Gastroenterology Today Summer 2024

Volume 34 No. 6 Summer 2024
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CONTENTS
CONTENTS
Gastroenterology Today
4 EDITOR’S COMMENT
9 CASE STUDY Epiploic Appendagitis: An Under-recognised
Cause of the Acute Abdomen
This issue edited by:
Aaron Bhakta
c/o Media Publishing Company
Greenoaks, Lockhill
Upper Sapey, Worcester, WR6 6XR
12 CASE STUDY Leicester nurses leading the way in capsule
sponge testing
15 FEATURE Endoscopic Ultrasonography-Guided Fine-
Needle Biopsy for Patients with Resectable
Pancreatic Malignancies
24 FEATURE Texture and color enhancement imaging improves
the visibility of gastric neoplasms: clinical trial with
image catalogue assessment using conventional and
newly developed endoscopes
31 COMPANY NEWS
ADVERTISING & CIRCULATION:
Media Publishing Company
Greenoaks, Lockhill
Upper Sapey, Worcester, WR6 6XR
Tel: 01886 853715
E: info@mediapublishingcompany.com
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PUBLISHED DATES:
March, June, September and December.
COPYRIGHT:
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COVER STORY
Opportunities in Endoscopy: Join Our 18WS Team in the Midlands and East of England
We’re healthcare providers supporting elective care backlogs in NHS trusts, and we are
looking for talented individuals to join our elite team of Endoscopy Consultants, Nurses,
HCAs, and Decontamination Technicians in the Midlands and the East of England.
PUBLISHERS STATEMENT:
The views and opinions expressed in
this issue are not necessarily those of
the Publisher, the Editors or Media
Publishing Company
Next Issue Autumn 2024
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GASTROENTEROLOGY TODAY – SUMMER 2024
3

EDITOR’S COMMENT
EDITOR’S COMMENT
Open for submissions
“Published
quarterly, with a
well established
distribution
list and no
processing
charges we
look forward
to receiving
potential
articles.”
Evidence-based practice (EBP) has been the gold standard in healthcare for nearly three centuries and
aims to assist physicians in providing the safest and most effective healthcare for their patients. The wellestablished
hierarchy of evidence lists systematic reviews and meta-analyses at the top however these
methodologies are not always appropriate or possible and in these instances case-control studies, case
series and case reports are utilised to support EBP.
Case series and reports are particularly useful in the study of rare diseases and also as an educational
opportunity to remind us all of conditions not frequently encountered in clinical practise but conditions that
need to be on our clinician radar.
Case reports are often difficult to publish but here at Gastroenterology Today we want to support this type
of publication. We are open to all types of article. Any potential articles can be submitted to:
info@mediapublishingcompany.com
Published quarterly, with a well established distribution list and no processing charges we look forward to
receiving potential articles.
A Poullis
St George’s Hospital
Gastroenterology Today
GASTROENTEROLOGY TODAY – SUMMER 2024
Publishers Comment
On behalf of everyone involved with the publishing of Gastroenterology Today I would like to say a big
thank you to our contributors for their input and a special thank you to our advertisers as without their
ongoing support we would not be able to print and despatch copies of this very unique publication to all
Gastroenterology Departments and Endoscopy Units. Wishing you all a prosperous 2024.
Terry Gardner
Publisher
4

Octasa ® 1600mg
delivers mesalazine
throughout the
entire colon 1
Octasa ® 1600mg
releases mesalazine
in the caecum
which spreads
throughout
the colon
even distally 2,3
Octasa ® 1600mg was equally effective at inducing endoscopic remission in patients
with different disease extents, even distal mild to moderate UC 4
See how
it works
Get your mild to moderate UC patients
into remission with Octasa ® 1600mg,
3 tablets (4.8g) once-daily* 1
OCTASA 400mg, 800mg & 1600mg Modified Release Tablets
(mesalazine) - Prescribing Information
Presentation: Modified Release tablets containing 400mg, 800mg or 1600mg
mesalazine. Indications: All strengths: Ulcerative Colitis - Treatment of mild to
moderate acute exacerbations. Maintenance of remission. 400mg & 800mg
only: Crohn’s ileocolitis - Maintenance of remission. Dosage and
administration: 400mg & 800mg tablets – Adults: Mild acute disease: 2.4g
once daily or in divided doses, with concomitant steroid therapy where indicated.
Moderate acute disease: 2.4g – 4.8g daily. 2.4g may be taken once daily or in
divided doses, higher doses should be taken in divided doses. Maintenance
therapy: 1.2g – 2.4g once daily or in divided doses. 1600mg tablets – Adults:
Acute exacerbations: up to 4.8g, once daily or in divided doses. Maintenance:
1600mg daily. Tablets must be swallowed whole. Elderly: 400mg & 800mg -
normal adult dose may be used unless liver or renal function is severely
impaired. 1600mg - no studies in elderly patients have been conducted.
Children: 400mg & 800mg - limited documentation of efficacy in children >6
years old. Dose to be determined individually. Generally recommended that half
the adult dose may be given to children up to a body weight of 40 kg; and the
normal adult dose to those above 40 kg. 1600mg – safety and efficacy not
established in children. Contra-indications: Hypersensitivity to salicylates,
mesalazine or any of the excipients, severe impairment of hepatic or renal
function (GFR less than 30 ml/min/1.73m 2 ). Warnings and Precautions:
Urinary status (dip sticks) should be determined prior to and during treatment, at
discretion of treating physician. Caution in patients with raised serum creatinine
or proteinuria. Stop treatment immediately if renal impairment is evident. Cases
of nephrolithiasis have been reported with mesalazine treatment. Ensure
adequate fluid intake during treatment. Severe cutaneous adverse reactions
(SCARS), including Drug reaction with eosinophilia and systemic symptoms
(DRESS), Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis
(TENS) have been reported. Stop treatment immediately if signs and symptoms
of severe skin reactions are seen. Haematological investigations are
recommended prior to and during treatment, at discretion of treating physician.
Stop treatment immediately if blood dyscrasias are suspected or evident.
Caution in patients with impaired hepatic function. Liver function should be
determined prior to and during treatment, at the discretion of the treating
physician. Do not use in patients with previous mesalazine-induced cardiac
hypersensitivity and use caution in patients with previous myo- or pericarditis of
allergic background. Monitor patients with pulmonary disease, in particular
asthma, very carefully. In patients with a history of adverse drug reactions to
sulphasalazine, discontinue immediately if acute intolerance reactions occur
(e.g. abdominal cramps, acute abdominal pain, fever, severe headache and
rash). Use with caution in patients with gastric or duodenal ulcers. Intact
400mg & 800mg tablets in the stool may be largely empty shells. If this occurs
repeatedly patients should consult their physician. Use with caution in the
elderly, subject to patients having normal or non-severely impaired renal and
liver function. Patients with rare hereditary problems of galactose intolerance,
the Lapp lactase deficiency or glucose-galactose malabsorption, should not
take the 400mg or 800mg tablets. Mesalazine may produce red-brown urine
discoloration after contact with sodium hypochlorite bleach (e.g. in toilets
cleaned with sodium hypochlorite contained in certain bleaches). Interactions:
No interaction studies have been performed. May decrease the anticoagulant
activity of warfarin. Caution when used with known nephrotoxic agents such as
NSAIDs, methotrexate and azathioprine. May increase the myelosuppressive
effects of azathioprine, 6-mercaptopurine or thioguanine. Monitoring of blood
cell counts is recommended if these are used concomitantly. Fertility,
pregnancy and lactation: Only to be used during pregnancy and lactation
when the potential benefit outweighs the possible risk. No effects on fertility
have been observed. Adverse reactions: Common: dyspepsia, rash.
Uncommon: eosinophilia (as part of an allergic reaction), paraesthesia, urticaria,
pruritus, pyrexia, chest pain. Rare: headache, dizziness, myocarditis,
pericarditis, abdominal pain, diarrhoea, flatulence, nausea, vomiting,
photosensitivity. Very rare: altered blood counts (aplastic anemia,
agranulocytosis, pancytopenia, neutropenia, leucopenia, thrombocytopenia),
blood dyscrasia, hypersensitivity reactions (such as allergic exanthema, drug
fever, lupus erythematosus syndrome, pancolitis), peripheral neuropathy,
allergic and fibrotic lung reactions (including dyspnoea, cough, bronchospasm,
alveolitis, pulmonary eosinophilia, lung infiltration, pneumonitis), interstitial
pneumonia, eosinophilic pneumonia, lung disorder, acute pancreatitis, changes
in liver function parameters (increase in transaminases and cholestasis
parameters), hepatitis, cholestatic hepatitis, alopecia, myalgia, arthralgia,
impairment of renal function including acute and chronic interstitial nephritis and
renal insufficiency, renal failure which may be reversible on withdrawal,
nephrotic syndrome, oligospermia (reversible). Not known: Drug reaction with
eosinophilia and systemic symptoms, Stevens-Johnson Syndrome, toxic
epidermal necrolysis, pleurisy, lupus-like syndrome with pericarditis and
pleuropericarditis as prominent symptoms as well as rash and arthralgia,
nephrolithiasis, intolerance to mesalazine with C-reactive protein increased and/
or exacerbation of symptoms of underlying disease, blood creatinine increased,
weight decreased, creatinine clearance decreased, amylase increased, red
blood cell sedimentation rate increased, lipase increased, BUN increased.
Consult the Summary of Product Characteristics in relation to other adverse
reactions. Marketing Authorisation Numbers, Package Quantities and
basic NHS price: 400mg - PL36633/0002; packs of 90 tablets (£19.50) and
120 tablets (£26.00). 800mg - PL36633/0001; packs of 90 tablets (£40.38)
and 180 tablets (£80.75). 1600mg – PL36633/0009; packs of 30 tablets
(£30.08). Legal category: POM. Marketing Authorisation Holder: Tillotts
Pharma UK Ltd, The Larbourne Suite, The Stables, Wellingore Hall, Wellingore,
Lincolnshire, LN5 0HX, UK. Octasa is a trademark. © 2022 Tillotts Pharma UK
Ltd. Further Information is available from the Marketing Authorisation Holder.
Date of preparation of PI: November 2022
Adverse events should be reported. Reporting forms and
information can be found at https://yellowcard.mhra.gov.uk.
Adverse events should also be reported to Tillotts Pharma
UK Ltd. (address as above) Tel: 01522 813500.
* Octasa ® 1600mg tablets can be administered in divided doses if required or if this aids adherence.
References: 1. Octasa ® 1600mg Modifi ed Release Tablets – Summary of Product Characteristics. 2. Varum F et al. Int J Pharm 2022;
625: 122055. 3. Data on fi le, Tillotts Pharma UK Limited. [OPTICORE ® scintigraphy data from Varum et al. 2022 visualised as cyan
heatmap – December 2023]. 4. D’Haens GR et al. Infl amm Intest Dis 2023; 8: 51–59.
Date of preparation: May 2024. PU-01740.

ADVERTORIAL
CAPSULE SPONGE TESTING:
THE FUTURE OF OESOPHAGEAL HEALTH
The surveillance of Barrett’s oesophagus represents a significant
opportunity to identify and treat oesophageal cancer earlier. However,
challenges in targeting necessary endoscopies have led to a heavily
resource-intensive pathway that needs support.
Challenges exacerbated by the COVID-19 pandemic and pre-existing
issues within the GI endoscopy landscape, such as inefficient patient
selection, rising demand, and workforce challenges, resulted in an
approximate 95% reduction in surveillance activities and routine
gastroscopies in that period. 1 There are currently over 17,056 people
waiting over six weeks for a gastroscopy procedure across England,
with 54% of those waiting over 13 weeks. 2
Early cancer detection and treatment with capsule sponge testing
A pioneering diagnostic tool, Cyted’s EndoSign ® capsule sponge
test offers a minimally invasive way to identify patients who are at an
increased risk of developing oesophageal cancer, particularly those
with chronic reflux symptoms or diagnosed with Barrett’s oesophagus.
Identifying at-risk patients who need further endoscopic investigation,
and diverting those who don’t, eases the pressure on endoscopy
services, and releases resources across the patient care pathway.
How it works:
• Swallowing the capsule: The patient swallows a capsule, similar in
size to a vitamin pill, which is tethered to a strong, thin thread.
• Capsule dissolves: Once the capsule reaches the stomach, its
outer layer dissolves to release a small sponge.
From a provider perspective, the test is efficient and practical, requiring
only about 10 minutes to complete in any outpatient setting, from GPs
and Community Diagnostics Centres, to hospital outpatient clinics.
This cost-effective and simple process helps healthcare providers
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supporting improved clinical capacity and lower waiting times.
Early detection is another pivotal advantage; by catching Barrett’s
oesophagus and oesophageal cancer early, the capsule sponge test
greatly improves the likelihood of successful treatment outcomes
and patient survival rates. This is particularly important in the case
of oesophageal cancer, where 81% of patients are diagnosed late (at
stages 3-4) when less than 20% of patients survive beyond the year
of diagnosis. 3
Piloting sponge capsule testing
In January 2021, NHSE launched a pilot of the capsule sponge test
for triaging patients with low-risk reflux symptoms on a routine referral
pathway in secondary care settings. Eligible patients waiting for a
routine endoscopy on the standard diagnostic pathway were offered a
capsule sponge test as an alternative to their endoscopy. Patients who
accepted the offer were subsequently diverted from the endoscopy
pathway and placed on an alternative pathway with the capsule
sponge test. The pilot;
• Reduced endoscopy pressures by 78% by diverting
unnecessary endoscopies 4
• Saved at least £420 per patient for NHS England 5
GASTROENTEROLOGY TODAY – SUMMER 2024
• Sponge expansion and retrieval: The clinician pulls the string, and
the sponge collects cells as it passes through the oesophagus.
• Cell analysis: The retrieved sponge containing a sample of
oesophageal cells is sent to Cyted Health’s laboratory and analysed
for any abnormalities and indications of oesophageal cancer or its
precancerous condition, Barrett’s oesophagus.
This minimally invasive approach avoids sedation, significantly
enhancing patient comfort and convenience. This makes it a preferable
option for many, mitigating the discomfort and anxiety associated with
conventional endoscopic examinations to help improve uptake.
• The capsule sponge testing pathway increased the prevalence of
Barrett’s diagnosis by around 40% compared to the counterfactual
group with the standard-of-care. 6
“Thousands of people have now benefitted from this incredibly efficient
test on the NHS – while the sponge on a string is small in size, it can
make a big difference for patients – they can conveniently fit the test
into their day and it can often replace the need for an endoscopy while
also helping to reduce waiting lists by freeing up staff and resources.”
Amanda Pritchard, Chief Executive, NHS
1
Rutter et al. “Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis.” Gut
vol. 70,3 (2021): 537-543.
2
NHS England. Diagnostic Waiting Times and Activity (DM01). February 2024.
3
Cancer Research UK. Early Diagnosis Data Hub: Incidence by Stage. Oesophageal Cancer, Stage 1, 2, 3 and 4 (England, excluding unknown
stage). 2023.
4
IQVIA, NHS England. NHS England Cytosponge evaluation for routine referrals: final report. 2023.
5
IQVIA, NHS England.
6
IQVIA, NHS England.
6

ADVERTORIAL
Capsule sponge testing success in Scotland
How it works:
Faced with disrupted endoscopy services following the pandemic,
NHS Scotland was an early adopter of the capsule sponge test,
a strategic shift to alleviate the strain on endoscopic services by
introducing a non-endoscopic, clinically robust alternative for
monitoring patients with Barrett’s oesophagus.
The deployment of the capsule sponge test across NHS Scotland for
Barrett’s surveillance procedures has yielded promising outcomes,
resulting in;
• A 77% reduction in demand for surveillance endoscopies. 7
• Median waiting list times reduced from 9 to 5 months. 8
Triage: Identify patients with chronic reflux or under Barrett’s
Oesophagus surveillance from the NHS backlog for routine endoscopy
referrals, excluding those unsuitable for the capsule sponge test.
Capsule sponge procedure: Eligible patients undergo the capsule
sponge test managed by Xyla, involving swallowing a capsule that
collects oesophageal cell samples.
EndoSign ® diagnostic test at Cyted Health: Samples are sent
to Cyted Health for the EndoSign® diagnostic test to detect
abnormalities.
Follow-Up: Acacium Group clinicians follow up with patients based on
pathology reports.
• The detection of concerning pathologies at endoscopy increased
from 10% to 50% of patients. 9
NHS Scotland’s efforts have set a new standard of care for Barrett’s
surveillance. The success of this programme has not only informed
clinical teams throughout the UK and Europe but has also spurred
audits and the optimisation of endoscopic resources. This has freed up
staff and facilities for other critical procedures, such as colonoscopies
and bowel screenings.
“This technology has been easy to use, very acceptable for patients
and closely audited to ensure we learn and are able to share as much
as we can from our experience. It is now established as a key tool in
how we use our endoscopic resource for assessment of patients and
surveillance of Barrett’s oesophagus.”
Mr Paul Glen, Upper GI Surgeon, NHS Greater Glasgow & Clyde (GGC)
Compounding the benefits of capsule sponge testing with a
managed service
Over the last 15 years, endoscopy has consistently ranked among the
top three clinical specialities sought for insourcing. This model requires
trusts to maintain operational and clinical oversight while utilising their
premises and equipment with external teams.
To mitigate these issues, Cyted Health has partnered with Xyla, part of
Acacium Group, the UK’s leading healthcare delivery partner, to deliver
an outsourced managed service that provides capacity, flexibility and
access to specialist workforce and equipment.
This service is an alternative pathway for patients who require
endoscopic evaluation, particularly due to chronic reflux symptoms or
surveillance of Barrett’s oesophagus.
Outcome-based actions: Positive results (15-20% of cases) lead to
an endoscopy referral. Negative results (80% of cases) ensure patients
are safely managed without endoscopy based on symptoms.
This fully managed service streamlines the patient journey by
integrating triage, testing, analysis, and follow-up. It effectively
addresses the backlog while ensuring patients receive the appropriate
level of care based on their test results.
The future of oesophageal health
The deployment of the capsule sponge test in over 60 hospitals and 20
community care-based clinics throughout the UK has demonstrated
substantial benefits. The ease of implementation and integration
into current healthcare pathways underscores its potential as a
transformative tool in managing gastrointestinal diseases. Cyted Health
and Acacium Group’s co-developed service offers a promising avenue
for reducing costs and waiting lists while improving cancer surveillance
and patient care at scale.
For more information, contact Charlene Tang, Head of Growth,
hello@cytedhealth.com
7
Scottish Health Technologies Group Assessment. Capsule sponge technologies for the detection of Barrett’s oesophagus and early stage
oesophageal cancer. November 2023.
8
Siobhan Chien, et al National adoption of an esophageal cell collection device for Barrett’s esophagus surveillance: impact on delay to investigation
and pathological findings. Diseases of the Esophagus (Online). 2024
9
Natalie Tse et al. Impact of introduction of a cytosponge barrett’s oesophagus surveillance service on the endoscopic pathology pattern. Gut
2023;72:A7-A8.
A fully managed capsule sponge service
Triage of those with chronic
reflux symptoms
Surveillance of those with
Barrett’s Oesophagus
NHS backlog for routine
endoscopy referrals
Not suitable for
capsule sponge test
Nurse led triage
EndoSign® diagnostic
procedure with Xyla
EndoSign ® diagnostic test at Cyted
Negative result (75-85%)
Xyla follow up with patient
following pathology report
Safely manage according
to symptoms
Positive result
(15-20%)
Patient referred
for Endoscopy
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CASE STUDY
EPIPLOIC APPENDAGITIS:
AN UNDER-RECOGNISED CAUSE
OF THE ACUTE ABDOMEN
K Jacob, M Colwill & A Poullis
Department of Gastroenterology, St George’s Hospital, London
appendage or a sub-serosal lymphatic channel that loops through their
base while travelling to mesenteric nodes. The average adult colon
contains 50 to 100 appendages that vary considerably in size, shape
and contour. They are more abundant and larger in the transverse
and sigmoid colon and on average tend to be 1 to 2 cm thick and 2 to
5cm long, although can rarely measure up to 15cm. 1 They are typically
larger in obese patients and in those who recently lost weight. 2,3 The
role of epiploic appendages is unknown, but they are theorised to
serve a function in protection similar to the greater omentum, possibly
acting as a cushion to protect colonic blood supply during peristalsis
and may contribute to colonic absorption. 2
Epiploic Appendagitis
Figure 1. An axial frame from our patient’s CT scan. The area circled
demonstrates an area of inflammatory change related to the fat
overlying the anti-mesenteric aspect of the sigmoid colon in the left
iliac fossa is identified, representing epiploic appendigitis.
Epiploic appendagitis is an ischaemic infarction of an epiploic
appendage. Primary epiploic appendagitis is caused by torsion
of the epiploic appendage or venous thrombosis of the draining
appendageal vein. Secondary epiploic appendagitis is associated with
inflammation of adjacent organs, for example diverticulitis, appendicitis
or cholecystitis.
Case
A 64 year old male with no significant past medical history presented
with a 7 day history of left lower quadrant pain and fevers without an
associated change in bowel habit, haematochezia or vomiting. On
examination he was tender throughout the left lower quadrant but not
peritonitic and there was no guarding. Initial blood tests revealed a
normal full blood count and biochemistry including C-reactive protein
and stool cultures were negative. He was managed initially with simple
analgesia but his symptoms did not resolve. Following this a Computed
Tomography (CT) scan of the abdomen revealed epiploic appendagitis
(Fig 1). He was treated with non-steroidal anti-inflammatories and his
symptoms completely resolved within 5 days.
Discussion
Pathophysiology
Epiploic appendages are small pouches of fat and small blood vessels
that protrude from the serosal surface of the colon into the peritoneal
cavity. Each appendage contains branches of the circular artery and
vein that supply the corresponding segment of the colon. Appendages
also contain lymphatic channels either with a lymph node within the
The incidence of epiploic appendagitis is not known but has been
reported in 2-7% of patients who were initially suspected of having
acute diverticulitis, and 0.3-1% of patients suspected of having acute
appendicitis. 4 It most commonly presents second to fifth decades of
life, with a mean age of diagnosis of 40 ears. The incidence of epiploic
appendagitis has been reported to be up to four times higher in men
compared to women. 4,5,6 Obesity, increased abdominal adipose tissue
and strenuous exercise may be contributing risk factors. 4,7,8
Epiploic appendagitis can occur throughout the colon, with a surgical
case series showing 57% of cases occurred in the rectosigmoid
junction, 26% in the ileocaecal region, 9% in the ascending colon, 6%
in the transverse colon and 2% in the descending colon. 4,7,9
Presentation
Epiploic appendagitis typically presents with localised abdominal
pain, more commonly on typically normal but can be mildly elevated.
Differential diagnosis can include appendicitis, diverticulitis, omental
infarction, pelvic inflammatory disease or a ruptured ovarian cyst.
Diagnosis
Pathological confirmation of diagnosis is uncommon. Diagnosis is
typically based on CT scanning of the abdomen and pelvis. Epiploic
GASTROENTEROLOGY TODAY – SUMMER 2024
9

FEATURE
appendagitis appears as an oval-shaped, 2-3 cm paracolic fatty mass
with thickened peritoneal lining and peri-appendigeal fat stranding
(known as a ring sign). 11 It is typically of slightly higher attenuation
than peritoneal fat and may contain a central dot of high attenuation
(known as the ‘dot sign’) possibly representing a thrombosed vessel in
the epiploic appendage. 10 CT changes of acute epiploic appendagitis
completely resolved in all patients undergoing a follow up CT scan 6
months after the initial presentation. 11-13 Magnetic resonance imaging
findings of epiploic appendagitis have not been well studied but appear
to be the left side (60 to 80%). Pain can be of variable intensity and
duration and exacerbated by coughing, deep inspiration, or stretching
(as the infarcted appendage is adherent to the parietal peritoneum).
It typically does not radiate. Patients may also present with a mild
fever, rebound tenderness and an abdominal mass. More rarely,
there may be associated nausea, vomiting and weight loss. White cell
count, erythryocyte sedimentation rate and C-reactive protein are in
congruence with CT findings. 14
Alternatively, abdominal ultrasound may be used demonstrating
a non-compressible, hyperechoic, solid oval mass with a subtle
hypoechoic rim located at the point of maximal tenderness. 7 Doppler
studies typically reveal absence of blood flow with the appendage,
with normal blood flow in the hyperechoic inflamed fat surrounding
the appendage. 15 Adding contrast shows a central area of no
enhancement with moderately increased vascularisation around the
avascular necrotic appendage. 16
Disease Course
Epiploic appendagitis is a self-limiting disease with signs and
symptoms normally resolving within 3 to 14 days. 7,17,18 It should be
treated conservatively with analgesia. Patients do not usually require
hospitalisation or antibiotics and surgery is typically reserved for
patients who fail to improve with conservative management or develop
complications (intussusception, abscess or bowel obstruction)
that cannot be managed nonoperatively. At surgery, the inflamed
appendage is typically ligated and resected. Recurrence is not well
studied but is likely very low.
4. Schnedl WJ, Krause R, Tafeit E, et al. Insights into epiploic
appendagitis. Nat Rev Gastroenterol Hepatol 2011; 8:45.
5. Ozdemir S, Gulpinar K, Leventoglu S, et al. Torsion of the primary
epiploic appendagitis: a case series and review of the literature.
Am J Surg 2010; 199:453.
6. Sand M, Gelos M, Bechara FG, et al. Epiploic appendagitis--
clinical characteristics of an uncommon surgical diagnosis. BMC
Surg 2007; 7:11.
7. Rioux M, Langis P. Primary epiploic appendagitis: clinical, US, and
CT findings in 14 cases. Radiology 1994; 191:523.
8. Nugent JP, Ouellette HA, O’Leary DP, et al. Epiploic appendagitis:
7-year experience and relationship with visceral obesity. Abdom
Radiol (NY) 2018; 43:1552.
9. Macari M, Laks S, Hajdu C, Babb J. Caecal epiploic appendagitis:
an unlikely occurrence. Clin Radiol 2008; 63:895.
10. Giannis D, Matenoglou E, Sidiropoulou MS, et al. Epiploic
appendagitis: pathogenesis, clinical findings and imaging clues of
a misdiagnosed mimicker. Ann Transl Med 2019; 7:814.
11. Singh AK, Gervais DA, Hahn PF, et al. CT appearance of acute
appendagitis. AJR Am J Roentgenol 2004;183:1303-7. 10.2214/
ajr.183.5.1831303.
12. Rao PM, Wittenberg J, Lawrason JN. Primary epiploic
appendagitis: evolutionary changes in CT appearance. Radiology
1997;204:713-7. 10.1148/radiology.204.3.9280248.
13. Mollà E, Ripolles T, Martinez MJ, et al. Primary epiploic
appendagitis: US and CT findings. Eur Radiol 1998;8:435-8.
10.1007/s003300050408.
14. Sirvanci M, Balci NC, Karaman K, et al. Primary epiploic
appendagitis: MRI findings. Magn Reson Imaging 2002; 20:137.
15. Deceuninck A, Danse E. Primary epiploic appendagitis: US and CT
findings. JBR-BTR 2006; 89:225.
16. Görg C, Egbring J, Bert T. Contrast-enhanced ultrasound of
epiploic appendagitis. Ultraschall Med 2009; 30:163.
17. Desai HP, Tripodi J, Gold BM, Burakoff R. Infarction of an epiploic
appendage. Review of the literature. J Clin Gastroenterol 1993;
16:323.
18. Legome EL, Belton AL, Murray RE, et al. Epiploic appendagitis:
the emergency department presentation. J Emerg Med 2002;
22:9.
Key Points
GASTROENTEROLOGY TODAY – SUMMER 2024
• Epiploic appendigitis is a rare pathology that can cause abdominal
pain and mimic several other acute abdominal pathologies including
appendicitis, colitis and diverticulitis
• It is benign and self-limiting and usually can be managed with
conservative measures
• Cross-sectional imaging is the gold-standard in diagnosis to assess
for ring sign or dot sign
References:
1. Linkenfeld F. Deutsche Ztschr f Chir. 1908;92:383 10.1007/
BF02799591.
2. Pines BR, Beller J. Primary torsion and infarction of the
appendices epiploicae. Arch Surg 1941; 42:775.
3. Ghahremani GG, White EM, Hoff FL, et al. Appendices epiploicae
of the colon: radiologic and pathologic features. Radiographics
1992; 12:59.
10

FEATURE
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GASTROENTEROLOGY TODAY – SUMMER 2024
11

CASE STUDY
GASTROENTEROLOGY TODAY – SUMMER 2024
LEICESTER NURSES LEADING THE
WAY IN CAPSULE SPONGE TESTING
Introduction
University Hospitals of Leicester NHS Trust (UHL) has transformed
patient access to diagnostics for Barrett’s oesophagus, a risk factor
for cancer, through the roll out of capsule sponge testing. The team’s
creation of a new nurse-led diagnostic pathway has allowed them to
cut gastroscopy waiting times, improve clinical capacity and deliver a
better experience for both patients and clinical staff.
The challenge
The team at UHL had an ambition to reduce wait times and improve
survival chances for a lesser-known group of patients with Barrett’s
oesophagus that affects around 1 million adults in Britain. 1 The
incidence of oesophageal adenocarcinoma in this group has increased
dramatically since the 1970s, 2 yet survival remains poor despite
advances in surgery and chemotherapy. In the UK, 81% are diagnosed
at stage 3 or 4, of which only ~20% survive for 1 year or more. 3
The only way of improving survival chances for this patient group is to
ensure early diagnosis and surveillance of Barrett’s Oesophagus.
However, the team were facing all-time high waits for gastroscopy and
saturated 2-week wait pathways, placing these patients at increased
risk of late diagnosis.
• Average patient wait time for this group: 6-12 months
• Number of staff able to perform the initial diagnostic test: 1
• Number of locations the initial diagnostic test was available from:1
The solution
The Trust joined the national capsule sponge testing pilot programme
and came to see the benefits of the simple, minimally-invasive
capsule sponge test. Testing was undertaken by a range of clinical
professionals from nurses to consultants – widening the possible
delivery of the service - which provided the potential to reduce
the wait associated with traditional endoscopist-led endoscopy
procedures. The team also improved their triaging process for the
test, adding electronic forms to improve the speed and accuracy of
patient selection.
Capsule sponge testing offered the opportunity for nurses to be
upskilled, providing improved career pathways which the team felt
would strengthen both their attraction and retention. By improving their
capacity to deliver the service, and upskilling their team, the Trust was
able to create a nurse-led clinic that could see more Barrett’s patients,
more quickly.
Customer testimonial
“What started as two nurses with an idea has become a key part of
our pathway and now my full time job! The training opportunity alone
has helped position ourselves as an innovative service that people
are excited to join. Our staff retention has improved and we’re already
hiring for more as we plan to roll out capsule sponge testing for other
patient groups, and look to GP referrals to reach even more people.
Our vision is that in time, all patients for Barrett’s surveillance and
investigation for GORD will be offered capsule sponge testing as a first
line diagnostic procedure.”
“Our nurse-led approach means we have more people that can deliver
the test, meaning each patient has a dedicated contact that supports
them through the entire process, from testing at their community
hospital to sending their diagnosis. It’s more convenient for them and
helps them feel personally looked after. They clearly prefer the test, and
so do we; all I want to do now is capsule sponge tests!”
Vanessa deVivian
Capsule Sponge Lead Nurse Specialist
“In selecting what improvement to pursue, we collectively agreed
that any new approach needed to help us recruit and retain more
diagnostic staff, to build more capacity and be able to rapidly reduce
the overall patient wait time.The testing process has delivered on all of
those targets!”
“The benefits to the patients have been huge. We proved the
effectiveness of the capsule sponge by first showing the waiting
times reductions for our Barrett’s patients, and then showing how
we’ve been able to catch cancer earlier. For the team, we’ve been
able to save endoscopy resources and give staff an exciting training
opportunity. The test has been a big hit here and we’re hoping our
nurse-led model can be an inspiration to other services to just go
for it!”
Colette J Green
Endoscopy team lead
1
Dymedex Market Development Consulting, GERD Sizing, 2015
2
Pohl H, Welch HG. The role of overdiagnosis and reclassification in the marked increase of esophageal adenocarcinoma incidence. J Natl Cancer
Inst. 2005;97(2):142-6.
3
Cancer Research UK. Early Diagnosis Data Hub: Incidence by Stage. Oesophageal Cancer, Stage 1, 2, 3 and 4 (England, excluding unknown
stage). Available at: https://crukcancerintelligence.shinyapps.io/EarlyDiagnosis/ Accessed 14 March 2023. 2023.
12

CASE STUDY
Outcomes
Following the success of the pilot, the Trust is aiming to expand both
the scope and the setting of its capsule sponge testing.
Vanessa (left), Dr Kadri, Colette and Rachel
To offer the test to even more at-risk patients, UHL is now looking at
ways to sustainably expand the offer to reflux patients who have had
at least 6-8 weeks of proton pump inhibitors (PPI). Another group that
UHL is looking to diagnose is patients with Gastroesophageal reflux
disease (GORD). Early intervention using capsule sponge testing would
detect undiagnosed Barrett’s oesophagus in this group of patients,
potentially decreasing mortality, improving patient experience and
reducing costs to the NHS.The cost savings per patient can be reinvested
in further service improvements through hiring dedicated staff
or pathway innovations in the wider service. The Trust’s ambition is to
accept direct GP referrals for patients with suspected GORD to further
reduce pressure on gastroscopy pathways.
Key findings
• 20-week reduction in patient waiting times.
• Increased capacity, with 3 staff able to perform the test. One
dedicated full-time nurse and two other part-time.
• Testing now available to more sites across the Trust and expanding
into community care.
Testing in the community is another area that UHL is planning to
explore. The team found that 99% of patients expressed a preference
for testing in a community hospital instead of the acute setting. In
response to this, the Trust is aiming to secure additional funding to
expand the service at St Luke’s Community Hospital to offer four full
lists per week (48 capsule sponge procedures). It is hoped that in time
this will become a site for referrals from neighbouring counties and will
support expansion into a further three community sites.
Conclusion
• The early detection of Barrett’s Oesophagus has helped to prevent
the occurrence of oesophageal cancers.
• Positive impact on staff retention and acquisition, with colleagues
expressing how valued they feel.
The Trust’s nurse-led model demonstrates a clear way for other
services to reduce the pressure on endoscopy teams, while still
offering exciting training opportunities and autonomy to those that
want to innovate. By expanding the deliverability of the testing, UHL is
leading the way in developing cost-effective, nurse-led services that
can provide better access, experience, and outcomes for patients.
• Cost reduction of around 50% compared with gastroscopy, due to
the different skill mix, setting and product.
The capsule sponge testing programme has also improved patient
experience by providing patient-centric care, closer to home. This more
focused approach has created less anxiety for patients throughout
their journey and greater patient satisfaction.
• 100% of patients who previously had gastroscopy said they would
prefer to have a capsule sponge testing in the future.
• Patients reported better tolerance to the procedure and lower
anxiety levels versus a gastroscopy.
• 99% of patients said they experienced little to no discomfort during
or after their capsule sponge test.
• “Dealing with the same person throughout the journey is
very reassuring.”
• “A lovely, relaxed experience, felt very cared for (strange for a
medical procedure).”
UHL’s vision is that in time, all patients for Barrett’s surveillance and
investigation for GORD will be offered capsule sponge testing as a firstline
diagnostic procedure. The determination of the UHL team means
that this vision will no doubt become reality.
GASTROENTEROLOGY TODAY – SUMMER 2024
13

FEATURE
GASTROENTEROLOGY TODAY – SUMMER 2024
14

FEATURE
ENDOSCOPIC ULTRASONOGRAPHY-
GUIDED FINE-NEEDLE BIOPSY
FOR PATIENTS WITH RESECTABLE
PANCREATIC MALIGNANCIES
Ming-Sheng Chien 1 , Ching-Chung Lin 1,2 and Jian-Han Lai 1,2,3,*
Gastroenterol. Insights 2024, 15, 375–385. https://doi.org/10.3390/gastroent15020026
ARTICLE
Abstract: Clinicians often use endoscopic ultrasonography to survey
pancreatic tumors. When endoscopists conduct this examination and
find the tumor to be unresectable, a fine-needle biopsy is subsequently
performed for tissue confirmation. However, if the tumor is deemed
resectable, the necessity of a pre-operative fine-needle biopsy remains
debatable. Therefore, we performed a retrospective analysis of a
single-center cohort of patients with pancreatic tumors who underwent
an endoscopic ultrasound-guided fine-needle biopsy or aspiration
(EUS-FNB or FNA) between 2020 and 2022. This study focused on
patients diagnosed with resectable malignant pancreatic tumors.
The exclusion criteria included individuals diagnosed with benign
pancreatic lesions and those with unresectable tumors. A total of 68
patients were enrolled in this study. Histological examination revealed
that pancreatic adenocarcinoma was the predominant type of tumor
(n = 42, 61.8%), followed by neuroendocrine tumors (n = 22, 32.3%),
and metastasis (n = 4, 5.9%). Notably, 17 patients had a history of other
cancers, with 23.5% being diagnosed with a metastatic tumor rather
than primary pancreatic cancer. Therefore, EUS-FNA/FNB is crucial in
patients with a resectable pancreatic tumor and a history of cancer to
differentiate between a primary and a metastatic tumor.
Keywords: endoscopic ultrasonography; fine-needle biopsy; malignant
pancreatic tumor; resectable tumor; pancreatic surgery
1. Introduction
Pancreatic cancer stands as a lethal malignancy, ranking among the
leading contrib-utors to cancer-related deaths [1,2]. Surgical resection
is the only curative approach for resectable pancreatic cancer. Imaging
examinations such as computed tomography (CT) and magnetic
resonance imaging (MRI) are valuable tools in identifying malignancy
and determining whether tumors are resectable or non-resectable
by assessing their interaction with nearby vascular structures, such
as the superior mesenteric artery and vein, portal vein, and celiac
artery. However, these imaging studies are unable to differentiate
between primary and metastatic tumors. The definitive determination
of the tumor type and origin relies on histological examination and
immunohistochemical staining.
In cases where tumors are deemed unresectable, tissue confirmation
is imperative to guide subsequent systemic treatment. The decision
making process regarding subsequent fine-needle aspiration or
biopsy (FNA or FNB) for tissue confirmation becomes pivotal when
endoscopists perform EUS in patients with pancreatic tumors.
Conversely, when tumors are considered resectable, surgical
resection is the primary recommendation for curative therapy.
Consequently, pre-operative tissue confirmation through FNB may not
be perceived as necessary for the majority of patients unless there is
disagreement among surgeons regarding the pre-operative imaging
study results, such as distinguishing between benign and malignant
conditions. However, certain studies have documented cases in which
patients underwent surgery only owing to the final diagnosis, which
unexpectedly revealed pancreatic metastasis [3]. In such instances,
if a pre-operative FNB was performed, unnecessary surgeries would
avoided, thereby emphasizing the significance of judicious decision
making in the diagnostic process.
This study aimed to examine patients diagnosed with resectable
pancreatic cancer based on pre-EUS evaluations, including CT,
magnetic resonance imaging (MRI), and abdominal US. The
objective of this study was to determine whether pre-operative tissue
confirmation using FNA or FNB influenced the subsequent treatment
plan, particularly the choice between surgical intervention and
systemic treatment. Additionally, we reviewed several studies published
in English to identify the distinct characteristics and features that
differentiate between primary and secondary pancreatic tumors.
2. Materials and Methods
This retrospective cohort study was conducted at a medical center in
Taiwan. We per-formed a retrospective analysis of a cohort of patients
with pancreatic tumors, specifically focusing on those who underwent
EUS-FNA and FNB between January 2020 and December 2022.
Patients diagnosed with benign tumors or unresectable malignancy
1
Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan; lineage2728@gmail.com
(M.-S.C.); sunny.lin56@msa.hinet.net (C.-C.L.)
2
Department of Medicine, MacKay Medical College, New Taipei City 25245, Taiwan
3
MacKay Medicine Nursing and Management, Taipei 11260, Taiwan
GASTROENTEROLOGY TODAY – SUMMER 2024
* Correspondence: jiannhann@gmail.com; Tel.: +886-2-25433535
15

FEATURE
beyond stage III according to the American Joint Committee on Cancer
8th edition were excluded. The definitive diagnosis relied on both
cytopathological and imaging findings, and not solely on the images.
The criteria for imaging in the differential diagnosis of benign and
malignant tumors were established based on previous studies [4,5]. In
the EUS images, the tumor presented as a hypoechoic heterogeneous
pattern, accompanied by an upstream pancreatic duct dilatation and
distal pancreas atrophy, raising suspicion of malignancy. The diagnosis
of background chronic pancreatitis was made using EUS based on the
proposed Rosemont criteria [6].
The adequacy of the obtained tissue was determined by the presence
of well-defined pancreatic ductal epithelium or stromal cells in the
retroperitoneal mass. An unsuccessful FNA/B cytopathological
diagnosis was defined as either a false negative or atypical result,
whereas a successful FNA/B diagnosis was defined as a suspicious
or positive finding of malignancy. Specimens categorized as
“atypical” exhibit a spectrum of architectural and/or cellular changes
that exceed the parameters of normal or reactive conditions. Nevertheless,
these alterations lack adequate quantitative or qualitative
criteria to categorize them as neoplastic (benign/other), suspicious,
or indicative of malignancy [7]. If a patient had an unsuccessful
FNA/B cytopathological diagnosis, further surgical tissue-proof or
transabdominal echo-guided metastatic lesion biopsy was arranged to
obtain a final histo-logical diagnosis. Patients who were diagnosed with
benign lesions underwent diagnostic imaging follow-up for at least 6
months to rule out the possibility of a missed diagnosis of malignancy.
For the analysis, we extracted the following personal and clinical data
from patient records: age, sex, presentation of chronic pancreatitis,
EUS findings (tumor location and size and number of FNA or FNB
passes), and cytopathological results. Because CT imaging data were
available for most patients, we opted to evaluate and incorporate CT
findings in our study. We also recorded whether the patients had a
history of other cancers before undergoing EUS.
2.1. Study Design
2.2. EUS-FNB
All EUS-FNA/FNB procedures were performed with the patients in
the left lateral decubitus position, under conscious sedation using
midazolam and fentanyl. Additional sedatives were administered by
endoscopists to achieve moderate conscious sedation. All EUS-
FNA/B procedures were performed by three endoscopists who had
completed the FNA learning curve [9]. The procedures were performed
using a GF-UCT260 curvilinear echoendoscope (Olympus Optical Co.,
Ltd., Tokyo, Japan). A 22-gauge FNA needle (EZ Shot 3 Plus, Olympus,
Tokyo, Japan) or a 22-gauge FNB needle (TopGain ® , Medi-Globe,
Achenmühle, Germany; Acquire TM, Boston Scientific, Natick, MA,
USA) was employed.
A fanning method was used for FNA/B, involving aspiration from at
least four different areas within the target lesion using a stylet slow-pull
or low negative suction technique. Subsequently, the endoscopists
preserved the acquired tissues in ethanol and formalin to prepare
cytological smears and pathological samples, respectively. Rapid
onsite cytological evaluation was not available in our hospital setting,
and the decision regarding the requisite number of FNA/FNB passes
for each case was individually made by the endoscopists, considering
the condition of the patient and the volume of tissue obtained
(macroscopic onsite quality evaluation) [10].
2.3. Statistical Analysis
Continuous variables were presented as the mean ± standard
deviation, and cate-gorical variables were expressed as frequencies
and percentages. The baseline clinical characteristics of the two
comparison groups were assessed using independent samples t-test,
Chi-square test, and crosstabs statistics, depending on the data
type. Student’s t-test for continuous variables was applied for the
comparison between two groups, and Chi-square or Fisher’s exact
test (when cell had an expected frequency less than 5) for categorical
variables was applied for measures of association. Statistical analyses
were performed using SPSS software (version 27.0; SPSS, Chicago,
IL, USA), with a significance level set at a two-sided p-value of 0.05.
GASTROENTEROLOGY TODAY – SUMMER 2024
Patients were initially classified into two groups: those with benign
and malignant tumors. If malignant tumors were suspected in the
initial imaging, it was necessary to assess the possibility of a tumor
resection based on evidence of large vessel invasion and regional
lymph node metastasis [8]. The characteristics of patients who had
resectable malignant pancreatic tumors were recorded, such as age,
sex, and history of cancer. Details of EUS and FNB procedures were
documented, including the FNB pass number and the success rate of
cytopathological diagnoses. Tumor characteristics, including location
and final histological diagnosis, were also recorded. We further
analyzed patients with a history of cancer and those without, with a
particular focus on comparing the rates of primary and metastatic
tumors between these two subgroups of patients. Furthermore, this
retrospective chart review received approval from the Institutional
Review Board of Mackay Memorial Hospital, Taiwan. The Ethics
Committee waived the requirement for informed consent, and the
medical records of each patient were anonymized and de-identified
before access.
To estimate the required sample size for our study, G*Power 3.1
software was utilized, employing Fisher’s exact test to compare two
independent proportions. The underlying assumptions included a
Type I error (α) set at 0.05 and a desired statistical power of 0.80. The
proportions of interest, denoted as p1 and p2, were assumed to be
0.65 and 0.95, respectively, with a ratio of the sample sizes between
the two groups (N2:N1) maintained at 3:1. Based on these parameters,
the calculated adequate sample size necessary to detect a statistically
significant difference between the two proportions with the specified
power and Type I error rate was determined to be 64 participants.
3. Results
A total of 180 patients with pathologically confirmed pancreatic
tumors were retro-spectively reviewed. Among them, 112 patients
were excluded from the analysis because they were diagnosed with
either benign (n = 6) or unresectable (n = 106) tumors. A flow diagram
of the participant selection is presented in Figure 1. The clinical
characteristics of the patients are shown in Table 1. Patients diagnosed
16

FEATURE
with resectable malignant pancreatic tumors and undergoing EUS- pheochromocytoma, and carcinoid tumors of the mediastinum. The
FNB comprised 27 men and 41 women, with a mean age of 64.53 ± diagnosis of pancreatic metastatic tumors was confirmed by tissue
13.5 years. Seventeen patients had a history of cancer, accounting proof via EUS-FNB/A and pathohistology, which included IHC staining.
hts 2024, 15, for FOR 25% PEER of all cases. REVIEW FNB tissue confirmation achieved a success The patient with solitary fibrous lung tumors was the oldest, 4 at 68 years
rate of 88.4%, with an average of 3.01 passes. The most common old, while the patient with lung adenocarcinoma was the youngest,
sites of tumor occurrence were the uncinate process and head (n =
47, 69.1%), followed by the body and tail (n = 21, 30.8%). The most
frequent histological types of pancreatic malignancies were pancreatic
adenocarcinoma (n = 42, 61.8%), neuroendocrine tumors (n = 22,
32.3%), and metastases (n = 4, 5.9%).
with secondary cases, with a mean size of 3.2 ± 2.60 cm (p = 0.07).
hts 2024, 15 with an average of 3.01 passes. The most common sites of tumor occurrence were the
The patients were divided into two groups: those with a history of In our study, the incidence of metastatic pancreatic tumors 378 tended to
cancer (n = 17) and those without (n = 51), as shown in Table 2. Of the
patients with a history of cancer, three had lung cancer, seven had
breast cancer, one had esophageal cancer, and six had other types
of cancer, such as hepatocellular carcinoma, endometrial carcinoma,
at 58 years old. These cases presented without typical features,
consistent with their respective primary origins and, in general, posed
malignant pancreatic tumors and undergoing EUS-FNB comprised 27 men and 41
women, with a mean age of 64.53 ± 13.5 years. Seventeen patients had a history of cancer,
accounting for 25% of all cases. FNB tissue confirmation achieved a success rate of 88.4%,
diagnostic challenges. There was no significant difference in the mean
age (p = 0.27) or sex (p = 0.66) between the two groups. The mean
size of primary pancreatic tumors was 2.25 ± 0.86 cm, compared
uncinate process and head (n = 47, 69.1%), followed by the body and tail (n = 21, 30.8%).
The most frequent histological types of pancreatic malignancies were pancreatic
adenocarcinoma histological types(n of = pancreatic 42, 61.8%), malignancies neuroendocrine were tumors pancreatic (n = 22, adenocarcinoma 32.3%), and metastases (n = 42,
(n adenocarcinoma or neuroendocrine tumors).
61.8%), = 4, 5.9%). neuroendocrine tumors (n = 22, 32.3%), and metastases (n = 4, 5.9%).
be higher in patients with a history of malignancy (23.5%) than in those
with no cancer history (p < 0.001). Notably, all patients without a history
of cancer were diagnosed with primary pancreatic cancer (either
Figure 1. Flowchart of patients considered for inclusion in the study.
Table 1. Patients with resectable malignant pancreatic tumors who underwent EUS-FNB (n = 68).
Age (year) 64.53 ± 13.5
Figure Male 1. Flowchart of patients considered for inclusion in the study. 27 (39.7%)
Table
History
1. Patients
of cancer
with
(n, %)
resectable malignant pancreatic tumors who underwent
17 (25%)
EUS-FNB (n = 68).
EUS-suspected malignancy 68
Age (year) 64.53 ± 13.5
Pass number (n) 3.01
Male 27 (39.7%)
Successful FNB tissue proof (n, %)
History of cancer (n, %)
61 (88.4%)
17 (25%)
EUS-suspected Location of tumormalignancy 68
Pass -Uncinate number (n) process and head 47 (69.1%) 3.01
Successful -Body and FNB tail tissue proof (n, %) 21 (30.8%) 61 (88.4%)
Location Kinds of tumor of tumor (PDAC/NET/Metastasis) (n, %)
-PDAC -Uncinate process and head 42 (61.8%) 47 (69.1%)
-Body and tail 21 (30.8%)
-NET 22 (32.3%)
Kinds of tumor (PDAC/NET/Metastasis) (n, %)
-Metastasis 4 (5.9%)
-PDAC 42 (61.8%)
EUS, endoscopic ultrasound; FNB, fine-needle biopsy; PDAC, pancreatic ductal adenocarcinoma; NET, neuroendocrine-NET
tumor.
22 (32.3%)
-Metastasis 4 (5.9%)
EUS, The endoscopic patients ultrasound; were divided FNB, into fine-needle two groups: biopsy; those PDAC, withpancreatic a historyductal of cancer adenocarcinoma;
(n = 17) and
NET, thoseneuroendocrine without (n = 51), tumor. as shown in Table 2. Of the patients with a history of cancer, three had
lung cancer, seven had breast cancer, one had esophageal cancer, and six had other types
GASTROENTEROLOGY TODAY – SUMMER 2024
17

ghts 2024, 15 379
FEATURE
history (p

Figure 2. (A) The computed tomography scan revealing a well-defined resectable tumor in the
Figure 2. (A) The computed tomography scan revealing well-defined resectable tumor in the
Figure pancreatic 2. (A) body, The computed accompanied tomography by pancreatic scan revealing duct dilatation a well-defined (arrow). resectable (B) During tumor inthe pancreatic
examination, body, accompanied the tumor exhibits by pancreatic a hypoechoic duct dilatation and heterogeneous (arrow). (B) During appearance. the EUSSubsequently, examination, the an
EUS
pancreatic body, accompanied by pancreatic duct dilatation (arrow). (B) During the EUS
examination, the tumor exhibits hypoechoic and heterogeneous appearance. FEATURE Subsequently, an
tumor FNB was
FNB was
exhibits performed,
performed,
a hypoechoic confirming
confirming
and heterogeneous it to be a metastatic
it to be metastatic
appearance. tumor
tumor
Subsequently, originating from
originating from
an FNB the
the
was previous
previous
performed, lung
lung
confirming adenocarcinoma
adenocarcinoma it to be (arrow).
(arrow). a metastatic tumor originating from the previous lung adenocarcinoma (arrow).
Figure 3. (A) The positron Figure
Figure emission 3. 3.
(A)
(A) (A) tomography The
The The
positron positron scan revealing emission emission a malignant tomography tomography tumor located scan
scan scan at revealing the revealing pancreatic a malignant malignant ahead malignant (arrow). tumor
tumor tumor
located
located located
at the
the at
(B) Magnetic resonance pancreatic imaging discloses head an (arrow). ill-defined (B) mass Magnetic in the pancreatic resonance head region, imaging leading discloses to pancreatic an duct ill-defined mass in the
the pancreatic head head (arrow). (B) (B) Magnetic resonance imaging disclosesan an ill-defined mass in the
dilatation (arrow). (C) In pancreatic the EUS examination, head region, a hypoechoic leading tumor to pancreatic was identified, duct leading dilatation to pancreatic (arrow). duct dilatation. (C) In the A EUS examination, a
pancreatic head region, leading to pancreatic duct dilatation (arrow). (C) In the EUS examination, a
subsequent FNB confirmed hypoechoic it to be a pancreatic tumor was lesion identified, metastasized leading from lung adenocarcinoma to pancreatic (arrow). duct dilatation. A subsequent FNB
hypoechoic tumor was identified, leading to pancreatic duct dilatation. subsequent FNB
confirmed it tumor to be was a pancreatic identified, lesion leading metastasized to pancreatic from duct lung dilatation. adenocarcinoma A subsequent (arrow). FNB confirmed
it
confirmed
to be a pancreatic
it to be lesion
pancreatic
metastasized
lesion metastasized
from lung adenocarcinoma
from lung adenocarcinoma
(arrow).
(arrow).
nonhematologic neo-plasms that exhibited pancreatic metastasis,
4. Discussion
4.
4. Discussion
Discussion
including renal cell carcinoma, melanoma, pulmonary small-cell
Pancreatic lesions, primarily pancreatic Pancreatic Pancreatic ductal adenocarcinomas, lesions, carcinoma, breast carcinoma, and sporadic cases of prostate carci-
90%
lesions, primarily pancreatic ductal adenocarcinomas, constitute over 90%
constitute over 90% of pancreatic
of neoplasms, pancreatic and despite neoplasms, surgical and noma, despite colon adenocarcinoma, surgical interventions, pulmonary squamous the cell prognosis carcinoma, remains
pancreatic neoplasms, and and despite despite surgical surgical interventions, interventions, the prognosis the prognosis remains remains challenging
challenging [1,11,12]. The
and gastrointestinal stromal tumors [16–18]. Notably, pancreatic
interventions, the prognosis remains The incidence of pancreatic metastasis from cancers of other origins
challenging [1,11,12]. [1,11,12]. The incidence incidence of pancreatic of pancreatic metastasis metastasis from from cancers cancers of other of other origins origins is
incidence of pancreatic metastasis
notably notably
from cancers
low,
of other
ranging
origins
from
is metastases predominantly target the pancreatic head, followed by 3% to 12% [13]. rare, it is notably low, low, ranging ranging from from 3% 3% to to 12% 12% [13]. [13]. Although rare, rare, it it poses a significant challenge
notably low, ranging from 3% to 12% [13]. Although rare, it poses pancreatic body and tail [17]. Contrary to a previous study that focused
a significant challenge for clinics in terms of diagnosis, and even on renal cell carcinoma (RCC), our analysis suggested that lung cancer
surgeons have expressed concerns, as they are reluctant to perform is more commonly linked to secondary pancreatic tumors (50%).
unnecessary pancreatectomies and risk unexpected diagnoses. However, considering the limited number of patients and the inclusion
of only resectable tumors in this study, it is important to acknowledge
Initially, secondary pancreatic tumors are often asymptomatic. In the potential for bias.
typical cases, an asymptomatic patient may exhibit evidence of
prior surgical interventions, such as nephrec-tomy, lobectomy, or The presentation timeframe of pancreatic metastasis varies, with
colon resection, during CT or abdominal US examinations. As the instances docu-mented to manifest long after the initial diagnosis and
disease progresses, symptoms such as epigastric pain, jaundice, treatment of the primary tumor averaging more than 8 years, with a
and weight loss may manifest, mirroring those observed in primary maximum duration of 17 years [19]. On average, in our study, the onset
pancreatic tumors. CT and MRI are instru-mental in providing a
of a second pancreatic cancer occurred approximately 42 months after
general assessment of the disease and evaluating the surrounding the initial cancer diagnosis, with the longest duration extending up to
lymphadenopathy, distal metastasis, and potential resection [14]. 120 months. The most common locations of secondary pancreatic
EUS plays a crucial role in offering a final diagnosis through tissue tumors were the pancreatic head and body. These findings are
proofing and aids in the selection of the most effective treatment for consistent with those of previous studies [17].
the patient [15].
In CT and MRI, some secondary pancreatic tumors may present
Analysis of autopsies and surgical cases identified prevalent
with characteristics of the original malignancy. RCC is the most
GASTROENTEROLOGY TODAY – SUMMER 2024
19

FEATURE
GASTROENTEROLOGY TODAY – SUMMER 2024
common cancer to metastasize to the pan-creas [19]. It typically
shows either intense homogeneous enhancement in small lesions
or rim enhancement in large lesions. In contrast, the outer regions
of colorectal metastases showed no difference from the normal
pancreatic tissue, whereas the inner area showed hypo-enhancement
due to central necrosis [20]. Additionally, a distinctive lesion may
be present in the pancreas that lacks the classic double duct sign
typically observed in primary pancreatic cancers. This is because,
quite often (approximately one-third of the time), tumors are initially
thought to be primary pancreatic tumors upon imaging stud-ies [12].
Hence, if a patient has a history of cancer and is newly diagnosed
with a pancreatic mass, the possibility of metastasis should be fully
evaluated. It can either initiate the most effective treatment or decrease
mortality and morbidity resulting from unnecessary surgery.
In EUS, the morphology of metastatic pancreatic tumors varies. They
are typically located at the head of the pancreas with regular borders,
although they are occasionally irregular. Hypoechogenic tumors are
predominant; however, hyperechoic metastases from bladder cancer
and anechoic metastases from melanoma have also been observed.
Mixed characteristics of metastatic pancreatic tumors are common,
such as renal cell carcinoma, in which echogenicity can vary. Similarly,
the consistency of metastatic pancreatic tumors may vary from solid
to cystic or heterogeneous [20,21]. In our study, the four metastatic
pancreatic tumors exhibited a hypoechoic heterogeneous pattern on
EUS images, similar to the primary tumors. Consequently, relying solely
on imaging for an accurate diagnosis in these cases is challenging.
Emphasizing the importance of a thorough history taking, particularly
regarding cancer, before performing EUS is crucial. It is highly likely
that the history of cancer was the sole piece of information hinting the
possibility of metastasis to the endoscopist.
A contrast-enhanced ultrasound (CE-EUS) was not employed in this
study because at our hospital, patients must pay for it out of pocket,
and not every patient agreed to its use. Although CE-EUS has been
recognized as useful for diagnosing primary pancreatic tumors, its
efficacy in detecting metastasis remains a subject of debate. A recent
study suggested its potential usefulness in the diagnosis of pancreatic
metastases [22]. RCC metastasis typically exhibits a hyperenhanced
pattern, which distinguishes it from primary adenocarcinoma, which
typically displays a hypoenhanced pattern. However, it can still be
challenging to differentiate it from a neuroendocrine tumor, which
also presents with a hyperenhanced pattern. In contrast, metastases
from other origins, such as the stomach, colon, and ovaries, exhibit
a hypoenhanced pattern [23]. Therefore, the use of contrast to
distinguish between primary and metastatic pancreatic tumors has no
value. Tissue acquisition remains the gold standard for diagnosis.
In accordance with the current guidelines, including the ESMO and
NCCN, if a patient presents with a suspected malignant pancreatic
tumor, lacks a history of cancer, and imaging studies suggest a
resectable tumor. Non-diagnostic biopsy should not delay surgical
resection when the clinical suspicion for pancreatic cancer is high
[24,25]. However, when a patient has a history of cancer, it becomes
crucial to consider the possibility of metastatic pancreatic cancer
originating from various organs. While rare, pancreatic metastases
pose a considerable clinical challenge due to their potential to influence
treatment decisions and affect patient outcomes. In such cases, a
biopsy is necessary to differentiate between a primary and metastatic
lesion before initiating treatment. EUS with an FNA/FNB is preferred
for this purpose due to its superior diagnostic yield, safety profile, and
potential to mitigate the risk of peritoneal seeding compared to the CTguided
approach [26–28].
In addition to tumor morphology, cytological and immunohistochemical
staining (IHC) were performed to confirm the final diagnosis. In this
comprehensive single-center study, EUS-guided tissue sampling
proved to be valuable and had a significant clinical impact [21]. EUS-
FNA was developed to acquire tissues using negative pressure for
cytological analyses. Cytological samples acquired using EUS-FNA
exhibit a relatively high diagnostic accuracy. Nonetheless, reliance
solely on cytological evaluation is insufficient to diagnose metastatic
pancreatic cancer. Recently, the introduction of FNB needles has
been aimed at enhancing the quality of tissue sampling, and they
are generally considered more effective in obtaining tissue cores,
compared with traditional FNA needles [7,29]. Tissue cores obtained
through an FNB allow for the preservation of architectural features and
facilitate the implementation of an IHC, which is a critical component in
the diagnosis of secondary pancreatic tumors. Moreover, an FNB is a
safe procedure for obtaining tissue samples even from older patients
who often have comorbidities and are undergoing anticoagulation
therapy [30]. Therefore, an FNB is the primary choice for pancreatic
tumor tissue sampling. A surgical biopsy is considered an alternative
method if an FNB is unsuccessful.
Notably, in this study, all the patients with no history of cancer
had primary pancreatic malignancies. Therefore, in daily practice,
when endoscopists encounter a pancreatic tumor during an EUS
that appears malignant (Figure 4), they should initially differentiate
between resectable and unresectable tumors. If the tumor is
deemed an unresectable malignancy, a subsequent FNB should be
performed for tissue sampling. Conversely, if the tumor is resectable,
a subsequent FNB should only be performed in patients with a
history of cancer. An FNB may not provide additional information or
influence the subsequent surgical plan in patients without a history of
cancer. Therefore, an FNB should be avoided in these patients and
surgical resection should be performed without pre-operative tissue
confirmation. This approach ensures a more efficient and tailored
diagnostic process based on individual patient profiles.
Pancreatic surgery is a possible curative management strategy not
only for primary pancreatic tumors, but also metastatic tumors.
However, the incidence of major complications is more than 40%.
These complications may arise from inherent risks associated with
pancreatectomy or preexisting comorbidities. Due to the associated
risks of morbidity and mortality in pancreatic surgery, it is advisable to
perform pancreatic resection when clinically necessary. Notably, when
dealing with a pancreatic mass, it is crucial to consider its potential as
a metastatic lesion, among other diagnostic possibilities. Hence, the
clinical background and pathological confirmation are necessary prior
to tumor resection. They can not only detect the involvement of major
vessels, such as the celiac artery, splenic artery, splenic vein, and
superior mesenteric artery, but can also provide tissue confirmation for
a definitive diagnosis [31,32].
The advantage of a surgical resection in terms of the overall survival
20

FEATURE
troenterol.
troenterol.
Insights
Insights
2024,
2024,
15,
15
FOR PEER REVIEW 9
383
has not yet been demonstrated, and the introduction of tyrosine
kinase inhibitors (TKIs) has changed the outcomes of patients with
unresectable metastatic disease. The median overall survival from
a pancreatic metastatic RCC diagnosis was more than 7 years for
both resected and unresected patients. Specifically, in patients who
underwent pancreatic surgery for pancreatic metastasis–RCCs, the
median overall survival was 103 months, with 43% still alive and 42%
of the resected patients without disease recurrence. For patients with
an unresected pancreatic metastatic RCC, the median overall survival
was 86 months, with 75% still alive at the time of analysis. However,
the difference in the overall survival between resected and unresected
patients was not significant (p = 0.201) [33]. Based on the results of
this study, the efficacy of surgery for pancreatic metastases remains
a topic of debate and surgery should not be the primary option, with
systemic treatment being the preferred choice. Therefore, an accurate
diagnosis through EUS tissue sampling is crucial.
In this study, we aimed to assist endoscopists in making decisions
during EUS examinations, including whether to perform an FNB
when a resectable pancreatic malignancy is encountered. As a result,
our focus was solely on patients who underwent EUS with an FNB,
and we did not include those who did not undergo a pre-operative
FNB. Therefore, separate and more extensive studies are needed to
evaluate resectable tumors across the entire patient population. Other
limitations of this study are its retrospective study design and relatively
small number of patients.
5. Conclusions
Imaging tests such as CT and EUS assess malignancy and tumor
resectability based on vascular involvement but cannot distinguish
between primary and metastatic tumors. EUS with an FNA/B is
crucial as it provides a definitive histological diagnosis for patients,
especially those with a prior history of cancer, helping differentiate
between metastatic and primary pancreatic tumors. This strategy not
only aids in avoiding unnecessary surgeries, but also facilitates the
prompt initiation of appropriate treatments, thereby optimizing patient
outcomes through a timely intervention.
Figure 4. The decision making process of EUS management in pancreatic tumors.
Pancreatic surgery is is a possible curative management strategy not only for primary
pancreatic tumors, but but also also metastatic metastatic Author
tumors.
Contributions: tumors. However, However, Conceptualization,
the incidence the M.-S.C. incidence and
of major
J.-H.L.; of formal
complications
is moreis than more 40%. than These 40%. complications These analysis, M.-S.C.; complications may writing—original arisemay from draft arise inherent preparation, from risks M.-S.C.; inherent associated
writing— risks
major
complications
associated with pancreatectomy with pancreatectomy or preexisting or preexisting comorbidities. review and editing, C.-C.L.
comorbidities. Due to and the J.-H.L.; associated supervision,
Due to the risks J.-H.L.
associated ofAll morbidity
authors
risks
of
and
morbidity
mortality
and
in pancreatic
mortality
surgery, have
in pancreatic
it is read advisable and agreed
surgery, to the
it is
perform published
advisable
pancreatic version of the
to perform
resection manuscript.
pancreatic
when
resection
clinically
when
necessary.
clinically
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necessary.
when dealing
Notably,
with
when
a pancreatic
dealing with
mass,
a
it
pancreatic
is crucial to
mass,
consider
it is
Funding: This research received no external funding.
crucial
its potential
to consider
as a metastatic
its potential
lesion,
as a
among
metastatic
other
lesion,
diagnostic
among
possibilities.
other diagnostic
Hence,
possibilities.
the clinical
Hence,
background
the clinical
and pathological
background
confirmation
and pathological
are necessary
confirmation
prior to
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necessary
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prior
They
Institutional Review Board Statement: Ethical review and approval to
can not only detect the involvement of major vessels, such as the celiac artery, splenic artery,
tumor resection. They can not only were detect waived the for involvement this study due to the of utilization major vessels, of anonymous such clinical as the
splenic vein, and superior mesenteric
celiac artery, splenic artery, splenic data
artery,
vein, for image
but
and presentation.
can also provide tissue confirmation for a
superior mesenteric artery, but can also
definitive diagnosis [31,32].
provide tissue confirmation for a definitive diagnosis [31,32].
The advantage of a surgical resection Informed inConsent termsStatement: of the overall Patient consent survival was has waived not due yet to been the
The advantage of surgical resection in terms of the overall survival has not yet been
demonstrated, and the introductionutilization of tyrosine of anonymous kinase clinical inhibitors data for image (TKIs) presentation. has changed the
demonstrated, and the introduction of tyrosine kinase inhibitors (TKIs) has changed the
outcomes of patients with unresectable metastatic disease. The median overall survival
outcomes of patients with unresectable metastatic disease. The median overall survival
from a pancreatic metastatic RCCData diagnosis
Availability
was
Statement:
more
No
than
new
7data years
were created.
for both resected
from a pancreatic metastatic RCC diagnosis was more than 7 years for both resected and
and unresected patients. Specifically, in patients who underwent pancreatic surgery for
unresected patients. Specifically, in Conflicts patients of Interest: who The underwent authors declare pancreatic no conflicts of surgery interest. for
pancreatic metastasis–RCCs, the median overall survival was 103 months, with 43% still
pancreatic metastasis–RCCs, the median The funders overall had no survival role in the design was 103 of the months, study; in the with collection, 43% still
alive and 42% of the resected patients
analyses,
without
or interpretation
diseaseof recurrence.
data; in the writing
For
of the
patients
manuscript;
with
or
an
alive and 42% of the resected patients without disease recurrence. For patients with an
unresected pancreatic metastatic RCC, in the the decision median to publish overall the results. survival was 86 months, with
unresected
75% still alive
pancreatic
at the time
metastatic
of analysis.
RCC, the
However,
median
the
overall
difference
survival
in
was
the
86
overall
months,
survival
with
75%
between
still
resected
alive at
and
the
unresected
time of analysis.
patients
However, the difference in the overall survival
References was not significant (p =0.201) [33]. Based on the
between
results of
resected
this study,
and
the
unresected
efficacy
patients
of surgery
was
for
not
pancreatic
significant
metastases
(p = 0.201)
remains
[33]. Based
a topic
on the
of
results debate of and this surgery study, should the efficacy not beof the 1. surgery primary Siegel, for R.L.; option, pancreatic Miller, K.D.; with Fuchs, metastases systemic H.E.; Jemal, treatment remains A. Cancer Statistics, a being topic the of
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22

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FEATURE
GASTROENTEROLOGY TODAY – SUMMER 2024
23

FEATURE
TEXTURE AND COLOR ENHANCEMENT
IMAGING IMPROVES THE VISIBILITY OF
GASTRIC NEOPLASMS: CLINICAL TRIAL
WITH IMAGE CATALOGUE ASSESSMENT
USING CONVENTIONAL AND NEWLY
DEVELOPED ENDOSCOPES
Toshiki Futakuchi 1 , Akira Dobashi 1* , Hideka Horiuchi 1 , Hiroto Furuhashi 1 , Hiroaki Matsui 1 , Yuko Hara 1 ,
Masakuni Kobayashi 1 , Shingo Ono 1 , Naoto Tamai 1 , Kazutaka Gomisawa 2 , Takashi Yamauchi 3 , Machi Suka 3
and Kazuki Sumiyama 1
Futakuchi et al. BMC Gastroenterology (2023) 23:389 https://doi.org/10.1186/s12876-023-03030-9
RESEARCH
Abstract
Background Texture and color enhancement imaging (TXI) enhances
the changes in endoscopic features caused by gastric neoplasms,
such as redness/whiteness and elevation/depression. This study
aimed to demonstrate the effectiveness of TXI in improving the visibility
of gastric neoplasms compared with white light imaging (WLI) using
conventional (CE) and newly developed endoscopes (NE).
scores of NE were superior to those of CE in all modalities. In the
secondary outcome, there was no factor affected the differences of
visibility scale scores between TXI-1/TXI-2 and WLI.
Conclusions This study demonstrated that TXI-1 and TXI-2 enhanced
the visibility scale scores of gastric neoplasms compared with that
of WLI. Moreover, newly developed endoscope has the potential to
improve visibility compared to conventional endoscope.
Trial Registration This study was registered with the University
Hospital Medical Information Network (UMIN000042429, 16/11/2020).
GASTROENTEROLOGY TODAY – SUMMER 2024
Methods We recruited patients who were histologically diagnosed with
gastric neoplasms; endoscopy was performed, and gastric neoplasms
photographed using three imaging modalities, including WLI, TXI mode
1 (TXI-1) and TXI mode 2 (TXI-2). Two different endoscopes (CE and
NE) were used for the same patients. Six endoscopists provided the
visibility scale scores ranging from 1 (poor) to 4 (excellent) for gastric
neoplasms. The primary outcome was the visibility scale scores based
on each modality and endoscope. The secondary outcome was the
identification of factors including H. pylori infection, atrophy, location,
size, morphology, histological diagnosis and intestinal metaplasia that
affect the differences in visibility scale scores between TXI-1/TXI-2
and WLI.
Results Fifty-two gastric neoplasms were analyzed. The mean visibility
scale scores with the NE were 2.79 ± 1.07, 3.23 ± 0.96 and 3.14 ± 0.92
for WLI, TXI-1 and TXI-2, respectively. The mean visibility scales with
the CE were 2.53 ± 1.10, 3.04 ± 1.05 and 2.96 ± 1.92 for WLI, TXI-1
and TXI-2, respectively. For both endoscopes, significant differences
were observed in visibility scale scores between WLI and TXI-1 (p
< 0.001) and between WLI and TXI-2 (p < 0.001). The visibility scale
*Correspondence:
Akira Dobashi
akira.dobashi1980@gmail.com
Full list of author information is available at the end of the article
Keywords Gastric neoplasms, Image enhanced endoscopy, Texture
and color enhancement imaging
Background
Gastric cancer was the fifth most common cancer and the third
most common cause of cancer-related deaths worldwide in 2020 [1].
Surgery is the mainstay of gastric cancer treatment; however, with early
detection, endoscopic treatment can be expected to provide a radical
cure through minimally invasive treatment. Endoscopic screening
for gastric cancer has allowed for a 30% reduction in gastric cancer
mortality [2–4]. Macroscopic types of early gastric cancer (EGC) show
elevation or depression, whereas the tumor color changes exhibit
redness or whiteness. However, early detection of gastric cancer can
be difficult, because changes in morphology and color are subtle,
and endoscopists may encounter difficulty in recognizing a lesion.
Moreover, EGC is highly associated with Helicobacter pylori (H. pylori)
infection, and map-like redness and mucosal changes caused by
H. pylori eradication make EGC detection difficult. Most diffuse type
24

FEATURE
gastric cancers comprise an endoscopically depressed type [5];
therefore, considering these characteristics of EGC, it is important that
slight changes in color and structure are detected during endoscopy.
Image-enhanced endoscopy (IEE), including narrow band imaging
(NBI), blue laser imaging (BLI) and linked color imaging (LCI), was
developed to improve the visibility of EGC and is currently clinically
available; LCI enhances red and white hues during endoscopy and has
been reported to improve gastric cancer detection and visibility [6–13].
As for the other IEEs, Yoshida et al. compared between secondgeneration
NBI and white light imaging (WLI) in EGC detection and
found no significant differences in the characteristics of the detected
lesions [14]. Nagashima reported that low magnifying NBI was able to
detect gastric neoplasm overlooked by WLI [15]. Dohi et al. reported
that BLI-bright had a higher real-time detection rate for EGC than
WLI [16].
Texture and color enhancement imaging (TXI) is a new IEE technology
that has been available in clinical practice since 2020. TXI can enhance
brightness, color contrast and texture changes during endoscopic
observation, and has been reported to improve the visibility and color
difference of gastric cancer compared with WLI [17–22]. Since the
previous studies on TXI were conducted on a small number of cases or
had retrospective study design, we attempted to prove the significance
of TXI by a prospective case collection with sample size calculation.
This study aimed to demonstrate that TXI—which was prospectively
corrected—improved the visibility of EGC compared with WLI
using conventional and newly developed endoscopes. Additionally,
we analyzed the effect of TXI on lesion characteristics and the
improvement in visibility for EGC.
Methods
Charge Coupled Device (CCD), while the NE uses a high-sensitivity
Complementary Metal-Oxide-Semiconductor (CMOS) which is
expected to improve image quality. The EVIS X1 system can promptly
change the image modalities (WLI, TXI, and NBI) via a button on the
scope holder.
Texture and color enhancement imaging
TXI is a newly developed IEE that enhances the texture, brightness
and color of endoscopic images obtained using WLI. First, the RGB
input image is classified into a base and a detail layer. Second, the
base layer is adjusted for brightness, followed by dynamic range
compression (tone mapping). Subsequently, texture enhancement
is applied to the detail layer to enhance subtle contrast. TXI mode 2
(TXI-2) is displayed by stacking the two layers, while the processing
designed to expand the difference between red and white hues yields
TXI mode 1 (TXI-1). TXI-1 is more tonally enhanced, while TXI-2 is more
similar to WLI [23]; TXI is thought to enhance subtle morphological
or color changes on the gastrointestinal surface caused by gastric
neoplasms.
Endoscopic procedure
All endoscopic examinations were performed under sedation with
intravenous midazolam (2–5 mg; Maruishi Pharmaceutical Co, Ltd.,
Osaka, Japan) or midazolam and pethidine hydrochloride (35 mg,
pethidine; Takeda Pharmaceutical Company, Tokyo, Japan). Prior
to treatment, an expert endoscopist performed an endoscopic
examination, and the unmagnified endoscopic images of the lesion
were stored in a middle-distant view with CE or NE using the three
modalities (WLI, TXI-1 and TXI-2). On the day of treatment, images of
the same lesion were stored in the same view as those in the other
endoscope using the three modalities (Fig. 1). In total, we obtained six
endoscopic images of each lesion using the three modalities and two
endoscopes.
Patients and study design
This was a single-center, prospective trial. We prospectively enrolled
patients who were diagnosed with gastric neoplasms (including
adenoma and adenocarcinoma) through endoscopic and histological
diagnosis, and who were referred to our hospital for treatment. Patients
were enrolled as consecutive cases in this study to eliminate selection
bias. Written informed consent was obtained from all patients.
The recruitment period was between August 2021 and July 2022.
The exclusion criteria were as follows: age < 20 years, pregnancy,
large lesions (> 8 cm) that did not fit in one endoscopic field of view,
and being evaluated as inappropriate by the attending doctor for this
study considering general condition. This study was approved by the
Institutional Review Board of the Jikei University School of Medicine
on 14 September 2020 (32–156(10,237)) and is registered with the
University Hospital Medical Information Network (UMIN000042429,
16/11/2020).
Endoscopic system and setting
We used the EVIS X1 (Olympus Corporation, Tokyo, Japan)
endoscopic system and high-definition endoscopes, which include
a conventional endoscope (CE) (GIF-H290Z; Olympus Corporation,
Tokyo, Japan) and a newly developed endoscope (NE) (GIF-XZ1200;
Olympus Corporation). Regarding the image sensor, the CE uses a
Evaluation of endoscopic images
We created an image catalogue where each gastric neoplasm had
six different images. The images were randomly arranged based
on a randomized table created using Excel software (Microsoft
Corporation, Redmond, Washington, USA). Six endoscopists provided
the visibility scales [9, 24]. All reviewers were instructed how to
apply and interpret the visibility scales by an organizer (A.D.), who
was not an image reviewer in this study. Visibility scale was scored
based on previous reports as follows: 1, poor (not detectable without
repeated careful examination); 2, fair (hardly detectable without
careful examination); 3, good (detectable with careful observation);
and 4, excellent (easily detectable) [10, 25]. The reviewers comprised
three expert endoscopists who were certified by the board of the
Japan Gastroenterological Endoscopy Society and had experience
with > 100 cases of endoscopic submucosal dissection for early
gastric cancer and three novices who had experience with < 100
esophagogastroduodenoscopies.
Outcomes
The primary outcome was the visibility scale score based on each
modality and endoscope. The secondary outcome was the effect of
lesion characteristics on the improvement of the visibility scale score
for EGC. The status of H. pylori infection was defined as follows:
positive (positive rapid urease test, anti-H. pylori antibody assay, or
GASTROENTEROLOGY TODAY – SUMMER 2024
25

FEATURE
fecal H. pylori antigen assay, before eradication), eradicated (negative
urease breath test or anti‐H. pylori antibody assay, post eradication),
and negative (negative rapid urease test, anti‐H. pylori antibody assay,
or fecal H. pylori antigen assay, without eradication) [26]. Atrophy
was graded as open type, closed type, or negative according to the
Kimura–Takemoto Classification [27]. The location of the neoplasm was
defined as U (upper third), M (middle third) and L (lower third) according
to the Japanese Classification of Gastric Carcinoma [28]. Morphology
was classified according to the Paris classification [29], and histological
diagnosis was based on Lauren’s classification [30]. A pathologist who
did not know the result of visibility scale scores evaluated the degree
Futakuchi et al. BMC Gastroenterology (2023) 23:389
of intestinal metaplasia classified as complete, incomplete, or negative
according to the previous report [31].
Sample size calculation
The mean visibility scale scores for EGC were reported to be 2.54 ±
1.10 (mean ± standard deviation) and 3.28 ± 0.97 for WLI and LCI,
respectively [9]. TXI was expected to improve the visibility of gastric
neoplasms to the same extent as that of LCI; therefore, we calculated
the sample size with an α value of 0.05 and a power of 0.90 using
a two-sided test. The required number of lesions was 42. Finally,
considering dropout or exclusion, we set the number of cases to 50.
Statistical analysis
All statistical analyses were performed using STATA (version 14.0;
Stata Corp., College Station, Texas, United States). Quantitative
parameters were compared using Student’s t test or the Mann- Page 4 of 9
Whitney U test. The normal distribution was analyzed using Shapiro-
Wilk test. For the secondary outcome, a two-way ANOVA was
GASTROENTEROLOGY TODAY – SUMMER 2024
Fig. 1 Example of early gastric cancer detected during this study. A depressed-type early gastric cancer in the lesser curvature lower body is detected
using the newly developed endoscope (GIF-XZ1200, Olympus). The diagnosis of lesion margins followed the pathology finding. a. Arrows indicate lesion
margins of gastric cancer in monochrome image. b. The lesion is difficult to detect in white light imaging. c. Texture and color enhancement imaging (TXI)
mode 1 enhances the color and texture, and the whole image turns pinkish compared to WLI in this image. The visibility of gastric cancer is improved. d.
TXI mode 2 enhances the texture, and the color tone is similar to that of WLI. The depression in the gastric cancer is enhanced
26
Bonferroni adjustment was used when testing for repetition
in ANOVA.
were male. H. pylori infection was positive, eradicated
and negative in 16, 24 and 12 lesions, respectively. Atrophy
was open type, closed type and negative in 42, 7 and 3

Futakuchi et et al. al. BMC Gastroenterology (2023) (2023) 23:389 23:389
Page 5 Page of 9 5 of 9
FEATURE
Fig. 2 Flow chart of this study participants
Fig. 2 Flow chart of this study participants
Table 1 Demographics of the patients and characteristics of the modalities (WLI, p = 0.002; TXI-1, p = 0.025; and TXI-2,
lesions
Table 1 Demographics of the patients and characteristics of the p = modalities excluded 0.004). after (WLI, the first p endoscopic = 0.002; TXI-1, examination p = 0.025; because and the gastric TXI-2,
Patients
lesions
Among
p cancer = 0.004). was experts, diagnosed visibility as advanced scale scores cancer. were Finally, 3.04 49 patients ± 1.00, met
(n = 49)
Patients
3.34 the ± 0.90 and 3.27 ± 0.90 with the NE, and 2.89 ± 1.02,
Sex Male/Female 37/12
Among inclusion experts, criteria, and visibility we obtained scale 312 scores endoscopic were images 3.04 ± (6 1.00,
(n = 49)
3.15 ± 1.00 and 3.04 ± 1.02 with the CE for WLI, TXI-1
Age, years
70.8 (33–86) 3.34 images ± 0.90 per lesion) and from 3.2752 ± 0.90 lesions with (Fig. the 2). NE, and 2.89 ± 1.02,
Sex Male/Female 37/12 and TXI-2, respectively. Significant differences were
(range)
3.15 ± 1.00 and 3.04 ± 1.02 with the CE for WLI, TXI-1
observed in the visibility scale scores between WLI and
Lesions
Age, years
(n = 52)
70.8 (33–86)
and Demographics TXI-2, of respectively. the patients and Significant characteristics differences of the lesions were are
(range)
TXI-1 (p = 0.008 for NE, 0.020 for CE); however, not
H. Pylori Positive/Eradicated/Negative 16/24/12 observed summarized in the Table visibility 1. The median scale age scores of the patients between was WLI 72.5 and
infection Lesions (n = 52)
between WLI and TXI-2 (p = 0.056 for NE, 0.175 for CE).
Among
TXI-1
(range: 33–86)
novices,
(p = 0.008
years,
visibility
for
and 75.5%
NE,
scale
0.020
(37/49) were
scores
for
male.
were
CE);
H.
2.54
however,
pylori infection
± 1.07,
not
Atrophy H. Pylori Open Positive/Eradicated/Negative type/Closed type/Negative 42/7/3 16/24/12
was positive, eradicated and negative in 16, 24 and 12 lesions,
Location
infection
3.12
between
± 1.01 and
WLI
3.01
and
± 0.92
TXI-2
with
(p =
the
0.056
NE,
for
and
NE,
2.16
0.175
± 1.06,
for CE).
U/L/M 6/15/31
respectively. Atrophy was open type, closed type and negative in 42,
Size(mm) Atrophy ≥ Open 10, < 10 type/Closed type/Negative 32/20 42/7/3 2.92 ± Among 1.09 and novices, 2.71 ± 1.11 visibility with scale the CE scores for WLI, were TXI-1 2.54 ± 1.07,
7 and 3 lesions, respectively; however, all lesions without atrophy
Morphology Location 0-I/0-IIa/0-IIb/0-IIc/0-III U/L/M 3/13/0/36/0 6/15/31 and 3.12 TXI-2, ± 1.01 respectively. and 3.01 ± For 0.92 both with types the NE, of endoscopes, and 2.16 ± 1.06,
were negative for H. pylori infection. Regarding location, 6, 15 and
Histological Size(mm) Diffuse ≥ 10, < type/Intestinal 10 type/Adenoma 7/43/2 32/20 significant 2.92 ± 1.09 differences and 2.71 were ± 1.11 observed with the in CE visibility for WLI, scale TXI-1
31 lesions were in U, M and L, respectively. The median (range) size
diagnosis Morphology 0-I/0-IIa/0-IIb/0-IIc/0-III 3/13/0/36/0 scores and between TXI-2, respectively. WLI and TXI-1 For (p both < 0.001 types for both of endoscopes, endoscopes),
significant and between differences WLI were and TXI-2 observed (p < 0.001 in visibility for both scale
of the lesions was 12.5 (1–75) mm, including 32 lesions ≥ 10 mm and
Intestinal Histological Complete/Incomplete/Negative Diffuse type/Intestinal type/Adenoma 20/28/4 7/43/2
20 lesions < 10 mm. The morphology was 0-I, 0-IIa and 0-IIc in 3,
metaplasia diagnosis
endoscopes). scores between WLI and TXI-1 (p < 0.001 for both endoscopes),
the secondary and between outcome, WLI no and factors TXI-2 were (p < 0.001 found for to both
U, upper third; M, middle third; L, lower third; H. pylori, Helicobacter pylori
13 and 36 lesions, respectively. Histological diagnoses were diffuse
Intestinal Complete/Incomplete/Negative 20/28/4 In
type, intestinal type and adenoma in 7, 43 and 2 lesions, respectively.
metaplasia
significantly endoscopes). affect the improvement in visibility of gastric
U, upper third; M, middle third; L, lower third; H. pylori, Helicobacter pylori
Intestinal metaplasia were complete, incomplete and negative in 20, 28
The mean visibility scale scores based on the endoscopes
and modalities are shown in Fig. 3. The mean visi-
and significantly WLI (Table affect 2). the improvement in visibility of gastric
neoplasms In the between secondary TXI-1 outcome, and WLI, no and factors between were TXI-2 found to
and 4 lesions, respectively.
performed bility The scale mean because scores visibility the with visibility the scale NE scale were scores 2.79 was based ± 1.07, evaluated on 3.23 the repeatedly ± 0.96 endoscopes
the 3.14 same and ± 0.92 reviewer. modalities for We WLI, used are TXI-1 the shown visibility and in TXI-2, scale Fig. 3. score The respectively. differences mean visi-
Discussion and
neoplasms between TXI-1 and WLI, and between TXI-2
The mean visibility scale scores based on the endoscopes and
by and
modalities
WLI
are
(Table
shown
2).
in Fig. 3. The mean visibility scale scores with the
between Visibility scale TXI-1 scale scores and WLI scores with of NE, the with between NE the were TXI-2 CE 2.79 and were ± WLI 1.07, 2.53 of 3.23 NE, ± 1.10, and ± 0.96 This study showed that TXI improved the visibility scale
NE were 2.79 ± 1.07, 3.23 ± 0.96 and 3.14 ± 0.92 for WLI, TXI-1 and
the 3.04 and following ± 3.14 1.05 ± lesion 0.92 and 2.96 for characteristics WLI, ± 1.92 TXI-1 for for WLI, ANOVA: and TXI-1 TXI-2, status and of respectively.
H. TXI-2, pylori scores Discussion of gastric neoplasms compared with WLI using
TXI-2, respectively. Visibility scale scores with the CE were 2.53 ± 1.10,
infection, respectively. Visibility atrophy, scale For location, both scores types size, with of morphology, endoscopes, the CE histological were significant 2.53 diagnosis ± differences
1.10, an This image catalogue comprising 52 consecutive gastric
3.04 ± study 1.05 and showed 2.96 ± that 1.92 for TXI WLI, improved TXI-1 and TXI-2, the visibility respectively. scale
and 3.04 intestinal ± 1.05
were metaplasia. and
observed
2.96 ± We 1.92
in set visibility the for scale WLI,
scale score TXI-1
scores differences and
between as TXI-2, the neoplasms
scores
in clinical practice. Moreover, visibility scale
For both of types gastric of endoscopes, neoplasms significant compared differences with were WLI observed using
dependent WLI
respectively.
and TXI-1 variables, For
(p
both and < 0.001 reviewers types
for
of
both and endoscopes,
endoscopes), each lesion significant characteristics and WLI
differences
were observed in visibility scale scores between neoplasms endoscopes), in and clinical WLI and practice. TXI-2 (p < 0.001 Moreover, for both visibility endoscopes). scale
scores
an
with the NE were significantly better than those
in visibility image scale catalogue scores between comprising WLI and 52 TXI-1 consecutive (p < 0.001 for gastric both
as and independent TXI-2 (p variables. < 0.001 for The both size was endoscopes). analyzed in two When groups, comparing
the lesions endoscopes, ≥ 10 mm or visibility < 10 mm. scale The significance scores with level the was NE set neoplasms, and selection bias was eliminated as much
with CE. This study included > 50 consecutive gastric
including WLI and TXI-1 (p < 0.001 for both endoscopes), and WLI scores When comparing with the the NE endoscopes, were significantly visibility scale better scores than with the those NE
at were p < 0.05, significantly and Bonferroni higher adjustment than those was with used when the CE testing for for all as possible. Visibility scale scores of TXI-1 were better
and TXI-2 (p < 0.001 for both endoscopes). When com-
with were significantly CE. This higher study than included those with > the 50 CE consecutive for all modalities gastric (WLI,
repetition in ANOVA.
than those of TXI-2; however, there was no significant
p = 0.002; TXI-1, p = 0.025; and TXI-2, p = 0.004).
paring the endoscopes, visibility scale scores with the NE
were significantly higher than those with the CE for all
Results
Endoscopic examinations were performed in 50 patients; 1 was
neoplasms, and selection bias was eliminated as much
as possible. Visibility scale scores of TXI-1 were better
than Among those experts, of visibility TXI-2; scale however, scores were there 3.04 was ± 1.00, no 3.34 significant ± 0.90
and 3.27 ± 0.90 with the NE, and 2.89 ± 1.02, 3.15 ± 1.00 and 3.04
± 1.02 with the CE for WLI, TXI-1 and TXI-2, respectively. Significant
GASTROENTEROLOGY TODAY – SUMMER 2024
27

Futakuchi et al. BMC Gastroenterology (2023) 23:389
FEATURE
Page 6 of 9
Fig. 3 Mean visibility scale scores for the GIF-XZ1200 and GIF-H290Z endoscopes. * p < 0.05. WLI, white light imaging; TXI, texture and color enhancement
imaging ; NS, not significant
GASTROENTEROLOGY TODAY – SUMMER 2024
difference. The encouraging outcomes from this benchmark
test were suggest observed that in TXI the visibility may enhance scale scores lesion between visibility, WLI
differences
and regardless TXI-1 (p = of 0.008 the for prevailing NE, 0.020 for conditions. CE); however, A not randomized
between WLI
and controlled TXI-2 (p = trial 0.056 is for warranted NE, 0.175 for to CE). evaluate whether TXI can
enhance the detection or delineation of EGC.
Among Recently, novices, LCI visibility was scale developed scores were as a 2.54 new ± 1.07, IEE 3.12 to assist ± 1.01 in
and detecting 3.01 ± 0.92 gastrointestinal with the NE, and neoplasms. 2.16 ± 1.06, 2.92 LCI ± 1.09 enhances and 2.71 the ±
1.11 color with change the CE for in WLI, endoscopic TXI-1 and images TXI-2, respectively. obtained For using both WLI. types
of
Some
endoscopes,
reports
significant
have shown
differences
that
were
LCI
observed
enhances
in visibility
the
scale
visibility
of gastric neoplasms, and three randomized con-
scores between WLI and TXI-1 (p < 0.001 for both endoscopes), and
between WLI and TXI-2 (p < 0.001 for both endoscopes).
trolled trials revealed that LCI improved the detection
rate of upper gastrointestinal neoplasms [11, 13, 32]. As
In the secondary outcome, no factors were found to significantly affect
expected, it was demonstrated that focusing on color
the improvement in visibility of gastric neoplasms between TXI-1 and
change was effective for detecting upper gastrointestinal
WLI, and between TXI-2 and WLI (Table 2).
neoplasms during endoscopy. Although LCI enhances
the brightness and visibility of red and white hues, TXI-1
Discussion
and TXI-2 can enhance the morphological changes in the
gastrointestinal mucosa. Considering that the mean visibility
scale scores in TXI-2 were significantly higher than
This study showed that TXI improved the visibility scale scores of
gastric neoplasms compared with WLI using an image catalogue
those in WLI, endoscopists should monitor the change in
comprising 52 consecutive gastric neoplasms in clinical practice.
elevation/depression to detect EGC.
Moreover, visibility scale scores with the NE were significantly
TXI-1 had the highest visibility scale scores compared
better than those with CE. This study included > 50 consecutive
to those of TXI-2 and WLI. These results may be owing
gastric neoplasms, and selection bias was eliminated as much as
to several reasons. First, completely flat type (0-IIb) EGC
possible. Visibility scale scores of TXI-1 were better than those of
is rare [29, 33], and no lesions were classified as 0-IIb
TXI-2; however, there was no significant difference. The encouraging
outcomes
in this study.
from this
Second,
benchmark
some
test
EGCs
suggest
do
that
not
TXI may
exhibit
enhance
color
lesion changes, visibility, and regardless it may of be the difficult prevailing conditions. to identify A randomized the lesion
controlled despite color trial is warranted enhancement to evaluate in whether the endoscopic TXI can enhance image. the
detection Therefore, delineation it would of be EGC. reasonable to improve the visibility
of EGC by enhancing both the texture and color, as
Recently, LCI was developed as a new IEE to assist in detecting
gastrointestinal neoplasms. LCI enhances the color change in
in TXI-1. However, it remains unknown whether color or
morphological endoscopic images changes obtained using are more WLI. Some effective reports in have improving shown
the that LCI visibility enhances of the EGC. visibility of gastric neoplasms, and three
randomized An analysis controlled of color trials revealed changes that between LCI improved the the inside detection and
outside rate of upper of a gastrointestinal lesion with neoplasms L* a* b* values [11, 13, was 32]. As used expected, to objectively
demonstrated evaluate that visibility focusing on [34]. color change Using was L* a* effective b* values, for detecting Abe
it was
et upper al. gastrointestinal [17] reported neoplasms a significant during color endoscopy. difference Although between LCI
the enhances inside the and brightness outside and of visibility lesions of red for and WLI white and hues, TXI TXI-1 (both and
TXI-1 TXI-2 can and enhance − 2), the whereas morphological Ishikawa changes et in al. the gastrointestinal
[18] reported
a
mucosa.
significant
Considering
color
that
difference
the mean visibility
between
scale
WLI
scores
and
in TXI-2
TXI-1.
were
Moreover,
significantly higher
Koyama
than those
et al.
in
[19]
WLI,
also
endoscopists
reported
should
that
monitor
color difference
between EGCs and non-neoplastic mucosa was
the
change in elevation/depression to detect EGC.
significantly higher in TXI than in WLI in all patients.
TXI-1 had the highest visibility scale scores compared to those of
We did not analyze the color difference using L* a* b*
TXI-2 and WLI. These results may be owing to several reasons. First,
values since a similar result was likely to be obtained
completely flat type (0-IIb) EGC is rare [29, 33], and no lesions were
in our study. As reported in our previous clinical study
classified as 0-IIb in this study. Second, some EGCs do not exhibit
using esophageal neoplasms, the L* a* b* values and visibility
scale scores may not completely correspond to one
color changes, and it may be difficult to identify the lesion despite
color enhancement in the endoscopic image. Therefore, it would be
another [35]. In addition to color differences, other information—such
as morphological changes and mucosal or
reasonable to improve the visibility of EGC by enhancing both the
texture and color, as in TXI-1. However, it remains unknown whether
microvascular patterns—may affect the visibility of EGC.
color or morphological changes are more effective in improving the
We analyzed characteristics whereby TXI significantly
visibility of EGC.
improved visibility scale scores of EGC by considering
the impact among endoscopists who evaluated the
An analysis of color changes between the inside and outside of a
endoscopic
lesion with L* a*
images;
b* values
however,
was used to
we
objectively
could
evaluate
not extract
visibility
the
characteristics.
[34]. Using L* a* b* values,
The results
Abe et
showed
al. [17] reported
a tendency
a significant
for TXI
color
to
always difference be between superior the to inside WLI, and regardless outside of lesions of the for lesion WLI and characteristics
(both TXI-1 and or − endoscopist’s 2), whereas Ishikawa experience. et al. [18] reported Particularly, a significant TXI
TXI
can color enhance difference between the visibility WLI and of TXI-1. EGC Moreover, regardless Koyama of et lesion al. [19]
color, morphological type, location, the status of H. pylori
also reported that color difference between EGCs and non-neoplastic
mucosa was significantly higher in TXI than in WLI in all patients.
We did not analyze the color difference using L* a* b* values since a
28

FEATURE
similar result was likely to be obtained in our study. As reported in our
previous clinical study using esophageal neoplasms, the L* a* b* values
and visibility scale scores may not completely correspond to one
another [35]. In addition to color differences, other information—such
as morphological changes and mucosal or microvascular patterns—
may affect the visibility of EGC.
We analyzed characteristics whereby TXI significantly improved
visibility scale scores of EGC by considering the impact among
endoscopists who evaluated the endoscopic images; however,
we could not extract the characteristics. The results showed a
tendency for TXI to always be superior to WLI, regardless of the lesion
characteristics or endoscopist’s experience. Particularly, TXI can
enhance the visibility of EGC regardless of lesion color, morphological
type, location, the status of H. pylori infection, atrophic gastritis,
and histology and intestinal metaplasia. This result was similar to
that previously reported in studies examining the visibility of gastric
neoplasms using LCI [9, 10].
Futakuchi et al. BMC Gastroenterology (2023) 23:389
In this study, TXI resulted in better gastric neoplasms visibility scale
scores than WLI; however, it remains unclear whether TXI actually
improved EGC detection. The effectiveness of NBI in the detection of
EGC is still controversial. The usefulness of LCI in detecting neoplasm
in the upper gastrointestinal tract has been reported in a randomized
controlled trials, and further studies should be conducted to determine
which IEE is most effective. The improved resolution may also
contribute to the detection rates, because this study demonstrates that
the visibility scale scores of NE was significantly better than that of CE.
Although 0-IIb lesions with minimal color changes are rare, TXI has
limited visibility enhancement for these lesions. Thus, other modalities,
such as magnifying endoscopy and NBI, may be superior for detecting
0-IIb lesions [36].
This study had some limitations. First, the modalities were not
completely blinded while scoring the visibility scale. Therefore, it is
undeniable that reviewers may have rated TXI higher than WLI. Second,
endoscopic examinations were conducted by expert endoscopists at a
single center. Since it is necessary to maintain highquality examinations
Page 7 of 9
and obtain appropriate endoscopic images, we included endoscopists
with experience in the protocol. Third, the images captured with each
Table 2 Visibility scale difference between WLI and TXI-mode 1 and between WLI and TXI-mode 2 and results of two-way ANOVA in
endoscopists and the six endoscopic features of gastric neoplasms
Scale score p value Scale score p value
difference
(TXI mode1-WLI),
mean ± SD
TXI
mode1
difference
(TXI mode2-WLI),
mean ± SD
TXI
mode2
H. pylori infection 0.618 0.382
Positive 0.34 ± 0.79 0.28 ± 0.79
Eradicated 0.53 ± 0.94 0.44 ± 0.83
Negative 0.38 ± 0.81 0.24 ± 0.72
Atrophy 0.07 0.175
Positive 0.45 ± 0.87 0.36 ± 0.81
Open type 0.44 ± 0.86 0.34 ± 0.81
Closed type 0.50 ± 0.93 0.48 ± 0.79
Negative 0.22 ± 0.79 0.06 ± 0.40
Location 0.915 0.337
U 0.17 ± 0.69 0.08 ± 0.89
M 0.38 ± 1.00 0.35 ± 0.78
L 0.51 ± 0.81 0.39 0.78
Size 0.372 0.14
10 mm 0.40 ± 0.85 0.26 ± 0.76
Morphology 0.924 0.954
0-I 0.28 ± 0.45 0.1 ± 0.31
0-IIa 0.55 ± 0.94 0.40 ± 0.82
0-IIc 0.41 ± 0.86 0.34 ± 0.81
Pathology diagnosis 0.762 0.931
Diffuse type 0.21 ± 0.71 0.17 ± 0.48
Intestinal type 0.47 ± 0.89 0.38 ± 0.85
Adenoma 0.58 ± 0.64 0.25 ± 0.43
Intestinal metaplasia 0.682 0.966
Complete 0.30 ± 0.89 0.43 ± 0.82
Incomplete 0.51 ± 0.88 0.34 ± 0.83
Negative 0.56 ± 0.81 0.29 ± 0.82
The visibility scale scores of newly developed endoscope are used for the analysis. Significance is calculated as < 0.0083 according to Bonferroni adjustment. There
is no factor which affected the improvement of visibility of gastric neoplasms in TXI-1 and TXI-2.
U, upper third; M, middle third; L, lower third.
GASTROENTEROLOGY TODAY – SUMMER 2024
infection, atrophic gastritis, and histology and intestinal
metaplasia. This result was similar to that previously
reported in studies examining the visibility of gastric
modalities, such as magnifying endoscopy and NBI, may
be superior for detecting 0-IIb lesions [36].
This study had some limitations. First, the modalities
29

FEATURE
GASTROENTEROLOGY TODAY – SUMMER 2024
endoscope and modality differed; six images were acquired per lesion
at different times, and the conditions varied slightly depending on gastric
peristalsis, air insufflation and endoscope stability.
Conclusions
TXI improved the visibility scale scores of gastric neoplasms compared
with those of WLI. Moreover, NE has the potential to improve visibility
compared to CE.
Abbreviations
ANOVA Analysis of variance
CE Conventional endoscope
EGC Early gastric cancer
IEE Image-enhanced endoscopy
LCI Linked color imaging
NBI Narrow-band imaging
NE Newly developed endoscope
TXI Texture and color enhancement imaging
WLI White light imaging
Acknowledgements
Not applicable.
Authors’ contributions
TF and AD designed and wrote this study; HH, HF, HM, YH, MK,
SO, and NT performed image collection and image evaluation; KG
was pathologically evaluated for intestinal metaplasia; TY and MS
contributed to statistical analysis; KS was the supervisor and all
authors read and approved the final manuscript.
Funding
There was no funding for this study.
Data availability
The datasets used and/or analyzed during the current study are
available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the ethical principles
and guidelines of the Declaration of Helsinki and was approved by the
Institutional Review Board of the Jikei University School of Medicine
on 14 September 2020 (32–156(10237)). All participants provided
written informed consent prior to enrollment in this study. This study
is registered with the University Hospital Medical Information Network
(UMIN000042429, 16/11/2020).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Endoscopy, The Jikei University School of Medicine,
3-25-8, Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
2
Department of Pathology, The Jikei University School of Medicine,
Tokyo, Japan
3
Department of Public Health and Environmental Medicine, The Jikei
University School of Medicine, Tokyo, Japan
Received: 4 May 2023 / Accepted: 5 November 2023
Published online: 13 November 2023
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