CHAPTER 6 Advanced imaging
6.1 Confocal endomicroscopy
Key Points
Introduction
Confocal laser endomicroscopy (CLE) is one of the newer advanced imaging methods for the gastrointestinal tract. Microscopic images of the gastrointestinal mucosa are obtained by illuminating the mucosa with blue laser light (488 nm), which causes fluorescence. The light reflected is collected through a pinhole-sized aperture and processed, creating a microscopic image. The laser light and collected light are ‘confocal’, meaning they are in the same focal plane. The images produced allow visualization of small structures, such as capillaries and colonic crypts and gastric pits (Figs 1–4), as well as individual cells, such as epithelial cells and red blood cells.
2 Equipment
There are currently two endomicroscopy systems available (Table 1). One is an endoscope-based endomicroscopy (eCLE) system, the EC-3870CIFK colonoscope, and EG-3870CIK upper endoscope (Pentax, Tokyo, Japan). A probe-based endomicroscopy (pCLE) system, the Cellvizio (Mauna Kea Technologies, Paris, France) is also available. Both systems allow standard endoscopic imaging while providing the ability to obtain microscopic views of the mucosa, but there are several differences between the two systems. Each system has an endomicroscopic image processor and separate screen for viewing endomicroscopic images. The confocal endoscope comes in lengths appropriate for colonoscopy and one for upper endoscopy, although the colonoscope-length endoscope can also be used for investigation of the upper GI tract. The confocal endoscope has the standard wheels, air, water, suction and photo buttons, and a standard-size biopsy channel. The miniprobes for pCLE can be used with a standard endoscope that has a 2.8 mm channel and the probes are attached to a special processor. They come in lengths appropriate for upper endoscopy, colonoscopy, and cholangioscopy. Both systems require a contrast agent to be used to collect images. The confocal endoscope can image sequentially from the surface, down to a depth of 250 µm, while the confocal probes have set ranges of imaging depth, ranging from 55–65 µm from the surface for the Gastroflex UHD probe to 70–130 µm for the Gastroflex probe. The resolution of the images is higher with the confocal endoscope than the probes, with a lateral resolution of 0.7 µm compared with 1–3.5 µm. The imaging rate for the confocal probe is higher than the confocal endoscope, with an imaging rate of 12 images per second compared with 0.8–1.6 images per second. The pCLE system also creates a ‘mosaic’ of images collected together to show a larger portion of the mucosa. Both systems allow image capture and export.
4 Technique
When ready to obtain eCLE images, place the tip of the confocal endoscope directly on the mucosa. The imaging window is located on the lower left portion of the tip and can be seen on the edge of the endoscopic image (Fig. 5). Applying suction using the endoscope can help stabilize your position. Once a stable position is obtained, press the home button (button 3), which will return the imaging to the surface (Fig. 6). Press button 4 to begin sectioning down through the mucosa. Depressing the button moves the imaging plane 4 µm deeper. The direction of imaging can be reversed towards the surface by quickly depressing button 4 twice. Microscopic images can be captured using the foot pedal, the mouse, or the touch screen.
6 Special considerations
6.3 Further research
Bojarski C, Gunther U, Rieger K, et al. In vivo diagnosis of acute intestinal graft-versus-host disease by confocal endomicroscopy. Endoscopy. 2009;41:433-438.
Dunbar KB, Okolo P3rd, Montgomery E, et al. Confocal laser endomicroscopy in Barrett’s esophagus and endoscopically inapparent Barrett’s neoplasia: a prospective, randomized, double-blind, controlled, crossover trial. Gastrointest Endosc. 2009;70:645-654.
Kiesslich R, Burg J, Vieth M, et al. Confocal laser endoscopy for diagnosing intraepithelial neoplasias and colorectal cancer in vivo. Gastroenterology. 2004;127:706-713.
Kiesslich R, Goetz M, Burg J, et al. Diagnosing Helicobacter pylori in vivo by confocal laser endoscopy. Gastroenterology. 2005;128:2119-2123.
Kiesslich R, Goetz M, Lammersdorf K, et al. Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis. Gastroenterology. 2007;132:874-882.
Kiesslich R, Hoffman A, Goetz M, et al. In vivo diagnosis of collagenous colitis by confocal endomicroscopy. Gut. 2006;55:591-592.
Kitabatake S, Niwa Y, Miyahara R, et al. Confocal endomicroscopy for the diagnosis of gastric cancer in vivo. Endoscopy. 2006;38:1110-1114.
Leong RW, Nguyen NQ, Meredith CG, et al. In vivo confocal endomicroscopy in the diagnosis and evaluation of celiac disease. Gastroenterology. 2008;135:1870-1876.
Lipson BK, Yannuzzi LA. Complications of intravenous fluorescein injections. Int Ophthalmol Clin. 1989;29:200-205.
Pech O, Rabenstein T, Manner H, et al. Confocal laser endomicroscopy for in vivo diagnosis of early squamous cell carcinoma in the esophagus. Clin Gastroenterol Hepatol. 2008;6:89-94.
Trovato C, Sonzogni A, Fiori G, et al. Confocal laser endomicroscopy for the detection of mucosal changes in ileal pouch after restorative proctocolectomy. Dig Liver Dis. 2009;41:578-585.
Wallace MB, Meining A, Canto MI, et al. The safety of intravenous fluorescein for confocal laser endomicroscopy in the gastrointestinal tract. Aliment Pharmacol Ther. 2010;31:548-552.
6.2 New endoscopic imaging modalities
Key Points
Introduction
To achieve the first of these objectives, NBI and AFI techniques are undergoing clinical validation, while for the second, methods involving CLE, endocytoscopy, OCT or elastic or non-elastic light-scattering spectroscopy (LSS) are being developed. NBI, AFI and CLE methods are currently available commercially, while OCT and other methods are only at the prototype stage of development. The use of these technologies is set to expand, but there are currently few controlled, randomized comparative studies to determine precisely the utility of these new tools in endoscopy. The range of potential applications is wide, but for the moment the main focus is on areas as outlined in Box 1.