Advanced imaging

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Last modified 21/04/2015

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CHAPTER 6 Advanced imaging

6.1 Confocal endomicroscopy

Summary

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 performing either eCLE or pCLE, complete the white light portion of the endoscopic exam before proceeding with endomicroscopy. This will allow you to select areas to image and will ensure that your contrast agent is still present when you are ready to begin imaging. If you are using topical contrast, clearing the mucosa with water may help you get more even staining of the mucosa. In the colon, a poor bowel preparation will significantly limit the use of topical contrast agents as they will not reach the mucosa and will also limit imaging with intravenous contrast, due to the presence of stool on the imaging window.

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.

To use the pCLE system, the probes are attached to the processor and passed through the instrument channel of a standard endoscope. The tip of the probe is placed directly on the surface of the mucosa and images are acquired. To obtain a stable image with the confocal probe system, a plastic cap on the end of the endoscope can be helpful, such as the plastic caps that come with the endoscopic mucosal resection (EMR) kits. Images can be obtained and saved, as can mosaic video sequences.

6 Special considerations

Further Reading

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

Summary

Introduction

The prognosis of gastrointestinal cancers depends upon their stage at presentation and most recent improvements in diagnostic endoscopy have therefore focused on earlier diagnosis. The introduction of videoendoscopy over 20 years ago was considered a major advance but merely hinted at the technological improvements that were possible in endoscopy. Progress since then has focused on improving image resolution, particularly by using optical or electronic magnification and by increasing the number of pixels and photodiodes per pixel. Monochromatic light or light containing only certain wavelengths or narrow spectral bands and use of wavelengths outside the visible light spectrum (ultraviolet or near infrared) have all recently been developed for endoscopy, as alternatives to standard white light of the visible spectrum. Combined with improvements in image definition and magnification, these novel imaging modalities offer enormous possibilities for diagnosis of early neoplasia. Multiple systems exist either commercially or as prototypes: narrow band imaging (NBI) endoscopy; confocal laser endomicroscopy (CLE); autofluorescence (AFI); optical coherence tomography (OCT); endocytoscopy; spectral fluorescence, and Raman effect or light-scattering spectroscopy. Two strategies are evolving beyond the impressive technological progress in miniaturizing the charge coupled devices (CCDs) at the tip of a flexible videoendoscope:

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.