Definition White Light Endoscopy Research Articles

Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.

Computer-aided detection versus advanced imaging for detection of colorectal neoplasia: a systematic review and network meta-analysis

Computer-aided detection (CADe) techniques based on artificial intelligence algorithms can assist endoscopists in detecting colorectal neoplasia. CADe has been associated with an increased adenoma detection rate, a key quality indicator, but the utility of CADe compared with existing advanced imaging techniques and distal attachment devices is unclear. For this systematic review and network meta-analysis, we did a comprehensive search of PubMed/Medline, Embase, and Scopus databases from inception to Nov 30, 2020, for randomised controlled trials investigating the effectiveness of the following endoscopic techniques in detecting colorectal neoplasia: CADe, high definition (HD) white-light endoscopy, chromoendoscopy, or add-on devices (ie, systems that increase mucosal visualisation, such as full spectrum endoscopy [FUSE] or G-EYE balloon endoscopy). We collected data on adenoma detection rates, sessile serrated lesion detection rates, the proportion of large adenomas detected per colonoscopy, and withdrawal times. A frequentist framework, random-effects network meta-analysis was done to compare artificial intelligence with chromoendoscopy, increased mucosal visualisation systems, and HD white-light endoscopy (the control group). We estimated odds ratios (ORs) for the adenoma detection rate, sessile serrated lesion detection rate, and proportion of large adenomas detected per colonoscopy, and calculated mean differences for withdrawal time, with 95% CIs. Risk of bias and certainty of evidence were assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. 50 randomised controlled trials, comprising 34 445 participants, were included in our main analysis (six trials of CADe, 18 of chromoendoscopy, and 26 of increased mucosal visualisation systems). HD white-light endoscopy was the control technique in all 50 studies. Compared with the control technique, the adenoma detection rate was 7·4% higher with CADe (OR 1·78 [95% CI 1·44-2·18]), 4·4% higher with chromoendoscopy (1·22 [1·08-1·39]), and 4·1% higher with increased mucosal visualisation systems (1·16 [1·04-1·28]). CADe ranked as the superior technique for adenoma detection (with moderate confidence in hierarchical ranking); cross-comparisons of CADe with other imaging techniques showed a significant increase in the adenoma detection rate with CADe versus increased mucosal visualisation systems (OR 1·54 [95% CI 1·22-1·94]; low certainty of evidence) and with CADe versus chromoendoscopy (1·45 [1·14-1·85]; moderate certainty of evidence). When focusing on large adenomas (≥10 mm) there was a significant increase in the detection of large adenomas only with CADe (OR 1·69 [95% CI 1·10-2·60], moderate certainty of evidence) when compared to HD white-light endoscopy; CADe ranked as the superior strategy for detection of large adenomas. CADe also seemed to be the superior strategy for detection of sessile serrated lesions (with moderate confidence in hierarchical ranking), although no significant increase in the sessile serrated lesion detection rate was shown (OR 1·37 [95% CI 0·65-2·88]). No significant difference in withdrawal time was reported for CADe compared with the other techniques. Based on the published literature, detection rates of colorectal neoplasia are higher with CADe than with other techniques such as chromoendoscopy or tools that increase mucosal visualisation, supporting wider incorporation of CADe strategies into community endoscopy services. None.

Gastric precancerous conditions in patients with chronic dyspepsia

Introduction Gastric cancer (GC) is one of the most lethal malignancies worldwide, though a decrease in incidence. Helicobacter pylori is positively associated with gastric precancerous conditions. Detection of these conditions, namely atrophic gastritis (AG) and intestinal metaplasia (IM), and their association with H pylori infection is important for further detection and reduction of overall cancer incidence. Aim To detect the prevalence of H pylori infection and gastric precancerous conditions in patients with chronic dyspepsia by High Definition White Light Endoscopy (HD-WLE) and Narrow Band Imaging with Magnifying Endoscopy (NBI-ME). Methods This was a hospital-based descriptive study including chronic dyspeptic patients aged over 50 years. H pylori infection was diagnosed by a rapid urease test. AG and IM were detected by endoscopy (HD-WLE and NBI-ME) and confirmed by histology. Detection rates of each method were compared. Results Totally 143 patients (55 males/88 females) with a mean age of 64.57 ± 9.957 years were included. H pylori infection rate was 53.84% (n = 77). Twenty-two patients with AG (44.9% of patients with atrophy) and 37.84% (14/37) of patients with IM have H pylori infection. There was a statistically significant difference in detection rates between HD-WLE and NBI-ME for IM (P=0.001) but not for AG (P=0.250). Conclusion H pylori infection is still high in Myanmar. There were significant associations between H pylori and gastric precancerous lesions. Detection of atrophic gastritis and intestinal metaplasia by routine usage of NBI-ME along with test and treat H pylori infection are the strategies to reduce the incidence of gastric cancer.

Barrett's esophagus: current standards in advanced imaging.

Esophageal adenocarcinoma (EAC) continues to be one of the fastest rising incident cancers in the Western population with the majority of patients presenting with late stage disease and associated with a dismal 5-year survival rate. Barrett's esophagus (BE) is the only identifiable precursor lesion to EAC. Strategies to screen for and survey BE are critical to detect earlier cancers and reduce morbidity and mortality related to EAC. A high-quality endoscopic examination with careful inspection of the Barrett's segment and adherence to the Seattle protocol for tissue sampling are critical. Advanced imaging modalities offer the potential to improve dysplasia detection, predict histopathology in real time and guide endoscopic eradication therapy (EET). Several technologies have been studied and although most are not yet recommended for routine clinical practice, high definition white light endoscopy (HD-WLE) as well as chromoendoscopy (including virtual chromoendoscopy) improved dysplasia detection in numerous studies supporting their use. Future studies should evaluate the role of artificial intelligence in optimizing detection of dysplasia in BE patients.

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

Background and aimsThe 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. MethodsConsecutive 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. ResultsA 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). ConclusionsOE and acetic acid showed comparable results diagnosing GIM in the study. Targeted biopsies plus random biopsies should be used complementary in high risk populations.

Meta-analysis of Virtual-based Chromoendoscopy Compared With Dye-spraying Chromoendoscopy Standard and High-definition White Light Endoscopy in Patients With Inflammatory Bowel Disease at Increased Risk of Colon Cancer.

Patients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer. We sought to assess the comparative efficacy of virtual chromoendoscopy (VCE) vs high definition white light endoscopy (HDWLE) or dye-spraying chromoendoscopy (DCE) through a meta-analysis and rating the quality of evidence. A systematic review of the literature was performed through February 15, 2019. Primary outcomes were number of patients in whom dysplasia was identified and number of dysplastic lesions identified in these patients. We included only randomized control trials (RCTs) and performed meta-analysis using RevMan5.3. Of the 3205 studies identified, 11 RCTs were included, with a total of 1328 patients. Per patient analysis, VCE was not statistically different compared with DCE (risk ratio [RR] 0.77; 95% CI, 0.55-1.08) or HDWLE (RR 0.72; 95% CI, 0.45-1.15). However, per dysplasia analysis, VCE was not statistically different compared with DCE (RR 0.72; 95% CI, 0.47-1.11) and inferior compared with HDWLE (RR 0.62; 95% CI, 0.44-0.88). The quality of evidence was moderate in the HDWLE and low to moderate in the DCE studies. Based on this meta-analysis, VCE was as good as HDWLE and DCE in identifying dysplasia per patient analysis. However, per dysplasia analysis, VCE was inferior compared with HDWLE and no different from DCE. Further studies need to examine the efficacy of each individual VCE technique.

Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019.

1: ESGE suggests that high definition endoscopy, and dye or virtual chromoendoscopy, as well as add-on devices, can be used in average risk patients to increase the endoscopist's adenoma detection rate. However, their routine use must be balanced against costs and practical considerations.Weak recommendation, high quality evidence. 2: ESGE recommends the routine use of high definition systems in individuals with Lynch syndrome.Strong recommendation, high quality evidence. 3: ESGE recommends the routine use, with targeted biopsies, of dye-based pancolonic chromoendoscopy or virtual chromoendoscopy for neoplasia surveillance in patients with long-standing colitis.Strong recommendation, moderate quality evidence. 4: ESGE suggests that virtual chromoendoscopy and dye-based chromoendoscopy can be used, under strictly controlled conditions, for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps and can replace histopathological diagnosis. The optical diagnosis has to be reported using validated scales, must be adequately photodocumented, and can be performed only by experienced endoscopists who are adequately trained, as defined in the ESGE curriculum, and audited.Weak recommendation, high quality evidence. 5: ESGE recommends the use of high definition white-light endoscopy in combination with (virtual) chromoendoscopy to predict the presence and depth of any submucosal invasion in nonpedunculated colorectal polyps prior to any treatment. Strong recommendation, moderate quality evidence. 6: ESGE recommends the use of virtual or dye-based chromoendoscopy in addition to white-light endoscopy for the detection of residual neoplasia at a piecemeal polypectomy scar site. Strong recommendation, moderate quality evidence. 7: ESGE suggests the possible incorporation of computer-aided diagnosis (detection and characterization of lesions) to colonoscopy, if acceptable and reproducible accuracy for colorectal neoplasia is demonstrated in high quality multicenter in vivo clinical studies. Possible significant risks with implementation, specifically endoscopist deskilling and over-reliance on artificial intelligence, unrepresentative training datasets, and hacking, need to be considered. Weak recommendation, low quality evidence.

443 Adjunctive Yield of Wide-Area Trans-Epithelial Sampling With Computer-Assisted Three-Dimensional Analysis in Detection of Dysplasia After Advanced Imaging and Random Biopsies in Barrett’s Esophagus

INTRODUCTION: Wide-area trans-epithelial sampling with computer-assisted three-dimensional analysis (WATS-3D) has been used for dysplasia detection in endoscopic surveillance of Barrett’s esophagus (BE). Little is known about the additive yield of WATS after a thorough exam with advanced imaging that consists of high definition white light endoscopy (HDWLE), narrow band imaging (NBI), volumetric laser endomicroscopy (VLE) with laser marking, and Seattle protocol biopsies (collectively termed HDWLE-NBI-VLE-SP exam). The aim of this study was to evaluate the adjunctive yield of WATS-3D after an HDWLE-NBI-VLE-SP exam. METHODS: This is a single center observational cohort study from January 2017 to December 2018. Charts were abstracted for consecutive patients that underwent an advanced imaging exam. Raised lesions were removed by endoscopic resection. Areas suspicious for dysplasia on NBI and VLE were biopsied or resected. This was followed by random biopsies. Finally WATS-3D brush biopsies were performed. RESULTS: One hundred and thirty eight cases were included in this study. Thirty-five cases (25% of the total ) were identified as some degree of dysplasia on the HDWLE-NBI-VLE-SP exam. Of these, 14 were reported as indefinite for dysplasia, 11 low-grade dysplasia (LGD), 8 high-grade dysplasia (HGD) or intramucosal cancer, and 2 T1b cancers. Adjunctive use of WATS-3D yielded an additional 12 new cases of dysplasia (9 with crypt dysplasia and 3 with LGD), for added yield of 34.3% (=12/35, 95% CI 14.6-62.2%). In addition, 8 cases of dysplasia found on the HDWLE-NBI-VLE-SP exam were upgraded by WATS-3D to a higher grade of dysplasia (5 with crypt dysplasia and 3 with HGD). Thus the absolute increase provided by WATS was 8.7% (=12/138) for a new diagnosis of dysplasia and was 14.5% (=20/138) when combining both new and upgraded diagnosis of dysplasia grade. CONCLUSION: The addition of WATS-3D to an already thorough exam with HDWLE-NBI-VLE-SP can increase the yield of dysplasia detection.

Systematic review with network meta-analysis: endoscopic techniques for dysplasia surveillance in inflammatory bowel disease.

International guidelines recommend dysplasia surveillance in IBD. To compare endoscopic techniques for dysplasia surveillance METHODS: We searched MEDLINE, Embase, CENTRAL for randomised trials through May 2019. We estimated odds ratios (ORs) for binary and mean differences (MDs) for continuous outcomes, using frequentist random-effects network meta-analysis. We assessed study risk of bias and appraised evidence certainty using GRADE. Eighteen trials (2638 participants) were included. Standard definition white-light endoscopy (OR 0.44, 95% CI 0.26-0.73; high certainty) and i-SCAN (OR 0.47, 95% CI 0.25-0.90; moderate certainty) had lower odds of detecting neoplasia than chromoendoscopy. Fujinon intelligent colour enhancement (FICE), standard definition white-light endoscopy and i-SCAN had lower odds for this outcome than full spectrum high definition white-light endoscopy (ORs 0.02 to 0.15; low certainty). Standard definition white-light endoscopy had lower odds of detecting nonpolypoid neoplasia than full spectrum high definition white-light endoscopy, narrow band imaging, chromoendoscopy and high definition white-light endoscopy (ORs 0.01-0.14; moderate certainty). Full spectrum high definition white-light endoscopy ranked as the best technique for both outcomes (moderate certainty). Standard definition white-light endoscopy had lower odds of detecting neoplasia by target biopsy (OR 0.27, 95% CI 0.08-0.91) and had shorter procedure time (MD -14.81minutes, 95% CI -25.03, -4.06) than chromoendoscopy (moderate certainty). Chromoendoscopy, high definition white-light endoscopy, narrow band imaging, autofluorescence, FICE and full spectrum high definition white-light endoscopy may be comparable for dysplasia surveillance. Standard definition white-light endoscopy and i-SCAN probably provide lower yields for neoplasia identification. Full spectrum high definition white-light endoscopy may represent the first-line approach.

Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019.

Patients with chronic atrophic gastritis or intestinal metaplasia (IM) are at risk for gastric adenocarcinoma. This underscores the importance of diagnosis and risk stratification for these patients. High definition endoscopy with chromoendoscopy (CE) is better than high definition white-light endoscopy alone for this purpose. Virtual CE can guide biopsies for staging atrophic and metaplastic changes and can target neoplastic lesions. Biopsies should be taken from at least two topographic sites (antrum and corpus) and labelled in two separate vials. For patients with mild to moderate atrophy restricted to the antrum there is no evidence to recommend surveillance. In patients with IM at a single location but with a family history of gastric cancer, incomplete IM, or persistent Helicobacter pylori gastritis, endoscopic surveillance with CE and guided biopsies may be considered in 3 years. Patients with advanced stages of atrophic gastritis should be followed up with a high quality endoscopy every 3 years. In patients with dysplasia, in the absence of an endoscopically defined lesion, immediate high quality endoscopic reassessment with CE is recommended. Patients with an endoscopically visible lesion harboring low or high grade dysplasia or carcinoma should undergo staging and treatment. H. pylori eradication heals nonatrophic chronic gastritis, may lead to regression of atrophic gastritis, and reduces the risk of gastric cancer in patients with these conditions, and it is recommended. H. pylori eradication is also recommended for patients with neoplasia after endoscopic therapy. In intermediate to high risk regions, identification and surveillance of patients with precancerous gastric conditions is cost-effective.

2017 David Sun Lecture: Screening and Surveillance of Barrett's Esophagus: Where Are We Now and What Does the Future Hold?

Barrett's esophagus and esophageal adenocarcinoma continue to present considerable management challenges in the Western world. Despite our best efforts to date, the prognosis of advanced esophageal adenocarcinoma remains poor and far too many individuals with esophageal adenocarcinoma have not had a prior endoscopy to detect Barrett's esophagus. As such, current strategies of screening for Barrett's esophagus and subsequent surveillance need to be further optimized. Screening today is limited to high definition white light endoscopy in high-risk patient populations and as such has multiple limitations. However, a variety of exciting new techniques including risk prediction tools, tethered capsule endomicroscopy, a cytology sponge, breath testing for exhaled volatile organic compounds, and assessment of the oral microbiome are now under study in an effort to develop less expensive population-based screening methods. Similarly, endoscopic surveillance, as currently practiced has a variety of limitations. Inexpensive readily available adjuncts are already available to optimize surveillance including increased inspection time in an effort to detect mucosal or vascular abnormalities, special attention to the right hemisphere of the esophagus, and utilization of narrow band imaging or other electronic chromoendoscopy techniques. To improve endoscopic surveillance, a variety of new paradigms are under study including wide area trans-epithelial sampling, advanced endoscopic imaging, molecular imaging, clinical risk stratification and utilization of biomarkers of increased risk. However, progress will be challenging due to the complexity of esophageal cancer biology and the rarity of progression to cancer among patients with nondysplastic Barrett's epithelium.

Essential Is Not Always Visible to the Eyes, Volumetric Laser Endoscopy Revealing Adenocarcinoma Beneath Squamous Mucosa on a Background of Barrettʼs Esophagus

Barett's esophagus is a major risk factor for esophageal adenocarcinoma. Surveillance of Barrett's esophagus has been achieved through protocols involving random biopsies. New diagnostic modalities have been developed in order to ensure a more targeted sampling, reducing this unpredictability. We present the following case that illustrates the importance of using new modalities for detecting underlying lesions that can go unseen by utilizing white light endoscopy alone. This is the case of a 50 year-old female patient who had a chronic history of gastroesophageal acid reflux. She was an active smoker and occasional alcohol consumer. An upper endoscopy was performed and revealed a hiatal hernia. Random biopsies from the Gastroesophageal junction were taken and revealed intestinal metaplasia with low grade dysplasia. Consequently, the patient was referred for Radiofrequency ablation. During an esophagogastroduodenoscopy, high definition white light endoscopy showed an area of endoscopic Barrett's esophagus. This area was without visible lesion, nodule, or ulcerations except for an elevated squamous epithelium at the gastroesophageal junction. The entire distal esophagus was examined using Volumetric Laser Endomicroscopy (VLE) and revealed a disrupted layering and glandular distortion in one area buried under the squamous epithelium. The area was removed enbloc using endoscopic mucosal resection (EMR). Pathology of the resected area revealed a high-grade dysplasia (carcinoma in situ) with intramucosal adenocarcinoma invading the lamina propria pT1a, pNx underneath an intact squamous epithelium. The patient had a follow up EGD with no evidence of recurrence. Subsequently, the patient had circumferential Radiofrequency Ablation (RFA). VLE is an enhanced form of optical coherence tomography. Studies have shown its role where white light endoscopy and Narrow Band Imaging fail to detect dysplasia. It allows a more targeted sampling of areas at higher probability of dysplasia and can reveal underlying adenocarcinoma beneath squamous mucosa that is not superficially visible.1710_A Figure 1. Endoscopic view of the GE junction showing the elevated mucosa1710_B Figure 2. Volumetric Laser endomicroscopy image showing the underlying glandular distortion.1710_C Figure 3. Histo-pathology showing intramucosal adenocarcinoma

Lugol Iodine Solution Reveals a Well Camouflaged Esophageal Squamous Cell Carcinoma

Introduction: Squamous cell carcinoma of the esophagus can be subtle and difficult to diagnose, especially early-stage esophageal squamous cell carcinoma. We describe a case of esophageal squamous cell carcinoma that was almost imperceptible on high-definition white light endoscopy until highlighted by Lugol iodine solution. Case description: A 62-year-old male smoker with alcohol use disorder and chronic pancreatitis was transferred to our institution for further management of a suspected squamous cell carcinoma (SCC) of the esophagus reportedly seen on upper endoscopy. An initial esophagogastroduodenoscopy (EGD) did not show any lesion despite a careful white-light examination. Decision was made to repeat an EGD with Lugol iodine chromendoscopy. Narrow band imaging was also used on repeat EGD for comparison. Endoscopic application of a dilute lugol iodine solution to the esophageal mucosa clearly delineated a 2 cm lesion at 21 cm from the incisors. Targeted biopsies to the mucosal irregularity were then performed and confirmed the diagnosis of esophageal SCC. The patient was clinically staged as 1a by PET-CT and EUS, completed definitive chemotherapy and radiation, and is doing well 6 months after initial diagnosis. Discussion: Lugol chromoendoscopy is a cheap and well-established method for highlighting glycogenpoor cells of early esophageal squamous cell carcinoma. It is most useful in screening high-risk patients such as those with a history of head and neck squamous cell carcinoma. Chest discomfort or pneumonitis are potential complications of Lugol chromendoscopy. Despite the fact that it is a safe, easy, cheap, and widely available technique in the detection of subtle esophageal squamous lesions, Lugol chromendoscopy is not widely practiced or taught in training programs, and we present this case to raise awareness of this technique.1767_A Figure 1. A subtle lesion is barely apparent on high definition white light endoscopy.1767_B Figure 2. Narrow band imaging (NBI) shows a more distinct border around the lesion.1767_C Figure 3. Chromendoscopy with a dilute lugol iodine solution clearly highlights the lesion.

Sa1727 - Chromoendoscopy Versus High Definition White Light Endoscopy for Dysplasia Detection in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Sa1727 - Chromoendoscopy Versus High Definition White Light Endoscopy for Dysplasia Detection in Patients with Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

A comparison study between Magniview and high definition white light endoscopy in detecting villous atrophy and coeliac disease: A single centre pilot study

Background and aimsCoeliac disease may be missed at gastroscopy. We aimed to assess the sensitivity of Pentax optical zoom technology endoscopes in detecting duodenal villous atrophy and the ease of image interpretation by non-coeliac specialists. MethodAll patients attending for a gastroscopy were assessed for endoscopic villous atrophy in part one and two of the duodenum with high definition white light endoscopy and magnification endoscopy. Endoscopic findings of the duodenum were compared to histology as the reference standard.A short training video of varying degrees of villous atrophy seen by magnification endoscopy was used to train individuals. They were then assessed for the ability to differentiate between normal duodenum and villous atrophy. ResultsTwo hundred and fifty patients were prospectively recruited (145 females, 58%; age range 16–84, median age 50.5). Ninety-six patients had villous atrophy on histology (38.4%) 154 were controls. Magnification endoscopy had a higher sensitivity in detecting villous atrophy compared to high definition white light endoscopy (86.4% versus 78.4%, p = .0005).9/10 individuals undertaking magnification endoscopy training correctly identified all cases of villous atrophy. ConclusionMagnification endoscopy has superior diagnostic sensitivity in detecting villous atrophy compared to high definition white light endoscopy and the potential to be easily adopted by all endoscopists.

The Essential is Not Always Visible to the Eyes: Volumetric Laser Endoscopy (VLE) Revealing Adenocarcinoma Beneath Squamous Mucosa on a Background of Barrettʼs Esophagus

Barett's esophagus is a major risk factor for esophageal adenocarcinoma. Surveillance of Barrett's esophagus has been achieved through protocols involving random biopsies. New diagnostic modalities have been developed in order to ensure a more targeted sampling, reducing this unpredictability. We present the following case that illustrates the importance of using new modalities for detecting underlying lesions that can go unseen by utilizing white light endoscopy alone. This is the case of a 50 year-old female patient who had a chronic history of gastroesophageal acid reflux. She was an active smoker and occasional alcohol consumer. An upper endoscopy was performed and revealed a hiatal hernia. Random biopsies from the Gastroesophageal junction were taken and revealed intestinal metaplasia with low grade dysplasia. Consequently, the patient was referred for Radiofrequency ablation. During an esophagogastroduodenoscopy, high definition white light endoscopy showed an area of endoscopic Barrett's esophagus. This area was without visible lesion, nodule, or ulcerations except for an elevated squamous epithelium at the gastroesophageal junction. The entire distal esophagus was examined using Volumetric Laser Endomicroscopy (VLE) and revealed a disrupted layering and glandular distortion in one area buried under the squamous epithelium. The area was removed enbloc using endoscopic mucosal resection (EMR). Pathology of the resected area revealed a high-grade dysplasia (carcinoma in situ) with intramucosal adenocarcinoma invading the lamina propria pT1a, pNx underneath an intact squamous epithelium. The patient had a follow up EGD with no evidence of recurrence. Subsequently, the patient had circumferential Radiofrequency Ablation (RFA). VLE is an enhanced form of optical coherence tomography. Studies have shown its role where white light endoscopy and Narrow Band Imaging fail to detect dysplasia. It allows a more targeted sampling of areas at higher probability of dysplasia and can reveal underlying adenocarcinoma beneath squamous mucosa that is not superficially visible.Figure. 1: a Endoscopic view of the GE junction showing the elevated mucosa.Figure. 1: b Endoscopic view of the GE junction showing the elevated mucosa.Figure. 2: Volumetric Laser endomicroscopy image showing the underlying glandular distortion.

Systematic assessment with I-SCAN magnification endoscopy and acetic acid improves dysplasia detection in patients with Barrett’s esophagus

Background and study aims Enhanced endoscopic imaging with chromoendoscopy may improve dysplasia recognition in patients undergoing assessment of Barrett's esophagus (BE). This may reduce the need for random biopsies to detect more dysplasia. The aim of this study was to assess the effect of magnification endoscopy with I-SCAN (Pentax, Tokyo, Japan) and acetic acid (ACA) on dysplasia detection in BE using a novel mucosal and vascular classification system. Methods BE segments and suspicious lesions were recorded with high definition white-light and magnification endoscopy enhanced using all I-SCAN modes in combination. We created a novel mucosal and vascular classification system based on similar previously validated classifications for narrow-band imaging (NBI). A total of 27 videos were rated before and after ACA application. Following validation, a further 20 patients had their full endoscopies recorded and analyzed to model use of the system to detect dysplasia in a routine clinical scenario. Results The accuracy of the I-SCAN classification system for BE dysplasia improved with I-SCAN magnification from 69 % to 79 % post-ACA (P = 0.01). In the routine clinical scenario model in 20 new patients, accuracy of dysplasia detection increased from 76 % using a "pull-through" alone to 83 % when ACA and magnification endoscopy were combined (P = 0.047). Overall interobserver agreement between experts for dysplasia detection was substantial (0.69). Conclusions A new I-SCAN classification system for BE was validated against similar systems for NBI with similar outcomes. When used in combination with magnification and ACA, the classification detected BE dysplasia in clinical practice with good accuracy.Trials registered at ISRCTN (58235785).

Mo1972 Prospective Comparison of the Novel Full Spectrum Endoscopy (Fuse) and Advanced High Definition-White Light Endoscopy for Detection of Polyps in Routine Practice

Mo1972 Prospective Comparison of the Novel Full Spectrum Endoscopy (Fuse) and Advanced High Definition-White Light Endoscopy for Detection of Polyps in Routine Practice

Virtual chromoendoscopy (I-SCAN) detects more polyps in patients with Lynch syndrome: a randomized controlled crossover trial.

ClinicalTrials.gov (NCT01823471).

Multicenter randomised controlled trial comparing the high definition white light endoscopy and the bright narrow band imaging for colon polyps.

AIMTo compare high definition white light endoscopy and bright narrow band imaging for colon polyps’ detection rates.METHODSPatients were randomised to high definition white light endoscopy (HD-WLE) or the bright narrow band imaging (bNBI) during withdrawal of the colonoscope. Polyps identified in either mode were characterised using bNBI with dual focus (bNBI-DF) according to the Sano’s classification. The primary outcome was to compare adenoma detection rates (ADRs) between the two arms. The secondary outcome was to assess the negative predictive value (NPV) in differentiating adenomas from hyperplastic polyps for diminutive rectosigmoid lesions.RESULTSA total of 1006 patients were randomised to HD-WLE (n = 511) or bNBI (n = 495). The mean of adenoma per patient was 1.62 and 1.84, respectively. The ADRs in bNBI and HD-WLE group were 37.4% and 39.3%, respectively. When adjusted for withdrawal time (OR = 1.19, 95%CI: 1.15-1.24, P < 0.001), the use of bNBI was associated with a reduced ADR (OR = 0.69, 95%CI: 0.52-0.92). Nine hundred and thirty three polyps (86%) in both arms were predicted with high confidence. The sensitivity (Sn), specificity (Sp), positive predictive value and NPV in differentiating adenomatous from non-adenomatous polyps of all sizes were 95.9%, 87.2%, 94.0% and 91.1% respectively. The NPV in differentiating an adenoma from hyperplastic polyp using bNBI-DF for diminutive rectal polyps was 91.0%.CONCLUSIONADRs did not differ between bNBI and HD-WLE, however HD-WLE had higher ADR after adjustment of withdrawal time. bNBI surpassed the PIVI threshold for diminutive polyps.