Abstracts

green, purple and blended, depending on the AF reflection. In addition, the strength ofAF imaging was quantified by using the software by calculating the fluorescence/reflex(F/R) ratio. The relationships between AFI images (predominant color) or F/R ratio, andhistological diagnosis of biopsy specimens obtained from the area were comparedretrospectively. Results: All normal mucosa showed ‘‘green area’’ and high F/R ratio.Lymphoid hyperplasia revealed ‘‘weak purple spots in green area’’, while lymphomalesion showed ‘‘strong purple spots’’. The mean F/R ratio of lymphoma was 0.63,significantly lower than those of lymphoid hyperplasia (0.99) (P!0.001), suggestingthat AF imaging is useful in discriminating lymphoma from benign lymphoidhyperplasia. When defining the cut-off value of F/R ratio as being 0.71, the sensitivity,specificity and over all accuracy that predicts the lymphoma is 77.8%, 84.8% and 83.3%,respectively.Conclusion: AF imaging by colonoscopy provides benefits in detectingcolonic lesions of malignant lymphoma of intestinal or systemic lymphoma and inmaking differentiation from benign lymphoid hyperplasia. AF imaging might contributeto recognize the slight changes due to intestinal lymphoma, leading us to appropriatetherapeutic strategy for either GI or systemic lymphoma.

S1432

Endoflag - A New Video Processing Technology Greatly

Enhancing Recognition and Characterization of Gastrointestinal

Lesions Seen with Standard Or High Definition EndoscopesRalf Kiesslich, Martin Goetz, Brigitte Schumacher, Erwin M. Santo,Markus F. Neurath, R. Guissin, Zamir HalpernIntroduction: Upper and lower endoscopy is the accepted standard identifyingearly or premalignant changes within the GI-tract. Recognition and characterizationare key concepts during standard definition (SD) or high definition (HD) videoendoscopy to identify and select all lesions with neoplastic potential. Aim of thecurrent study was to define the diagnostic improvement of a new video processingtechnology (Endoflag), which enhances vessel and tissue architecture without lightloss. Methods:12 HD images (Pentax, EPKi-processor) and 6 SD images (Pentax,EPK1000-processor) before and after processing with Endoflag were displayed ina random fashion to 43 experienced endoscopists from Germany, France, Argentina,Czechoslovakia and Israel. Participants were asked to score each image based onpolyp morphology (Paris Classification); Vascularity, Surface architecture (Pit PatternClassification), histological prediction and overall diagnosis. In addition, theimprovement or worsening for every category after Endoflag processing was judgedusing a numeric scale (þ5 Z maximal improvement; -5 Z maximalaggravation).Finally, two endoscopic videos (1 HD; 1 SD) were displayed on a splitscreen showing regular input and Endoflag enhancement simultaneously. Participantswere asked to comparatively judge the split screen video based on additional lesions;acceleration of the procedure, reliability and confidence level (all in %).Results:Allparticipants (100%) graded Endoflag superior to regular input of HD or SDendoscopy images. Furthermore, Endoflag leads to a change in the diagnosis of thedifferent subcategories in 16.6% (HD: 14.0%; SD: 22.8%) due to a better visualisationof the displayed lesions and vascularisation after Endoflag processing (Averageperceptual effect of changed diagnosis: Overall: þ3.4; HD þ3.4; SD þ3.5). The valuesfor the video comparison were all in favour for Endoflag. Additional lesions visible:þ28% HD; þ14% SD, acceleration of the procedure: þ19% HD; þ5% SD, improvedreliability: þ26% HD; þ 16% SD; improved confidence þ31% HD; þ19%SD.Conclusions:Endoflag is a newly available post processing video technology, whichgreatly enhances the recognition and characterisation of lesions in the GI tract.Endoflag is able to improve standard video endoscopy as well as high definitionendoscopy which might be of great clinical benefit.

S1433

Usefulness of Transnasal Endoscopy with FICE for Diagnosis

of Recurrent Esophageal VaricesYoshihiro Furuichi, Takashi Kawai, Shigeki Ichimura, Ryou Metoki,Jyunichi Taira, Katsutoshi Sugimoto, Masahiko Yamada, Yasuharu Imai,Ikuo Nakamura, Fuminori MoriyasuIntroduction: FUJI Intelligent Color Enhancement (FICE) is a novel endoscopicdiagnosis technique that can spectrally separate any wavelength of lights andprocess and reconstruct an obtained image. There are 10 preset patterns (No.0w9) in the FICE system, which can be changed during theexamination.Objectives: To study the usefulness of transnasal endoscopy (TNE)with FICE for diagnosis of recurrent esophageal varices (EVs).Subjects: We included20 patients (age: 63.0 � 6.9 years, Child-Pugh score: 5.4 � 0.8) with recurrent EVsthat were within 2 years after implementation of EIS (or EVL), who had experiencedendoscopy during the period between 2006 and 2007. All of the patients weretreated with conventional endoscopy (EGD) and TNE around the same time; theTNE was also performed in combination with FICE. Methods: The endoscopicequipment was a Fujinon EG-530N and an EG-590WR for the TNE and theconventional EGD, respectively.1. Vividness in images of treatment scars,microvascular dilation around the treated area, and recurrence of the varices wascompared in the conventional EGD and the TNE with and without FICE. Vividnessin the images was evaluated by 3 observers in a blinded manner (bad: 0, normal: 1,good: 2) using the images obtained by the TNE alone as a benchmark for the

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scoring. 2. The discomfort level of the subjects on the TNE was evaluated usinga visual analogue scale on the following 4 items; uncomfortable feeling oninsertion, difficulty breathing, feeling like vomiting, and feeling of fullness (nopain:0 - worst discomfort:10). Results: 1. While scores for images obtained by theTNE alone were lower than those by conventional EGD, the vividness was clearer inall types of images with concomitant use of FICE, especially the vividness of themicrovessels around treated area. The scores of the individual images were 1.7 �0.3, 1.2 � 0.5, and 1.0 for the surgical scars, 1.7 � 0.5, 1.6 � 0.7, and 1.0 for themicrovessels, and 1.8 � 0.3, 1.5 � 0.6, and 1.0 for the varices in the conventionalEGD, the TNE with FICE, and the TNE alone, respectively. This result suggests thatFICE is useful for early detection of recurrence of EVs. Furthermore, higherdistinctness was obtained with the 3, 6, and 9 preset FICE patterns. 2. Thetransnasal examination was favorable in terms of least uncomfortable feeling oninsertion (1.4), difficulty breathing (1.4), and feeling like vomiting (0.75).Conclusion: For diagnosis of EVs, TNE is inferior to conventional EGD in definition,but causes less discomfort and the vividness is clearer with concomitant use ofFICE. These results suggest that TNE with FICE would be very useful for thediagnosis of recurrent EVs.

S1434

Local Heterogeneity of Fluorescence Confocal Endomicroscopy

Image Patterns in Ulcerative Colitis (UC)-Associated DysplasiaFinlay a. Macrae, Prithi S. Bhathal, Wendy J. Mclaren, Elise R. Murr,Peter M. DelaneyBackground & Aim: Confocal endomicroscopy (EM) has been shown to accuratelypredict histology of biopsies (1) and increase the diagnostic yield for neoplasia inpatients with UC (2). The microscopic imaging technique inherently samplesmultiple focal regions within and around a specified excisional biopsy site. Thisstudy documented the local heterogeneity of EM images in regions of UC diseaseactivity. Methods: Patients undergoing colonoscopy for UC surveillance wereexamined using a Pentax EC-3870CIFK endomicroscope. The instrument was usedfor both white light endoscopy (WLE) and EM, the latter utilising IV fluoresceinsodium for image contrast (5ml of a 10% solution). Multiple microscopic fields weresampled using EM in regions then targeted for biopsy. The findings of EM and thehistology of biopsies were correlated by the gastroenterologist, an expertpathologist and two trained observers. Results: The local heterogeneity of EMimages (N Z 454) sampled from 60 microscopic fields of mucosa within 21 biopsysites revealed greater diversity of pathology than described for biopsy, includinghyperplasia, low-grade dysplasia and high-grade dysplasia. Features including cryptdistortion, crypt atrophy, epithelial pseudostratification and pleomorphism,depletion of goblet cells and inflammatory cells in the lamina propria wereobserved both in the EM images and conventional histology. Changes such asvillous transformation and distortion of the sub-surface microvasculature weremore easily identified in the en face EM view. In all cases, only a subset of EMimages at each site was required to provide patterns described in agreement withbiopsy. However, in 14 EM fields (i.e. 23% of sites examined) collected from at least5 biopsy sites, a further subset included a higher grade of disease than reported forbiopsy as assessed by the expert pathologist, resulting in an upgrade of thediagnosis. Conclusions: EM is a sensitive technique to rapidly examine keyhistological features of diseased or dysplastic colonic mucosa in UC duringotherwise conventional colonoscopy. The ability to interrogate multiple fields ofheterogeneous tissue suggests EM is a more sensitive indicator of dysplasia thanbiopsy. This finding raises the suggestion that EM should be used to improvepatient diagnosis, management and therapy. References 1. Kiesslich R, et al.Technology Insight: Confocal laser endoscopy for in vivo diagnosis of colorectalcancer. Nature Clin Prac Oncology 2007;4(8):480-490.2. Kiesslich R, et al.Chromoscopy-guided endomicroscopy increases the diagnostic yield ofintraepithelial neoplasia in ulcerative colitis. Gastroenterology 2007;132:874-882.

S1435

Does Sequential Examination of the Colon with White Light

Endoscopy (WLE) Followed By Narrow Band Imaging (NBI)

Increase the Yield of Dysplasia in Patients with Long Standing

Inflammatory Bowel Disease (IBD)?Amit Rastogi, Sharad C. Mathur, Krishna Pondugula, Sachin B. Wani,Peggy Callahan, Ajay Bansal, John D. Keighley, Prateek SharmaBackground: Patients with long standing IBD (ulcerative colitis or Crohn’s colitis)are at an increased risk of developing colon cancer and surveillance colonoscopywith random biopsies is recommended in these pts. Early neoplasia is often flat andsubtle and hence can easily be missed. Chromoendoscopy has been shown toimprove detection of dysplasia in these patients, but has not gained widespreadacceptance. Aim: To evaluate whether sequential examination of the colon withWLE followed by NBI increases the yield of dysplasia in IBD patients undergoingcolonoscopic surveillance.Methods: Patients with long standing IBD (O 8-10 years),referred for surveillance colonoscopy, were prospectively enrolled. Polyethyleneglycol based solution was used for colonic preparation. All procedures wereperformed with a high definition colonoscope with NBI capability (CF-H 180 AL,

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Abstracts

Olympus, America). After cecal intubation, colon was initially examined by WLEfrom the cecum to the hepatic flexure and targeted (if lesions seen) followed byrandom four quadrant biopsies were obtained. The cecum was then re-intubatedand the same segment was re-examined with NBI and targeted biopsies wereobtained from any suspicious lesions. Suspicious lesions were defined as raisedprotuberant or polypoid areas, flat areas with abnormal discoloration compared tosurrounding mucosa or Kudo pit pattern III, IV, V. The remainder of the colon wasexamined in a similar fashion in 15 -20 cm segments. The number of random andtargeted biopsies with WLE and targeted biopsies with NBI were recorded. Thebiopsies were evaluated by blinded pathologists according to the Vienna criteria.Results: 27 pts (18 UC; 9 Crohn’s colitis) were enrolled (96.2% males, 88%Caucasians). The mean procedure duration was 45 min (Range - 22 to 66 min). Atotal of 768 random biopsies were obtained using WLE, 8 biopsies positive for lowgrade dysplasia (LGD) in 2 patients and 4 biopsies showed indefinite for dysplasiain 1 patient. 91 targeted biopsies were obtained from 34 suspicious lesions withWLE; 8 positive for LGD in 4 patients. Using NBI, 71 targeted biopsies wereobtained from 49 suspicious lesions; 5 were positive for LGD in 4 patients. Thus,a total of 8 patients were detected with LGD; 2 detected by only NBI but missed byWLE. No high grade dysplasia or invasive cancer was detected. Conclusions: Theresults of this pilot trial show that NBI examination of the colon with targetedbiopsies (after a standard WLE examination with random biopsies) detectsadditional areas and patients with dysplasia. The additional use of NBI may thuscomplement our current surveillance practices in IBD patients.

S1436

Clinical Usefulness of NBI Magnification in Routine

Colonoscopic ExaminationYuko Hiraga, Shiro Okamoto, Hideyuki Shima, Kanji Kodama,Shuji Yamaguchi, Naomi SasakiNBI system that emphasizes capillary patterns with one button is clearly simplerthan chromoendoscopy using chromoagents, and it is easy, but a hue quite variesand requires habituation to manage it. [AIM] We compared NBI magnification withconventional magnification using chromoagents and reviewed the findings ofmicrovascular architecture that should be paid attention in NBI magnification fordiagnosis of colorectal neoplasms. Materials and Methods: We examined a total ofcolorectal neoplasm 279 lesions (32 non-neoplasms, 201 low-grade adenomas, 12high-grade adenomas, 25 intramucosal carcinomas, and 9 invasive carcinomas),treated by endoscopic or surgical resection and diagnosed clinicopathologically. Weperformed the following NBI examination items and compared with pit patterndiagnoses and clinicopathological diagnoses about those lesions. 1) The hue at distantview: ‘‘light’’, ‘‘same’’, ‘‘dense’’. 2) The patterns of capillary vessels: ‘‘surrounds-pit-type’’ and ‘‘not-surrounds-pit-type’’ (‘‘corkscrew’’, ‘‘moniliform’’, ‘‘sparse-punctate’’and ‘‘dendriform’’). Results: All 48 light hue lesions, except one lesion, werehyperplastic polyps and low-grade adenomas. Among 186 protruded type lesions,dense hue lesions accounted for 139 lesions. But in 93 superficial type lesions, densehue lesions were in 55%, and same hue lesions were seen in 24%. In 19 dendriform-type lesions, 18 lesions were hyperplastic polyp, and 17 lesions were type II pit. All 232surrounds-pit-type lesions were type non-V pit pattern lesions and had no invasivecarcinomas. Twenty-eight not-surrounds-pit-type lesions, with irregular thick capillaryvessels, had 9 invasive carcinomas. All 10 sparse-punctate-type lesions were type V pitpattern lesions, and had 8 invasive carcinomas. Nine type Vi-high grade pit patternlesions had 7 invasive carcinomas. The sensitivity for the NBI capillary patterns(sparse-punctate-type) in detecting invasive carcinomas was 80%, with a specificity of99.6%, and diagnostic accuracy of 98.9%. These values were the same as pit patternsdiagnosis (type Vi-high grade pit pattern), but improvement of sensibility was presentby putting a NBI capillary patterns diagnosis together for a pit pattern diagnosis.Conclusions: When become accustomed to NBI observation, we believe that NBImagnification reduces trouble of chromoendoscopy, and enables for simpler andmore efficient screening colonoscopy. Furthermore, we expect effect of addition toa detailed invasion depth diagnosis of type Vi-high grade pit pattern lesions.

S1437

The Intra and Inter Observer Variability of Narrow Band Imaging

to Differentiate Hyperplastic Versus Adenomatous PolypsKandarp Patel, Francisco C. Ramirez, Richard Gerkin, Nooman GilaniBackground: Narrow band imaging (NBI), a novel endoscopic technology usesoptical filters for red-green-blue sequential illumination and narrows the bandwidthof spectral transmittance highlighting superficial mucosal capillaries and improvingcontrast for adenomas. Aims: This study evaluated the intra and inter observeragreement of endoscopists to differentiate hyperplastic polyps (HPP) and tubularadenomatous polyps (TAP) using conventional white light andNBI.Methods:Photographs of 24 polyps (12 HPP and 12 TAP) from 14 patients wererandomly displayed to 5 experienced endoscopists in white light and NBI. Beforedisplaying the photographs, endoscopists were familiarized with pit patterns ofHPP and TAP as described by Kudo et al. For analyses, Chi square and kappa testingwere used. Results: See Table 1 See Table 2 Under white light imaging, there wasgood inter observer agreement (Kappa Z 0.65). Under NBI, there was moderateinter observer agreement (Kappa Z 0.44). Seven times a polyp was called TAP

AB136 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008

when viewed under white light and subsequently called HP when seen using NBI.Twenty-one times a polyp was called HPP when viewed under white light andsubsequently called TAP when seen using NBI. The kappa for intra observeragreement (between methods) was 0.52. Conclusions: Using white light,endoscopist accuracy was similar for detection of HPP and TAP. However, using NBI,the accuracy to detect HPP was decreased. More polyps were called TAP when seenin NBI than in white light. Among experienced endoscopists, there was goodagreement when using white light and moderate agreement when using NBI.

Table 1. Accuracy Using White Light

Correct Incorrect Accuracy (%)

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Hyperplastic

42 18 70 Adenomatous 48 12 80 Chi square difference for HPP vs TAP, pZ.292 (ns)

Table 2. : Accuracy Using NBI

Correct Incorrect Accuracy (%)

e

Hyperplastic

30 30 50 Adenomatous 48 12 80 Chi square difference for HPP vs TAP, p!.001

S1438

A New Method for Entero-Enteral AnastomosisMargherita Cadeddu, Charles a. Mosse, Priya a. Jamidar, Mehran Anvari,Michael Boyd, Christopher P. SwainBackground: Hand-sewn enteral anastomoses are time-consuming at laparotomyand laparoscopy. During NOTES procedures they are extremely difficult. Stapledanastomoses require a two centimeter enterotomy in either bowel limb; thisremaining defect must be either stapled or sewn closed. A new method for formingenteroenteral anastomoses (EEA) was developed and tested in bench, non-survivaland survival pig models. This method allows EEAs to be formed through incisions 2mm in diameter. If flexible access is available in one lumen, then only one incisionneeds to be made. This can be easily performed at open surgery, laparoscopy andNOTES. Methods: A hollow ferrous tube was tapered for insertion over a flexibleguidewire. It featured ‘hinges’ to allow shape change during the anastomosisformation. This metal rod (component A) compressed the intervening small boweltissue against a series of cylindrical hollow neodymium iron boron alloy magnets(component B), that were placed in the other small bowel limb. In NOTESprocedures, using a double channel gastroscope, the two limbs to be anastomosedwere held together with a suture. Tissue was grasped with forceps and a needle-knife incision allowed a nitinol 0.00035 inch diameter guidewire to be passed intothe lumen. Component A was pushed into the lumen using a 7 French plastic pushingcatheter. Using a similar method, a guidewire was inserted into the other small bowellimb and the cylindrical magnets were pushed into the lumen, where they lockedtogether on the ante-mesenteric border of the small bowel, compressing theintervening tissue. The length of the anastomosis could be varied by extending thelength of the metal cylinder and increasing the number of magnets. This formeda compression anastomosis. The small enteral openings were closed with TASsutures, clips or 3-0 vicryl sutures. Results: At open and laparoscopic surgery an EEAwas created with this technique. Three weeks post-surgery, the anastomoses wereidentified at autopsy examination. This was completed in 5 pigs, all of whom survivedwithout complications. The autopsy examination revealed no peritoneal soiling, andwell- healed anastomotic sites. The anastomoses were patent in all pigs. By NOTES,the EEA was also created using the two components with an anastomosis beingformed uneventfully. Conclusion: A new method for enteroenteral anastomosis wasdeveloped and tested. The method has advantages over sutured or stapledanastomoses. The enterotomy made is very small. The method is much easier thana traditional anastomosis if a NOTES procedure is being done. The new device wastrialed in non-survival and survival studies.

S1439

A New Field of Endoscopic Treatment, Superficial Pharyngeal

Cancer: A Case Series of 115 Superficial CancersManabu Muto, Keiko Minashi, Tomonori Yano, Shigeaki Yoshida,Satoshi Fujii, Atsushi OchiaiBackgrounds: The pharyngeal space is the entrance to any endoscopic examinationof the upper gastrointestinal tract. Squamous cell carcinoma (SCC) is the mostfrequent neoplasm in this region. However, most patients with SCC are diagnosedat an advanced stage and have poor prognoses. We have previously reported thatnarrowband imaging combined with magnifying endoscopy is useful in detectingsuperficial cancers in this region. However, there are very real problems, includingwho should treat a superficial cancer in the pharynx. We investigated the feasibilityof endoscopic treatment of superficial pharyngeal cancers and evaluated theirclinical outcomes. Methods: Between April 2002 and April 2007, 115 superficial

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