant potential. Acetic acid chromoendoscopy is a simple technique that can be used with any endoscope system. It has been utilised for the identification of Barrett's intestinal metaplasia; and more importantly, for the localisation of early neoplasia within Barrett's, which is often focal, subtle and very easy to miss by random quadrantic biopsies alone. Acetic acid is routinely utilised in specialised centres and its use is expanding. This article examines the evidence base behind acetic acid chromoendoscopy and looks at where further research needs to be directed.

Electronic chromoendoscopy

Electronic chromoendoscopy technologies provide image enhancement and may improve the diagnosis of mucosal lesions. Although strides have been made in standardization of image characterization, especially with NBI, further image-to-pathology correlation and validation are required. There is promise for the development of a resect and discard policy for diminutive adenomas by using electronic chromoendoscopy; however, before this can be adopted, further community-based studies are needed. Further validated training tools for NBI, FICE, and i-SCAN will also be required for the use of these techniques to become widespread.

Acetic acid chromoendoscopy in Barrett's esophagus surveillance is superior to the standardized random biopsy protocol: results from a large cohort study (with video)

BACKGROUND

Currently, various advanced endoscopic techniques are available with varying success rates. These technologies are manufacturer dependent, which has financial implications in the current era of austerity. Acetic acid is a commonly available dye that has been used in the detection of neoplasia within Barrett's esophagus. It has been shown to be effective in detecting neoplasia in high-risk subgroups, but its efficacy in a low-prevalence surveillance population remains unproven.

OBJECTIVE

This study aimed to investigate the effectiveness of acetic acid chromoendoscopy in a Barrett's esophagus surveillance population. We aimed to compare the neoplasia yield of acetic acid chromoendoscopy (AAC) with the neoplasia yield from standardized random biopsy (SBP) protocol-guided biopsies in the routine surveillance of patients with Barrett's esophagus.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital in the United Kingdom.

PATIENTS

Patients 18 years of age and older with a diagnosis of Barrett's esophagus undergoing surveillance gastroscopy.

INTERVENTIONS

AAC versus standardized random biopsy protocol (SBP) for Barrett's esophagus surveillance.

MAIN OUTCOME MEASUREMENTS

Neoplasia detection in 2 groups.

RESULTS

The overall neoplasia detection rates for all grades of neoplasia were 13 of 655 (2%) in the SBP-guided biopsy cohort and 41 of 327 (12.5%) in the AAC cohort (P = .0001). On per-patient analysis, a 6.5-fold gain in neoplasia detection was seen in the AAC cohort compared with the SBP cohort (0.13 vs 0.02, P = .000). In the SBP cohort, a total of 13 of 655 (2%) neoplasias were detected, of which 3 of 655 patients (0.5%) had low-grade dysplasia, 7 of 655 (1%) had high-grade dysplasia, and 3 of 655 (0.5%) were found to have superficial cancer (T1a/T1b). In the AAC cohort, a total of 41 of 327 neoplasias (12.5%) were found, of which 9 of 327 patients (2.7%) had low-grade dysplasia, 18 of 327 (5.5%) had high-grade dysplasia, and 14 of 327 (4.2%) were found to have superficial cancer. The number of biopsies required to detect 1 neoplasia was 15 times lower in the AAC cohort (40 biopsies) than in the SBP cohort (604 biopsies). On per-biopsy analysis, a 14.7-fold increase in neoplasia detection was seen in the AAC cohort per biopsy compared with the SBP cohort (0.025 vs 0.0017; P = .000).

LIMITATIONS

Not a randomized, controlled study.

CONCLUSIONS

Our study demonstrates that acetic acid detects more neoplasias than conventional protocol-guided mapping biopsies and requires 15 times fewer biopsies per neoplasia detected.

State of the art in advanced endoscopic imaging for the detection and evaluation of dysplasia and early cancer of the gastrointestinal tract

Ideally, endoscopists should be able to detect, characterize, and confirm the nature of a lesion at the bedside, minimizing uncertainties and targeting biopsies and resections only where necessary. However, under conventional white-light inspection – at present, the sole established technique available to most of humanity – premalignant conditions and early cancers can frequently escape detection. In recent years, a range of innovative techniques have entered the endoscopic arena due to their ability to enhance the contrast of diseased tissue regions beyond what is inherently possible with standard white-light endoscopy equipment. The aim of this review is to provide an overview of the state-of-the-art advanced endoscopic imaging techniques available for clinical use that are impacting the way precancerous and neoplastic lesions of the gastrointestinal tract are currently detected and characterized at endoscopy. The basic instrumentation and the physics behind each method, followed by the most influential clinical experience, are described. High-definition endoscopy, with or without optical magnification, has contributed to higher detection rates compared with white-light endoscopy alone and has now replaced ordinary equipment in daily practice. Contrast-enhancement techniques, whether dye-based or computed, have been combined with white-light endoscopy to further improve its accuracy, but histology is still required to clarify the diagnosis. Optical microscopy techniques such as confocal laser endomicroscopy and endocytoscopy enable in vivo histology during endoscopy; however, although of invaluable assistance for tissue characterization, they have not yet made transition between research and clinical use. It is still unknown which approach or combination of techniques offers the best potential. The optimal method will entail the ability to survey wide areas of tissue in concert with the ability to obtain the degree of detailed information provided by microscopic techniques. In this respect, the challenging combination of autofluorescence imaging and confocal endomicroscopy seems promising, and further research is awaited.

Endoscopic Optical Coherence Tomography for Clinical Gastroenterology

Optical coherence tomography (OCT) is a real-time optical imaging technique that is similar in principle to ultrasonography, but employs light instead of sound waves and allows depth-resolved images with near-microscopic resolution. Endoscopic OCT allows the evaluation of broad-field and subsurface areas and can be used ancillary to standard endoscopy, narrow band imaging, chromoendoscopy, magnification endoscopy, and confocal endomicroscopy. This review article will provide an overview of the clinical utility of endoscopic OCT in the gastrointestinal tract and of recent achievements using state-of-the-art endoscopic 3D-OCT imaging systems.

Endoscopic diagnosis of early Barrett's neoplasia: perspectives for advanced endoscopic technology

Barrett's esophagus (BE) is a metaplastic condition that occurs secondary to gastroesophageal reflux disease. BE is also a precursor to esophageal adenocarcinoma, which, although still rare in Japan, is one of the most rapidly increasing cancers in Western countries. However, the prevalence of gastroesophageal reflux disease has increased significantly over the past few decades in Japan, possibly leading to an incremental rise in BE and the associated inherent risk of adenocarcinoma. Given the poor prognosis of advanced-stage Barrett's adenocarcinoma, endoscopic surveillance is recommended for subjects with BE to detect early neoplasias including dysplasia. However, endoscopic identification of dysplastic lesions is still not sufficiently reliable or subjective, making targeted therapy extremely difficult. Over the past few years, improvements in image resolution, image processing software, and optical filter technology have enabled identification of dysplasia and early cancer in BE patients. We retrieved as many studies on advanced endoscopic technologies in BE as possible from MEDLINE and PubMed. The present review focuses on the emergent clinically available technologies to provide an overview of the technologies, their practical applicability, current status, and future challenges.

I-SCAN targeted versus random biopsies in Barrett's oesophagus

BACKGROUND

The accuracy and effectiveness of targeted oesophageal biopsies in Barrett's oesophagus to detect dysplasia using new magnification techniques are unknown. Aim of this study was to investigate whether the combined use of acetic acid, magnification and electronic filters allows the same accuracy as the four-quadrant random biopsies pattern; pathologist interobserver agreement both in low grade and high grade dysplasia was also assessed.

METHODS

Fifty-four consecutive patients newly diagnosed with Barrett's oesophagus were enrolled in a prospective study from a single endoscopy unit. Biopsies were evaluated by the local pathologist and by an expert pathologist from another pathology unit.

MAIN OUTCOME MEASUREMENT

Dysplasia detection rate and interobserver agreement for the histologic diagnosis of dysplasia.

RESULTS

The use of acetic acid, magnification and electronic filters showed an unacceptably low dysplasia detection rate by the two pathologists (9.2% and 5.5% for targeted biopsies, respectively). The interobserver agreement for low grade dysplasia between pathologists was low (Cohen's K weighted=0.45).

CONCLUSIONS

In an average setting, the standard four-quadrant method should still be preferred, along with the implementation of a routine second evaluation by an expert pathologist.

Endoscopic tools for the diagnosis and evaluation of celiac disease

Celiac disease (CD) is an autoimmune disease of the small bowel induced by ingestion of wheat, rye and barley. Current guidelines indicate histological analysis on at least four duodenal biopsies as the only way to diagnose CD. These indications are based on the conception of the inability of standard endoscopy to make diagnosis of CD and/or to drive biopsy sampling. Over the last years, technology development of endoscopic devices has greatly ameliorated the accuracy of macroscopic evaluation of duodenal villous pattern, increasing the diagnostic power of endoscopy of CD. The aim of this paper is to review the new endoscopic tools and procedures proved to be useful in the diagnosis of CD, such as chromoendoscopy, Fujinon Intelligent Chromo Endoscopy, Narrow Band Imaging, Optical Coherence Tomography, Water-Immersion Technique, confocal laser endomicroscopy, high-resolution magnification endoscopy, capsule endoscopy and I-Scan technology.

Red flag imaging techniques in Barrett's esophagus

The key to detection and treatment of early neoplasia in Barrett's esophagus (BE) is thorough and careful inspection of the Barrett's segment. The greatest role for red flag techniques is to help identify neoplastic lesions for targeted biopsy and therapy. High-definition white light endoscopy (HD-WLE) can potentially improve endoscopic imaging of BE compared with standard endoscopy, but little scientific evidence supports this. The addition of autofluorescence imaging to HD-WLE and narrow band imaging increases sensitivity and the false-positive rate without significantly improving overall detection of BE-related neoplasia.

[Esophageal precancerous lesions: early diagnosis, treatment, and preservation of quality of life]

Modern high-resolution video endoscopes allow detailed examination of the esophageal mucosa and diagnosis of early neoplastic changes in the gastrointestinal tract. Whereas Barrett's esophagus is a precancerous condition that can develop into adenocarcinoma, there is no defined precancerous lesion for squamous cell carcinoma. Various diseases are associated with the development of esophageal squamous cell carcinoma. Chromoendoscopy has become an established method in the diagnostic work-up for better visualization of early neoplasia. If Barrett's esophagus is present, acetic acid spraying or virtual chromoendoscopy can be used to accentuate the display of superficial gyriform structures in the mucosa. The gold standard for detecting squamous cell carcinoma is still the use of Lugol solution. When early neoplasia is suspected, diagnostic endoscopic resection should be performed. This allows precise histological assessment of the tumor. Early diagnosis of neoplastic changes in the esophagus provides patients not only with the option of curative therapy but also with a good quality of life through preservation of the esophagus.

Screening for precancerous lesions of upper gastrointestinal tract: from the endoscopists' viewpoint

Upper gastrointestinal tract cancers are one of the most important leading causes of cancer death worldwide. Diagnosis at late stages always brings about poor outcome of these malignancies. The early detection of precancerous or early cancerous lesions of gastrointestinal tract is therefore of utmost importance to improve the overall outcome and maintain a good quality of life of patients. The desire of endoscopists to visualize the invisibles under conventional white-light endoscopy has accelerated the advancements in endoscopy technologies. Nowadays, image-enhanced endoscopy which utilizes optical- or dye-based contrasting techniques has been widely applied in endoscopic screening program of gastrointestinal tract malignancies. These contrasting endoscopic technologies not only improve the visualization of early foci missed by conventional endoscopy, but also gain the insight of histopathology and tumor invasiveness, that is so-called optical biopsy. Here, we will review the application of advanced endoscopy technique in screening program of upper gastrointestinal tract cancers.

Indications, stains and techniques in chromoendoscopy

Early detection of malignancies within the gastrointestinal tract is essential to improve the prognosis and outcome of affected patients. However, conventional white light endoscopy has a miss rate of up to 25% for gastrointestinal pathology, specifically in the context of small and flat lesions within the colon. Chromoendoscopy and other advanced imaging techniques aim at facilitating the visualization and detection of neoplastic lesions and have been applied throughout the gastrointestinal tract. Chromoendoscopy, particularly in combination with magnifying endoscopy has significantly improved means to detect neoplastic lesions in the gastrointestinal mucosa, particularly in ulcerative colitis and Crohn's colitis. In addition, chromoendoscopy is beneficial in the upper gastrointestinal tract, especially when evaluating Barrett's oesophagus (BO) for the presence of dysplasia. Furthermore, it also improves characterization, differentiation and diagnosis of endoscopically detected suspicious lesions, and helps to delineate the extent of neoplastic lesions that may be amenable to endoscopic resection. This review discusses the dyes, indications and advanced endoscopic imaging methods used in various chromoendoscopic techniques, and presents a critical overview of the existing evidence supporting their use in current practice with a particular emphasis on the role in inflammatory bowel disease and BO.

Use of i-scan Endoscopic Image Enhancement Technology in Clinical Practice to Assist in Diagnostic and Therapeutic Endoscopy: A Case Series and Review of the Literature

Background. i-scan is a software-driven technology that allows modifications of sharpness, hue, and contrast to enhance mucosal imaging. It uses postimage acquisition software with real-time mapping technology embedded in the endoscopic processor. Aims. To review applications of i-scan technology in clinical endoscopic practice. Methods. This is a case series of 20 consecutive patients who underwent endoscopic procedures where i-scan image enhancement algorithms were applied. The main outcome measures were to compare mucosal lesions with high-definition white light endoscopy (HD-WLE) and i-scan image enhancement for the application of diagnostic sampling and therapy. Results. 13 cases involving the upper GI tract and 7 cases of the lower GI tract are included. For upper GI tract pathology i-scan assisted in diagnosis or therapy of Barrett's esophagus with dysplasia, esophageal adenocarcinoma, HSV esophagitis, gastric MALT lymphoma, gastric antral intestinal metaplasia with dysplasia, duodenal follicular lymphoma, and a flat duodenal adenoma. For lower GI tract pathology i-scan assisted in diagnosis or therapy of right-sided serrated adenomas, flat tubular adenoma, rectal adenocarcinoma, anal squamous cell cancer, solitary rectal ulcer, and radiation proctitis. Conclusions. i-scan imaging provides detailed topography of mucosal surfaces and delineates lesion edges, which can directly impact endoscopic management.

Efficacy of flexible spectral imaging color enhancement on the detection of small intestinal diseases by capsule endoscopy

OBJECTIVE

The aim of this study was to estimate the efficacy of flexible spectral imaging color enhancement (FICE) on the detection of small intestinal diseases by capsule endoscopy (CE).

METHODS

Six individuals without significant lesions and 18 patients with following diseases were selected: four tumors, five angioectasias, seven ulcerative diseases, one ulcerative lesion and tumor and one ulcerative lesion and angioectasia. Three endoscopists reviewed all CE videos on standard and three types of FICE modes and compared their sensitivity and specificity for detection of small intestinal diseases.

RESULTS

The overall sensitivity of CE was 94.4% at standard mode, 90.7% at FICE channel (Ch) 1, 87.0% at FICE Ch 2 and 87.0% at FICE Ch 3 and the overall specificity of CE was 66.7%, 55.6%, 77.8% and 66.7%, respectively, per patient. There was no significant difference between the standard and each FICE mode. In per-lesion analysis, FICE Ch 1 detected more angioectasias and ulcerative lesions than the standard mode (angioectasia, 25.7 vs 21.0, P = 0.005; ulcerative lesions, 19.3 vs 14.0, P = 0.06). However, FICE Ch 1 missed more tumors than the standard mode (4.3 vs 10.0, P = 0.003).

CONCLUSIONS

Although FICE Ch 1 is better in detecting angioectasias and ulcerative lesions and worse in tumors or polyps than the standard mode, the patient-based sensitivity and specificity of small intestinal diseases are not different between standard and each FICE mode. Further experiences with and improvement of FICE are required.

[Utility of capsule endoscopy with flexible spectral imaging color enhancement in the diagnosis of small bowel lesions]

INTRODUCTION

Capsule endoscopy (CE) is the technique of choice to detect small bowel lesions. Flexible spectral imaging color enhancement (FICE) software has recently been incorporated into the new RAPID 6.0 workstation, which allows three distinct patterns to be visualized in the mucosal structure according to different wavelengths. The aim of this study was to evaluate whether CE-FICE is more effective in detecting lesions than standard visualization.

PATIENTS AND METHODS

Fifty lesions were detected by CE in 41 consecutive patients in 2010. These patients were administered PillCamTM SB2 in our center and were classified into three groups: 1) vascular lesions and angiodysplasias (18 lesions), 2) erosions and ulcers (18 lesions) and 3) polyps and tumors (14 lesions). Subsequently, these lesions were independently analyzed with the available FICE patterns by three endoscopists, who assigned them a score according to the changes in the visualization of each FICE mode: +2, strong improvement; +1, slight improvement; 0, no relevant changes; -1, slight worsening; -2, clear worsening. When the sum of the scores of the three observers was 3 or more, visualization was considered to have improved; a score of 2 to -2 indicated no change; and a score of from -3 to -6 indicated poorer visualization.

RESULTS

The FICE 1 mode improved visualization of angiodysplastic and vascular lesions in 16/18 patients (88.9%) and that of erosions/ulcers in 14/18 patients (77.8%). The FICE 2 mode improved these lesions in 88.9% and 55.5%, respectively. The FICE 3 mode only improved visualization of these lesions in 5/18 (27.7%) and 1/18 patients (5.5%), respectively. Likewise, the distinct FICE modes improved visualization of polyps/tumors in 2/14 (14.2%), 3/13 (21.4%) and 4/14 (28.5%) for FICE 1, 2 and 3, respectively.

CONCLUSIONS

The application of CE-FICE modes 1 and 2 could improve the characterization of angiodysplastic/vascular lesions and erosions or ulcers in small bowel lesions. However, FICE 3 seems to provide no significant advantages. None of the CE-FICE modes seems to improve the characterization of polyps and tumors.

Efficacy of computed image modification of capsule endoscopy in patients with obscure gastrointestinal bleeding

AIM: To investigate whether flexible spectral color enhancement (FICE) improves diagnostic yields of capsule endoscopy (CE) for obscure gastro-intestinal bleeding (OGIB).

METHODS: The study subjects consisted of 81 patients. Using FICE, there were three different sets with different wavelengths. Using randomly selected sets of FICE, images of CE were evaluated again by two individuals who were not shown the conventional CE reports and findings. The difference between FICE and conventional imaging was examined.

RESULTS: The overall diagnostic yields in FICE sets 1, 2, 3 and conventional imaging (48.1%) were 51.9%, 40.7%, 51.9% and 48.1%, respectively, which showed no statistical difference compared to conventional imaging. The total numbers of detected lesions per examination in FICE imaging and conventional imaging were 2.5 ± 2.1 and 1.8 ± 1.7, respectively, which showed a significant difference (P = 0.01).

CONCLUSION: The diagnostic yield for OGIB is not improved by FICE. However, FICE can detect significantly more small bowel lesions compared to conventional imaging.

Advanced endoscopic imaging for Barrett's Esophagus: current options and future directions

Barrett's esophagus is the precursor to esophageal adenocarcinoma, one of the most rapidly increasing cancers in the United States. Given the poor prognosis of late-stage adenocarcinoma, endoscopic surveillance is recommended for subjects with Barrett's esophagus to detect early neoplasia. Current guidelines recommend "random" four-quadrant biopsies taken every 1-2 cm throughout the Barrett's segment. However, this only samples a minority of epithelium and has been shown to miss areas of endoscopically- inapparent neoplasia (high grade dysplasia or cancer). Recent efforts have focused on developing novel diagnostic imaging technologies to detect the subtle epithelial changes associated with dysplasia and neoplasia in Barrett's esophagus. Some of these modalities serve as "red flag" technologies designed to detect areas of abnormality within large surface areas. Other technologies serve to characterize areas of visible abnormality, offering a higher spatial resolution to confirm/exclude the presence of neoplasia. This review summarizes several available and evolving imaging technologies used in the endoscopic diagnosis and surveillance of Barrett's associated neoplasia.

Consensus statements for management of Barrett's dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process

BACKGROUND & AIMS

Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett's esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA.

METHODS

We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement.

RESULTS

Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated.

CONCLUSIONS

We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.

Capsule endoscopy with flexible spectral imaging color enhancement reduces the bile pigment effect and improves the detectability of small bowel lesions

BACKGROUND

Capsule endoscopy with flexible spectral imaging color enhancement (CE-FICE) has been reported to improve the visualization and detection of small-bowel lesions, however, its clinical usefulness is still not established. Therefore, we conducted a study to evaluate whether CE-FICE contributes to improve the detectability of small-bowel lesions by CE trainees.

METHODS

Four gastroenterology trainees without prior CE experience were asked to read and interpret 12 CE videos. Each of the videos was read by conventional visualization method and under three different FICE settings. To evaluate whether the lesion recognition ability of the CE trainees could be improved by the FICE technology, the lesion detection rate under each of the three FICE settings was compared with that by conventional CE. CE trainees tend to miss small-bowel lesions in bile-pigment-positive condition, therefore we evaluated whether CE-FICE contributes to reducing the bile-pigment effect. The bile-pigment condition was determined by the color values around the small-bowel lesions according to the results of the receiver-operating-characteristic analysis. Moreover, we also evaluated whether poor bowel preparion might affect the accuracy of lesion recognition by CE-FICE.

RESULTS

Of a total of 60 angioectasias, CE trainees identified 26 by conventional CE, 40 under FICE setting 1, 38 under FICE setting 2, and 31 under FICE setting 3. Of a total of 82 erosions/ulcerations, CE trainees identified 38 by conventional CE, 62 under FICE setting 1, 60 under FICE setting 2, and 20 under FICE setting 3. Compared with conventional CE, FICE settings 1 and 2 significantly improved the detectability of angioectasia (P = 0.0017 and P = 0.014, respectively) and erosions/ulcerations (P = 0.0012 and P = 0.0094, respectively). Although the detectability of small-bowel lesions by conventional CE (P = 0.020) and under FICE setting 2 (P = 0.0023) was reduced by the presence of bile-pigments, that under FICE setting 1 was not affected (P = 0.59). Our results also revealed that in poor bowel visibility conditions, CE-FICE yielded a high rate of false-positive findings.

CONCLUSIONS

CE-FICE may reduce the bile-pigment effect and improve the detectability of small-bowel lesions by CE trainees; the reliability of CE-FICE may be improved by good bowel preparation.

Endoscopic therapies for Barrett's-associated dysplasia: a new paradigm for a new decade

The emergence of endoscopic therapies for Barrett's esophagus (BE)-associated dysplasia has significantly altered the management of this complex disease. Over the past decade, there has been a paradigm shift from that of pure surveillance to a more therapeutic approach in eradicating dysplastic BE. This strategy includes less invasive options than esophagectomy for high-grade dysplasia and early eradication of confirmed low-grade dysplasia. Although multiple modalities exist for endoscopic therapy, endoscopic mucosal resection coupled with radiofrequency ablation appears to be the most effective therapy, with minimal complications. Recent advances in endoscopic eradication therapies for dysplastic BE have fueled excitement for a significant weapon against the rising incidence of esophageal cancer.