Clinical Endoscopy

Review

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for pancreatic cystic lesions: current status and future prospects: Clement Chun Ho Wu, Samuel Jun Ming Lim, Damien Meng Yew Tan; Clin Endosc 2024;57(4):434-445. Published online July 8, 2024; DOI: https://doi.org/10.5946/ce.2023.157

Pancreatic cystic lesions (PCLs) have increased in prevalence due to the increased usage and advancements in cross-sectional abdominal imaging. Current diagnostic techniques cannot distinguish between PCLs requiring surgery, close surveillance, or expectant management. This has increased the morbidity and healthcare costs from inappropriately aggressive and conservative management strategies. Endoscopic ultrasound (EUS) needle-based confocal laser endomicroscopy (nCLE) allows for microscopic examination and delineation of the surface epithelium of PCLs. Landmark studies have identified characteristics distinguishing various types of PCLs, confirmed the high diagnostic yield of EUS-nCLE (especially for PCLs with an equivocal diagnosis), and shown that EUS-nCLE helps to change management and reduce healthcare costs. Refining procedure technique and reducing procedure length have improved the safety of EUS-nCLE. The utilization of artificial intelligence and its combination with other EUS-based advanced diagnostic techniques would further improve the results of EUS-based PCL diagnosis. A structured training program and device improvements to allow more complete mapping of the pancreas cyst epithelium will be crucial for the widespread adoption of this promising technology.

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Endoscopic ultrasound through-the-needle biopsy of pancreatic cystic neoplasms: Update on indications, safety profile, and research directions
Joana Mota, Tiago Ribeiro, Maria Cristina Conti Bellocchi, Nicolò De Pretis, Luca Frulloni, Joanne Lopes, Sokol Sina, Jahnvi Dhar, Jayanta Samanta, Guilherme Macedo, Filipe Vilas-Boas, Stefano Francesco Crinò
Best Practice & Research Clinical Gastroenterology.2026; 81: 102058. CrossRef
Recent Advances in Endoscopic Ultrasound for Pancreatic Cystic Lesions
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Journal of Digestive Endoscopy.2026; 17(02): 081. CrossRef
Cystic neoplasms of pancreas
Krithi Krishna Koduri, Jahangeer Basha, Sundeep Lakhtakia
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Recurrent acute pancreatitis due to a subtle branch-duct type intraductal papillary mucinous neoplasm: A case report
Xiao Han, Xing-Ya Guo, Yin-Shi Huang, Ge Yu, Jie Lu, Rong Wan, Li-Juan Yang, Cong-Ying Chen
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Claudio Ricci, Marianna Signoretti, Elisabetta Goni, Stefano Crippa
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Endoscopic techniques for the diagnosis of pancreatic cystic lesions
Sahib Singh, Saurabh Chandan, Rakesh Vinayek, Jahnvi Dhar, Jayanta Samanta, Gabriele Capurso, Ivo Boskoski, Cristiano Spada, Jorge D Machicado, Stefano Francesco Crinò, Antonio Facciorusso
World Journal of Gastroenterology.2025;[Epub] CrossRef
Pathognomonic Signs in Pancreatic Cystic Lesions: What Gastroenterologists and Involved Clinicians Need to Know
Alberto Martino, Luca Barresi, Francesco Paolo Zito, Michele Amata, Roberto Fiorentino, Severo Campione, Alessandro Iacobelli, Enrico Crolla, Roberto Di Mitri, Carlo Molino, Marco Di Serafino, Giovanni Lombardi
Gastroenterology Insights.2024; 15(3): 810. CrossRef

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Original Article

The role of needle-based confocal laser endomicroscopy in the diagnosis of pancreatic neuroendocrine tumors: Masanori Yamada, Kazuo Hara, Nobumasa Mizuno, Shin Haba, Takamichi Kuwahara, Nozomi Okuno, Yasuhiro Kuraishi, Takafumi Yanaidani, Sho Ishikawa, Tsukasa Yasuda, Toshitaka Fukui; Clin Endosc 2024;57(3):393-401. Published online September 12, 2023; DOI: https://doi.org/10.5946/ce.2023.068

Graphical Abstract Abstract PDF

Background
/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a highly accurate method for diagnosing pancreatic neuroendocrine tumors (PNETs); however, some PNETs are difficult to diagnose. Recently, the efficacy of needle-based confocal laser endomicroscopy (nCLE) in diagnosing solid pancreatic masses has been reported. However, the efficacy of nCLE in the diagnosis of PNETs remains unknown and only a small number of cases have been reported. Hence, this study aimed to evaluate the efficacy of nCLE in the diagnosis of PNETs.
Methods
This single-center retrospective study evaluated 30 consecutive patients with suspected PNETs on contrast-enhanced computed tomography, who consented to nCLE combined with EUS-FNA and were diagnosed using EUS-FNA or surgical resection. The diagnostic criteria for PNETs using nCLE were based on the nesting and trabecular and glandular arrangement of tumor cell clusters surrounded by capillary vessels and fibrosis, as reported in previous studies.
Results
The diagnosis using nCLE was classified into three categories: misdiagnosis in three cases (10%), non-diagnostic in six cases (20%), and diagnostic in 21 cases (70%). nCLE was able to diagnose PNET in one of the two cases with inconclusive EUS-FNA.
Conclusions
Although further development of the resolution and optimization of the diagnostic criteria are required, nCLE may constitute a useful diagnostic option in cases of inconclusive EUS-FNA for PNETs.

Citations

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Recent Advances in Endoscopic Ultrasound for Pancreatic Cystic Lesions
Veeral M. Oza, Anuroop Yekula, Truptesh H. Kothari
Journal of Digestive Endoscopy.2026; 17(02): 081. CrossRef
Endoscopic Ultrasound for the Management of Pancreatic Neuroendocrine Tumors: Diagnosis, Treatment, and Future Perspectives
Angelo Bruni, David Meacci, Roberto Falbo, Marco Fichera, Francesco Poggioli, Riccardo Casadei, Claudio Ricci, Leonardo Henry Eusebi
Journal of Gastroenterology and Hepatology.2026; 41(4): 1173. CrossRef
Recent developments in the diagnosis of pancreatic neuroendocrine neoplasms
Anna Battistella, Matteo Tacelli, Paola Mapelli, Marco Schiavo Lena, Valentina Andreasi, Luana Genova, Francesca Muffatti, Francesco De Cobelli, Stefano Partelli, Massimo Falconi
Expert Review of Gastroenterology & Hepatology.2024; 18(4-5): 155. CrossRef
Advancements and challenges in gastrointestinal imaging
Eun Jeong Gong, Chang Seok Bang
World Journal of Clinical Cases.2024; 12(33): 6591. CrossRef

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Systematic Review and Meta-Analysis

Confocal Laser Endomicroscopy in the Diagnosis of Biliary and Pancreatic Disorders: A Systematic Analysis: Do Han Kim, Somashekar G. Krishna, Emmanuel Coronel, Paul T. Kröner, Herbert C. Wolfsen, Michael B. Wallace, Juan E. Corral; Clin Endosc 2022;55(2):197-207. Published online November 29, 2021; DOI: https://doi.org/10.5946/ce.2021.079

Abstract PDF

Background
/Aims: Endoscopic visualization of the microscopic anatomy can facilitate the real-time diagnosis of pancreatobiliary disorders and provide guidance for treatment. This study aimed to review the technique, image classification, and diagnostic performance of confocal laser endomicroscopy (CLE).
Methods
We conducted a systematic review of CLE in pancreatic and biliary ducts of humans, and have provided a narrative of the technique, image classification, diagnostic performance, ongoing research, and limitations.
Results
Probe-based CLE differentiates malignant from benign biliary strictures (sensitivity, ≥89%; specificity, ≥61%). Needlebased CLE differentiates mucinous from non-mucinous pancreatic cysts (sensitivity, 59%; specificity, ≥94%) and identifies dysplasia. Pancreatitis may develop in 2-7% of pancreatic cyst cases. Needle-based CLE has potential applications in adenocarcinoma, neuroendocrine tumors, and pancreatitis (chronic or autoimmune). Costs, catheter lifespan, endoscopist training, and interobserver variability are challenges for routine utilization.
Conclusions
CLE reveals microscopic pancreatobiliary system anatomy with adequate specificity and sensitivity. Reducing costs and simplifying image interpretation will promote utilization by advanced endoscopists.

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Confocal laser endomicroscopy improves diagnosis of cholangiocarcinoma: a case report and review
Zewen Xu, Yongrong Li, Liwei Dong, Chaochao Chen, Wenwen Wang, Zhoutao He, Cheng Lan
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Modern endoscopic strategies for the diagnosis and management of cholangiocarcinoma
Coskun Ozer Demirtas, Anna Pelach Pueyo, Amanda H Lim, Faisal Shaukat Ali, Tyler M Berzin
Frontline Gastroenterology.2026; : flgastro-2026-103852. CrossRef
Probe-based confocal laser endomicroscopy: progress, challenges, and emerging applications
Mohammed Ayyad, Dhir Gala, Maram Albandak, Ritik M. Goyal, Yazan Abboud, Ahmed Al-Khazraji, Kaveh Hajifathalian
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Updates in Diagnosis and Endoscopic Management of Cholangiocarcinoma
Roxana-Luiza Caragut, Madalina Ilie, Teodor Cabel, Deniz Günșahin, Afrodita Panaitescu, Christopher Pavel, Oana Mihaela Plotogea, Ecaterina Mihaela Rînja, Gabriel Constantinescu, Vasile Sandru
Diagnostics.2024; 14(5): 490. CrossRef
Endoscopic Ultrasound-Guided Needle-Based Confocal Endomicroscopy as a Diagnostic Imaging Biomarker for Intraductal Papillary Mucinous Neoplasms
Shreyas Krishna, Ahmed Abdelbaki, Phil A. Hart, Jorge D. Machicado
Cancers.2024; 16(6): 1238. CrossRef
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Olesja Basina, Aleksejs Derovs, Jeļena Derova, Sandra Lejniece
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American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: summary and recommendations
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Advanced Science.2022;[Epub] CrossRef
Endoscopic ultrasound-guided tissue acquisition: Needle types, technical issues, and sample handling
Woo Hyun Paik
International Journal of Gastrointestinal Intervention.2022; 11(3): 96. CrossRef

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Case Report

High-Resolution Probe-Based Confocal Laser Endomicroscopy for Diagnosing Biliary Diseases: Hiroki Koda, Kazuo Hara, Okuno Nozomi, Takamichi Kuwahara, Mizuno Nobumasa, Shin Haba, Miyano Akira, Isomoto Hajime; Clin Endosc 2021;54(6):924-929. Published online March 15, 2021; DOI: https://doi.org/10.5946/ce.2020.191

Abstract PDF

Probe-based confocal laser endomicroscopy is an endoscopic technique that enables in vivo histological evaluation using fluorescent pigment. The ability to diagnostically differentiate between benign and malignant biliary disease using the “CholangioFlex^TM”, a dedicated biliary device, has been reported. However, the Miami and Paris classifications, used as diagnostic criteria, mainly evaluate findings in the submucosa, and visualizing the epithelium as the main site of lesions remains difficult. To address this problem, we verified the imaging findings and diagnostic ability of three types of probes: CholangioFlex^TM, GastroFlex^TM, and AlveoFlex^TM. With GastroFlex^TM, the clear mucosal epithelium was observed, and differential diagnoses as benign/malignant could be made based on epithelial findings. GastroFlex^TM may be a good first-choice probe for probe-based confocal laser endomicroscopy of biliary diseases, and a new diagnostic classification based on bile duct epithelial findings may provide useful criteria independent of the Miami or Paris classifications.

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Challenges and Prospects of Using Novel Nonlinear Effects in Multimode Optical Fibers for Multiphoton Endomicroscopy
Lidiya V. Boldyreva, Denis S. Kharenko, Kirill V. Serebrennikov, Anna A. Evtushenko, Viktor V. Shloma, Daba A. Radnatarov, Alexandr V. Dostovalov, Zhibzema E. Munkueva, Oleg S. Sidelnikov, Igor S. Chekhovskoy, Kirill S. Raspopin, Mikhail D. Gervaziev, Ste
Diagnostics.2026; 16(3): 438. CrossRef
Early detection of biliary adenocarcinoma using probe-based confocal laser endomicroscopy: a case report
Jiangshan Wu
American Journal of Cancer Research.2025; 15(6): 2642. CrossRef
Intraductal papillary neoplasm of the biliary tract with typical clinicopathological, endoscopic features: A case report
Tian-Yuan Gu, Su-Hang Wang, Shu-Ying Yang, Si-Qi Zhao, Min-Jie Chen, Xiao-Ping Li, Zheng-Wei Song, Xiao-Xia Gu, Fei Chen
World Journal of Gastrointestinal Surgery.2025;[Epub] CrossRef
Cholangioscopy-based convoluted neuronal network vs. confocal laser endomicroscopy in identification of neoplastic biliary strictures
Carlos Robles-Medranda, Jorge Baquerizo-Burgos, Miguel Puga-Tejada, Domenica Cunto, Maria Egas-Izquierdo, Juan Carlos Mendez, Martha Arevalo-Mora, Juan Alcivar Vasquez, Hannah Lukashok, Daniela Tabacelia
Endoscopy International Open.2024; 12(10): E1118. CrossRef
A Comparative Analysis of Artificial Intelligence-based Digital Cholangioscopy and Probe-based Confocal Laser Endomicroscopy for Detecting Malignant Bile Duct Lesions: A single-centre retrospective study
C. Robles-Medranda, J. Baquerizo-Burgos, M. Puga-Tejada, D. Cunto, M. Egas-Izquierdo, M. Arevalo-Mora, J. C. Mendez, J. Alcivar-Vasquez, H. Alvarado-Escobar, H. Pitanga-Lukashok, D. Tabacelia
Endoscopy.2023; 55(S 02): S134. CrossRef

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Original Article

Confocal Laser Endomicroscopic Findings of Refractory Erosive Reflux Disease versus Non-Erosive Reflux Disease with Anti-Reflux Mucosectomy: An in vivo and ex vivo Study: Eunju Jeong, In Kyung Yoo, Abdullah Özgür Yeniova, Dong Keon Yon, Joo Young Cho; Clin Endosc 2021;54(1):55-63. Published online May 7, 2020; DOI: https://doi.org/10.5946/ce.2020.040

Abstract PDF Supplementary Material

Background
/Aims: To date, there is no standard tool to diagnose gastroesophageal reflux disease (GERD). Typically, GERD is a non-erosive reflux disease (NERD) that does not present endoscopic abnormalities. Confocal laser endomicroscopy (CLE) has been shown to be an effective tool to identify and diagnose GERD. We aimed to investigate the cellular and vascular changes in vivo and ex vivo through CLE in patients with GERD.
Methods
Patients with refractory GERD who underwent mucosectomy were recruited. The distal esophagus was observed in vivo using CLE. Mucosectomy tissue was stained with acriflavine and CLE image was obtained ex vivo. We compared cellular and vascular changes in CLE between erosive reflux disease (ERD), NERD, and a control group.
Results
Eleven patients who underwent anti-reflux mucosectomy and five control patients were enrolled in the study. Patients with ERD and NERD presented greater dilated intercellular space than patients in the control group on CLE image. The diameter, number, and cross-sectional area of the intra-papillary capillary loops (IPCLs) were significantly larger in the ERD group than in the NERD group. The irregular shape of the IPCLs were observed in both patients with ERD and NERD.
Conclusions
The irregular shape of the IPCLs were significantly correlated with a positive diagnosis of GERD. CLE may diagnose NERD with high sensitivity and accuracy.

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Tail clamping induces anxiety-like behaviors and visceral hypersensitivity in rat models of non-erosive reflux disease
Mi Lv, Xin Liu, Kai-Yue Huang, Yu-Xi Wang, Zheng Wang, Li-Li Han, Hui Che, Lin Lv, Feng-Yun Wang
World Journal of Psychiatry.2026;[Epub] CrossRef
Endoscopic diagnosis of non-erosive reflux disease
Wen-Ting Zhang, Min Xu, Ying Zheng, Jie Wu, Yi-Jun Zheng, Jia Wei, Tong Kang, Jiong Jiang, Yan Cheng
World Journal of Gastroenterology.2026;[Epub] CrossRef
Efficacy and safety of antireflux mucosectomy versus radiofrequency ablation of the lower esophageal sphincter for the treatment of GERD: a systematic review and meta-analysis
Cristian A. Angeramo, Mateo Lendoire, Fernando A.M. Herbella, Francisco Schlottmann
Gastrointestinal Endoscopy.2025; 102(1): 14. CrossRef
The role of confocal laser endomicroscopy in pediatric gastrointestinal diseases: a narrative review
Irene Dalpiaz, Luca Scarallo, Marco Andreini, Sara Renzo, Giusy Russo, Cosimo Ruggiero, Danila Volpe, Paolo Lionetti, Salvatore Oliva
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Outcomes of Endoscopic Antireflux Mucosectomy for the Treatment of Gastroesophageal Reflux Disease
Martin Galvarini, Cristian A. Angeramo, Javier Kerman, Rubén Balmaceda, Ignacio Debes, Fernando A.M. Herbella, Francisco Schlottmann
Journal of Clinical Gastroenterology.2024; 58(9): 851. CrossRef
Gastroesophageal reflux disease: indications for antireflux surgery, outcomes, and side effects
Francisco Schlottmann, Sofia Bertona, Fernando A.M. Herbella, Marco G. Patti
Expert Review of Gastroenterology & Hepatology.2024; 18(11): 693. CrossRef
Anti-reflux mucosal resection for treatment of refractory gastro-oesophageal reflux disease: Efficacy and impact on perioperative indicators
Xing-Feng Ge, Xian Zhu, Fei Min, Jian-Wei Shen
World Chinese Journal of Digestology.2023; 31(4): 157. CrossRef
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Peiting Xue, Xiuli Zuo
Advances in Bioscience and Biotechnology.2023; 14(06): 279. CrossRef

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Review

The Role of Needle-Based Confocal Laser Endomicroscopy in the Evaluation of Pancreatic Cystic Lesions: A Systematic Review: Yung Ka Chin, Clement Chun Ho Wu, Damien Meng Yew Tan; Clin Endosc 2021;54(1):38-47. Published online March 31, 2020; DOI: https://doi.org/10.5946/ce.2019.200-IDEN

Abstract PDF

The prevalence of pancreatic cystic lesions (PCLs) has increased recently due to the increased use of cross-sectional abdominal imaging and the ageing global population. Current diagnostic techniques are inadequate to distinguish between PCLs that require surgery, close surveillance, or expectant management. This has resulted in increased morbidity from both inappropriately aggressive and conservative management strategies. Needle-based confocal laser endomicroscopy (nCLE) has allowed microscopic examination and visual delineation of the surface epithelium of PCLs. Landmark studies in this decade have correlated nCLE and histological findings and identified characteristics differentiating various types of PCLs. Subsequent studies have confirmed the high diagnostic yield of nCLE and its diagnostic utility in PCLs with an equivocal diagnosis. Moreover, nCLE has been shown to improve the diagnostic yield of PCLs. This will help avoid unnecessary pancreatic surgery, which carries significant morbidity and mortality risks. The early detection of high-grade dysplasia in PCLs will provide early surgical treatment and improve outcomes for pancreatic cancer. Despite the high upfront cost of nCLE, the improved diagnostic accuracy and resultant appropriate management have resulted in improved cost effectiveness. Refining the procedure technique and limiting the procedure length have significantly improved the safety of nCLE. A structured training program and device improvements to allow more complete mapping of the pancreatic cyst epithelium will be crucial for the widespread adoption of this promising technology.

Citations

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Identifying Neoplastic Versus Non-neoplastic Pancreatic Cystic Lesions—What Is the Current Evidence?
Arjun Chatterjee, Renan Prado, Clifton G. Fulmer, Christopher Coppa, Daniel Joyce, Syed Mohiuddin, Prabhleen Chahal, Tyler Stevens
Digestive Diseases and Sciences.2025; 70(10): 3246. CrossRef
Molecular Pathology of Pancreatic Cystic Lesions with a Focus on Malignant Progression
Yan Hu, Dan Jones, Ashwini K. Esnakula, Somashekar G. Krishna, Wei Chen
Cancers.2024; 16(6): 1183. CrossRef
Applications and Prospects of Artificial Intelligence-Assisted Endoscopic Ultrasound in Digestive System Diseases
Jia Huang, Xiaofei Fan, Wentian Liu
Diagnostics.2023; 13(17): 2815. CrossRef
EUS-guided fine needle aspiration-based clues to mistaken or uncertain identity: serous pancreatic cysts
Michele T. Yip-Schneider, Rodica Muraru, Rachel C. Kim, Howard H. Wu, Stuart Sherman, Aditya Gutta, Mohammad A. Al-Haddad, John M. Dewitt, C. Max Schmidt
HPB.2023; 25(12): 1587. CrossRef
Current trends in the management of pancreatic cystic neoplasms in Korea: a national survey
Hyung Ku Chon, Sung Hoon Moon, Sang Wook Park, Woo Hyun Paik, Chang Nyol Paik, Byoung Kwan Son, Tae Jun Song, Dong Won Ahn, Eaum Seok Lee, Yun Nah Lee, Yoon Suk Lee, Jae Min Lee, Tae Joo Jeon, Chang-Hwan Park, Kwang Bum Cho, Dong Wook Lee
The Korean Journal of Internal Medicine.2022; 37(1): 63. CrossRef
Confocal Laser Endomicroscopy in the Diagnosis of Biliary and Pancreatic Disorders: A Systematic Analysis
Do Han Kim, Somashekar G. Krishna, Emmanuel Coronel, Paul T. Kröner, Herbert C. Wolfsen, Michael B. Wallace, Juan E. Corral
Clinical Endoscopy.2022; 55(2): 197. CrossRef
Accuracy and agreement of a large panel of endosonographers for endomicroscopy-guided virtual biopsy of pancreatic cystic lesions
Jorge D. Machicado, Bertrand Napoleon, Anne Marie Lennon, Samer El-Dika, Stephen P. Pereira, Damien Tan, Rahul Pannala, Mohit Girotra, Pradermchai Kongkam, Helga Bertani, Yunlu Feng, Hao Sijie, Ning Zhong, Vincent Valantin, Sarah Leblanc, Alice Hinton, So
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Wei Chen, Nehaal Ahmed, Somashekar G. Krishna
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Diagnostic Value of Endomicroscopy for Gastrointestinal Diseases: New Possibilities and Concepts
Ralf Kiesslich
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Original Article

Bimodal Chromoendoscopy with Confocal Laser Endomicroscopy for the Detection of Early Esophageal Squamous Cell Neoplasms: Piyapan Prueksapanich, Thanawat Luangsukrerk, Rapat Pittayanon, Anapat Sanpavat, Rungsun Rerknimitr; Clin Endosc 2019;52(2):144-151. Published online October 5, 2018; DOI: https://doi.org/10.5946/ce.2018.091

Abstract PDF

Background
/Aims: This study aimed to evaluate the diagnostic accuracy of dual-focus narrow-band imaging (dNBI) and Lugol’schromoendoscopy (LCE) combined with probe-based confocal laser endomicroscopy (pCLE) to screen for esophageal squamous cell neoplasms (ESCNs) in patients with a history of head and neck cancer.
Methods
From March to August 2016, dNBI was performed. Next, LCE was performed, followed by pCLE and biopsy. Histology has historically been the gold standard to diagnose ESCN. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of dNBI and LCE adjunct with pCLE were determined.
Results
Twenty-four patients were included. Ten ESCNs were found in 8 patients (33%). Forty percent of high-graded intraepithelial neoplasias and all low-grade intraepithelial neoplasias were overlooked by dNBI. The sensitivity, specificity, PPV, NPV, and accuracy of dNBI vs. LCE combined with pCLE were 50% vs. 80%, 62% vs. 67%, 36% vs. 44%, 75% vs. 91%, and 83% vs. 70%, respectively.
Conclusions
The use of dNBI to detect ESCN was suboptimal. LCE with pCLE following dNBI had additional value for detecting esophageal dysplasia not detected by dNBI. The use of pCLE to detect dNBI-missed lesions yielded a high NPV, while pCLE-guided biopsy could reduce the number of unnecessary biopsies.

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Confocal laser endomicroscopy for upper gastrointestinal neoplasia: Systematic review and meta-analysis
Ji-Yeon Lee, Seung-Hee Lee, Young-Geon Ji, Hwoon-Yong Jung, Ja-Seong Koo, Jae-Myung Park
Endoscopy International Open.2026;[Epub] CrossRef
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Clinical and Translational Gastroenterology.2026; 17(7): e01044. CrossRef
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Wei Han, Rui Kong, Nan Wang, Wen Bao, Xinli Mao, Jie Lu
Cancers.2023; 15(3): 776. CrossRef
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Sang Kil Lee
Clinical Endoscopy.2019; 52(2): 91. CrossRef
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Lizzy Wijmans, Paul Baas, Thomas E. Sieburgh, Daniel M. de Bruin, Petra M. Ghuijs, Marc J. van de Vijver, Peter I. Bonta, Jouke T. Annema
Chest.2019; 156(4): 754. CrossRef

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Focused Review Series: Current Status of Endoscopy in the Management of Inflammatory Bowel Disease

Role of Advanced Endoscopic Imaging Techniques in the Management of Inflammatory Bowel Disease: Eun Soo Kim; Clin Endosc 2017;50(5):424-428. Published online September 29, 2017; DOI: https://doi.org/10.5946/ce.2017.143

Abstract PDF

Endoscopy plays a crucial role in the management of inflammatory bowel disease (IBD) in terms of diagnosis, monitoring of mucosal status, and surveillance of colitis-associated neoplasia. Mucosal healing evaluated by endoscopy has been recognized as the target of treatment in the era of powerful biologics therapy. The optimal modality for identifying dysplasia in IBD has yet to be well defined. Increasing progress has recently been made in endoscopic technologies to more accurately assess mucosal inflammation and more effectively detect dysplasia. Here we review the data of advanced endoscopic imaging techniques such as chromoendoscopy, virtual chromoendoscopy, endocytoscopy, and confocal laser endomicroscopy in the management of IBD.

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Yingtong Chen, Xiaoyi Xu, Min Wang, Xiang Wang, Yan Wang, Yong Zhang, Jin Huang, Yuwen Tao, Wentao Fan, Lili Zhao, Li Liu, Zhining Fan
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Mohammed El-Dallal, Ye Chen, Qianyun Lin, Shana Rakowsky, Lindsey Sattler, Joshua Foromera, Laurie Grossberg, Adam S Cheifetz, Joseph D Feuerstein
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Hiroshi Nakase, Takehiro Hirano, Kohei Wagatsuma, Tadashi Ichimiya, Tsukasa Yamakawa, Yoshihiro Yokoyama, Yuki Hayashi, Daisuke Hirayama, Tomoe Kazama, Shinji Yoshii, Hiro‐o Yamano
Digestive Endoscopy.2020;[Epub] CrossRef
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Kyeong Ok Kim, Michael V. Chiorean
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Surgical Clinics of North America.2019; 99(6): 1111. CrossRef

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Reviews

Raman Spectroscopy for the Endoscopic Diagnosis of Esophageal, Gastric, and Colonic Diseases: Neel Sharma, Nobuyoshi Takeshita, Khek Yu Ho; Clin Endosc 2016;49(5):404-407. Published online September 22, 2016; DOI: https://doi.org/10.5946/ce.2016.100

Abstract PDF

Globally white-light endoscopy with biopsy sampling is the gold standard diagnostic modality for esophageal, gastric, and colonic pathologies. However, there is overwhelming evidence to highlight the deficiencies of an approach based predominantly on eyeball visualization. Biopsy sampling is also problematic due in part to excessive sampling and hence attendant cost. Various innovations are currently taking place in the endoscopic domain to aid operators in diagnosis forming. These include narrow band imaging which aims to enhance the surface anatomy and vasculature, and confocal laser endomicroscopy which provides real time histological information. However, both of these tools are limited by the skill of the operator and the extensive learning curve associated with their use. There is a gap therefore for a new form of technology that relies solely on an objective measure of disease and reduces the need for biopsy sampling. Raman spectroscopy (RS) is a potential platform that aims to satisfy these criteria. It enables a fingerprint capture of tissue in relation to the protein, DNA, and lipid content. This focused review highlights the strong potential for the use of RS during endoscopic gastroenterological examination.

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A Review of Probe-Based Confocal Laser Endomicroscopy for Pancreaticobiliary Disease: Kunal Karia, Michel Kahaleh; Clin Endosc 2016;49(5):462-466. Published online September 19, 2016; DOI: https://doi.org/10.5946/ce.2016.086

Abstract PDF

Confocal laser endomicroscopy (CLE) is a novel in vivo imaging technique that can provide real-time optical biopsies in the evaluation of pancreaticobiliary strictures and pancreatic cystic lesions (PCLs), both of which are plagued by low sensitivities of routine evaluation techniques. Compared to pathology alone, CLE is associated with a higher sensitivity and accuracy for the evaluation of indeterminate pancreaticobiliary strictures. CLE has the ability to determine the malignant potential of PCLs. As such, CLE can increase the diagnostic yield of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound, reducing the need for repeat procedures. It has been shown to be safe, with an adverse event rate of ≤1%. Published literature regarding its cost-effectiveness is needed.

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New Scopes, New Accessories, New Stents for Interventional Endoscopic Ultrasound: Christopher G. Chapman, Uzma D. Siddiqui; Clin Endosc 2016;49(1):41-46. Published online January 28, 2016; DOI: https://doi.org/10.5946/ce.2016.49.1.41

Abstract PDF

Technological advances have rapidly expanded the therapeutic potential of endoscopic ultrasound (EUS). Innovations in stent technology; directed adjunctive therapy for pancreatic tumors, including radiofrequency ablation and fiducial marker placement; advanced imaging modalities, including needle-based confocal laser endomicroscopy; and new echoendoscopes, such as the forward-viewing linear echoendoscope, are emerging as safe and effective tools and devices for providing a broad range of treatments and therapies previously not thought possible. In this review, we summarize and discuss the new echoendoscopes, accessories, and stents for interventional EUS and highlight the recent literature on technical and therapeutic efficacy. The therapeutic role and indications for EUS are rapidly evolving well beyond its current limits as new EUS-specific designed tools are designed, and ultimately, should help achieve the goal of improving patient outcomes.

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Vaibhav Wadhwa, Nicole Patel, Dheera Grover, Faisal S. Ali, Nirav Thosani
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Application and Efficacy of Super-Magnifying Endoscopy for the Lower Intestinal Tract: Naoki Hosoe, Haruhiko Ogata; Clin Endosc 2016;49(1):37-40. Published online January 28, 2016; DOI: https://doi.org/10.5946/ce.2016.49.1.37

Abstract PDF

Endoscopy plays a significant role in the diagnosis, management, and surveillance of colorectal cancer (CRC) and inflammatory bowel diseases (IBDs). Moreover, magnifying endoscopy and image-enhanced endoscopy has a crucial role in the clinical setting. Recently, a super-magnifying endoscope has been developed, and two devices, confocal laser endomicroscopy (CLE) and an endocytoscopy system (ECS), which allow in vivo microscopic inspection of the microstructural mucosal features of the gastrointestinal tract, are currently available. Studies on the use of ECS in CRC were reported by a Japanese group. Additionally, a few studies on the use of ECS in IBD have been reported. CLE has been shown to be reliable in assessing the activity of the disease in IBDs in both ulcerative colitis and Crohn’s disease. Various published studies evaluated the use of CLE during colonoscopy to distinguish colorectal polyp pathology and neoplasia. However, these studies are heterogeneous, and further evidence is necessary to confirm the efficacy of CLE.

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From clinical uncertainties to precision medicine: the emerging role of the gut barrier and microbiome in small bowel functional diseases
Wojciech Marlicz, Diana E Yung, Karolina Skonieczna-Żydecka, Igor Loniewski, Saskia van Hemert, Beata Loniewska, Anastasios Koulaouzidis
Expert Review of Gastroenterology & Hepatology.2017; 11(10): 961. CrossRef

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Focused Review Series: Image Enhanced Endoscopy

Usefulness and Future Prospects of Confocal Laser Endomicroscopy for Gastric Premalignant and Malignant Lesions: Sang Kil Lee; Clin Endosc 2015;48(6):511-515. Published online November 30, 2015; DOI: https://doi.org/10.5946/ce.2015.48.6.511

Abstract PDF

Confocal laser endomicroscopy (CLE) is a new technology enabling endoscopists to visualize tissue at the cellular level. CLE has the fundamental potential to provide a histologic diagnosis, and may theoretically replace or reduce the need for performing biopsy for histology. The clinical benefits of CLE are more obvious in esophageal disease, including Barrett’s esophagus. Currently, this technology has been adapted to the diagnosis and surveillance of Barrett’s esophagus and related neoplasia. Standard white light endoscopy is the primary tool for gastric cancer screening. Currently, the only method available to precisely diagnose these lesions is upper endoscopy with an appropriate biopsy. A recent study showed that CLE could characterize dysplasia or cancer and identify the risk factors for gastric cancer, such as intestinal metaplasia and the presence of Helicobacter pylori in vivo, although fewer studies on CLE were performed on the stomach than on Barrett’s esophagus and other esophageal diseases. However, the application of CLE to routine clinical endoscopy continues to be refined. This review focused on the usefulness and future prospects of CLE for gastric premalignant and malignant lesions.

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Focused Review Series: Endoscopic and Molecular Imaging of Premalignant GI Lesions, Part II

Confocal Laser Endomicroscopy and Molecular Imaging in Barrett Esophagus and Stomach: Kwi-Sook Choi, Hwoon-Yong Jung; Clin Endosc 2014;47(1):23-30. Published online January 24, 2014; DOI: https://doi.org/10.5946/ce.2014.47.1.23

Abstract PDF

Detection of premalignant lesions in the upper gastrointestinal tract may facilitate endoscopic treatment and improve survival. Despite technological advances in white light endoscopy, its ability to detect premalignant lesions remains limited. Early detection could be improved by using advanced endoscopic imaging techniques, such as magnification endoscopy, narrow band imaging, i-scanning, flexible spectral imaging color enhancement, autofluorescence imaging, and confocal laser endomicroscopy (CLE), as these techniques may increase the rate of detection of mucosal abnormalities and allow optical diagnosis. The present review focuses on advanced endoscopic imaging techniques based on the use of CLE for diagnosing premalignant lesions in Barrett esophagus and stomach.

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The Use of Confocal Laser Endomicroscopy in Diagnosing Barrett’s Esophagus and Esophageal Adenocarcinoma
Jitka Vaculová, Radek Kroupa, Zdeněk Kala, Jiří Dolina, Tomáš Grolich, Jakub Vlažný, David Said, Lydie Izakovičová Hollá, Petra Bořilová Linhartová, Vladimír Procházka, Marek Joukal, Petr Jabandžiev, Ondřej Slabý, Lumír Kunovský
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Probe‐based confocal laser endomicroscopy versus biopsies in the diagnostics of oesophageal and gastric lesions: A prospective, pathologist‐blinded study
Marek Kollar, Jana Krajciova, Lucia Prefertusova, Eva Sticova, Jana Maluskova, Zuzana Vackova, Jan Martinek
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Special Issue Article of IDEN 2013

Confocal Microscopy in the Esophagus and Stomach: Adam Templeton, Joo Ha Hwang; Clin Endosc 2013;46(5):445-449. Published online September 30, 2013; DOI: https://doi.org/10.5946/ce.2013.46.5.445

Abstract PDF

Probe-based confocal microscopy (pCLE) is actively being investigated for applications in the esophagus and stomach. The use of pCLE allows real-time in vivo microscopy to evaluate the microarchitecture of the mucosal epithelium. pCLE appears to be particularly useful in identifying mucosal dysplasia and early malignancies that cannot be clearly distinguished using high-definition white light endoscopy, chromoendoscopy, or magnification endoscopy. In addition, the ability to detect dysplastic tissue in real-time may shift the current screening practice from random biopsy to targeted biopsy of esophageal and gastric cancers and their precursor lesions. We will review the use of pCLE for detection and surveillance of upper gastrointestinal early luminal malignancy.

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Reviews

Endoscopic Imaging in Barrett's Oesophagus: Applications in Routine Clinical Practice and Future Outlook: Sam Costello, Rajvinder Singh; Clin Endosc 2011;44(2):87-92. Published online December 31, 2011; DOI: https://doi.org/10.5946/ce.2011.44.2.87

Abstract PDF

The practice for endoscopic surveillance of Barrett's oesophagus has evolved from "blind" or random 4 quadrant biopsies (Seattle protocol) to a more "intelligent" targeted biopsy approach. This evolution has been possible due to the rapid advances in endoscopic imaging technology and expertise in the last decade. Previous endoscopes had relatively poor image resolution that often did not allow the subtle mucosal changes associated with dysplastic Barrett's mucosa to be identified. Newer endoscopic imaging techniques available today may allow endoscopists to identify areas of dysplasia or malignancy and target biopsies accordingly. These modalities which include narrow band imaging, chromoendoscopy, autofluorescence imaging, and confocal endomicroscopy as well as a few novel imaging modalities on the horizon will be discussed further.

Citations

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The Role of Adjunct Imaging in Endoscopic Detection of Dysplasia in Barrett’s Esophagus
Pujan Kandel, Michael B. Wallace
Gastrointestinal Endoscopy Clinics of North America.2017; 27(3): 423. CrossRef
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Recent Advances in Image-enhanced Endoscopy: Won Young Cho, Jae Young Jang, Don Haeng Lee, The Endoscopic Technology and Investigation Study Group; Clin Endosc 2011;44(2):65-75. Published online December 31, 2011; DOI: https://doi.org/10.5946/ce.2011.44.2.65

Abstract PDF

The desire to better recognized such malignancies, which may be difficult to distinguish from inflammation or trauma, has accelerated the development of endoscopy with new optical technologies. Narrow-band imaging is a novel endoscopic technique that may enhance the accuracy of diagnosis using narrow-bandwidth filters in a red-green-blue sequential illumination system. Autofluorescence imaging is based on the detection of natural tissue fluorescence emitted by endogenous molecules. I-scan technology using a digital filter that modifies normal images through software functions, is the newly developed image-enhanced endoscopic technology from PENTAX. Flexible spectral imaging color enhancement enhances the visualization of mucosal structure and microcirculation by the selection of spectral transmittance with a dedicated wavelength. Confocal laser endomicroscopy images were collected with an argon beam with a scanning depth of 0 (epithelium) to 250 µm (lamina propria) and analyzed using the reflected light.

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Original Article

Bimodal Chromoendoscopy with Confocal Laser Endomicroscopy for the Detection of Early Esophageal Squamous Cell Neoplasms: Published online November 30, 1999

Abstract: Background
/Aims: This study aimed to evaluate the diagnostic accuracy of dual-focus narrow-band imaging (dNBI) and Lugol’schromoendoscopy (LCE) combined with probe-based confocal laser endomicroscopy (pCLE) to screen for esophageal squamous cell neoplasms (ESCNs) in patients with a history of head and neck cancer.
Methods
From March to August 2016, dNBI was performed. Next, LCE was performed, followed by pCLE and biopsy. Histology has historically been the gold standard to diagnose ESCN. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of dNBI and LCE adjunct with pCLE were determined.
Results
Twenty-four patients were included. Ten ESCNs were found in 8 patients (33%). Forty percent of high-graded intraepithelial neoplasias and all low-grade intraepithelial neoplasias were overlooked by dNBI. The sensitivity, specificity, PPV, NPV, and accuracy of dNBI vs. LCE combined with pCLE were 50% vs. 80%, 62% vs. 67%, 36% vs. 44%, 75% vs. 91%, and 83% vs. 70%, respectively.
Conclusions
The use of dNBI to detect ESCN was suboptimal. LCE with pCLE following dNBI had additional value for detecting esophageal dysplasia not detected by dNBI. The use of pCLE to detect dNBI-missed lesions yielded a high NPV, while pCLE-guided biopsy could reduce the number of unnecessary biopsies.

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