Clin Endosc.  2019 Mar;52(2):107-113. 10.5946/ce.2018.189.

Advanced Treatment and Imaging in Colonoscopy: The Pocket-Creation Method for Complete Resection and Linked Color Imaging for Better Detection of Early Neoplastic Lesions by Colonoscopy

• Yamamoto H
• Shinozaki
• Hayashi Y
• Miura Y
• Khurelbaatar T
• Osawa H
• Lefor AK

• KMID: 2447666
• DOI: http://doi.org/10.5946/ce.2018.189

Abstract

Early detection and resection of neoplastic lesions are key objectives to diminish colorectal cancer mortality. Resection of superficial colorectal neoplasms, cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection have all been developed and used worldwide. The pocket-creation method facilitates the resection of tumors in difficult and routine locations. Early detection is the most important first step to maximize the benefits of recent advancements in endoscopic techniques. However, the detection of small, flat-shaped, or faded color lesions remains difficult. Linked color imaging, a novel multi-light technology, facilitates the recognition of minor differences in tissue by enhancing the color contrast between early colorectal neoplasms and surrounding normal mucosa in a bright field of view. The most striking feature of linked color imaging is its ability to display the color of early neoplastic lesions as distinct from inflammatory changes, both of which have similar "redness" when viewed using white light imaging. To increase the detection rate of neoplasms, linked color imaging should be used from the outset for endoscopic observation. Early detection of superficial colorectal tumors can result in decreased mortality from colorectal cancer and maintain a good quality of life for patients.

Keyword

Endoscopy; Endoscopic submucosal dissection; Early detection; Cancer; Colorectal neoplasms

MeSH Terms

Colonoscopy*
Colorectal Neoplasms
Endoscopy
Humans
Methods*
Mortality
Mucous Membrane
Quality of Life
SNARE Proteins
Strikes, Employee
SNARE Proteins

Figure

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  Fig. 1. Sequence for the pocket-creation method of endoscopic submucosal dissection.

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  Fig. 2. Advantages of the pocket-creation method (PCM). Minimal mucosal incision prevents dispersion of injected solution resulting in long-lasting maintenance of mucosal elevation. In the pocket, both traction and countertraction are obtained, and the tip of the endoscope is stabilized. Even in difficult locations, PCM enables stable submucosal dissection. A stabilized endoscope in the pocket synchronizes cardiac and respiratory movement.

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  Fig. 3. (A) Pre-processing illumination technology of linked-color imaging (LCI): 410-nm violet light can penetrate only a short distance from the mucosal surface and is easily absorbed by hemoglobin. Typically, the dilated microvasculature is concentrated in the superficial mucosa in neoplastic lesions and in the deep mucosa in inflammatory lesions. Therefore, the 410-nm violet light is absorbed by neoplastic lesions but is reflected by inflammatory lesions. (B) The post-processing technology of LCI: color contrast is enhanced to make the red and white lesions become redder and whiter, respectively. WLI, white light imaging.

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  Fig. 4. small sessile sigmoid colon polyp. (A) Easily detected by linked-color imaging. (B) Difficult detection by white-light imaging. (C) Blue laser imaging scan with magnification shows meshed capillaries compatible with a benign neoplastic lesion (JNET type 2A). (D) Cold-snare polypectomy.

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  Fig. 5. A small sessile sigmoid colon polyp. (A) Easy detection by linked-color imaging. (B) Difficult detection by white-light imaging. (C) Blue laser imaging scan with magnification shows meshed capillaries (JNET type 2A). (D) Cold-snare polypectomy.

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  Fig. 6. A small sessile rectal polyp. (A) Easy detection by linked-color imaging. (B) Difficult detection by white-light imaging. (C) Blue laser imaging scan with magnification shows meshed capillaries (JNET type 2A). (D) Cold-snare polypectomy.

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  Fig. 7. Early colon cancer in the transverse colon. (A) Detectable using linked-color imaging. (B) Difficult detection by white light imaging. (C, D) Blue laser imaging scan with magnification shows irregular capillaries and an irregular surface pattern (JNET type 2B) that suggests superficial carcinoma.

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  Fig. 8. Endoscopic submucosal dissection of a laterally spreading tumor of non-granular pseudo-depressed type (the lesion in Fig. 7), using the pocket-creation method. (A) Mucosal elevation using sodium hyaluronate. (B) Submucosal dissection in the pocket. (C) Blue laser imaging scan of the resected specimen shows irregular capillaries (JNET type 2B). (D) Chromoendoscopy image with indigocarmine dye spray of the resected specimen shows en bloc resection. Pathology: Well-differentiated tubular adenocarcinoma, 25×21 mm in size, and intramucosal cancer with no lymphatic and venous invasions, and negative resection margins. A complete en bloc resection.

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