Clinical Endoscopy

International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy: Seung Joo Kang, Chung Hyun Tae, Chang Seok Bang, Cheol Min Shin, Young-Hoon Jeong, Miyoung Choi, Joo Ha Hwang, Yutaka Saito, Philip Wai Yan Chiu, Rungsun Rerknimitr, Christopher Khor, Vu Van Khien, Kee Don Choi, Ki-Nam Shim, Geun Am Song, Oh Young Lee, The Korean Society of Gastrointestinal Endoscopy Task Force on Clinical Practice Guidelines; Clin Endosc 2024;57(2):141-157. Published online March 14, 2024; DOI: https://doi.org/10.5946/ce.2024.002

Abstract PDF PubReader ePub: Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.

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Performance comparison between two computer-aided detection colonoscopy models by trainees using different false positive thresholds: a cross-sectional study in Thailand: Kasenee Tiankanon, Julalak Karuehardsuwan, Satimai Aniwan, Parit Mekaroonkamol, Panukorn Sunthornwechapong, Huttakan Navadurong, Kittithat Tantitanawat, Krittaya Mekritthikrai, Salin Samutrangsi, Peerapon Vateekul, Rungsun Rerknimitr; Clin Endosc 2024;57(2):217-225. Published online February 7, 2024; DOI: https://doi.org/10.5946/ce.2023.145

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: This study aims to compare polyp detection performance of “Deep-GI,” a newly developed artificial intelligence (AI) model, to a previously validated AI model computer-aided polyp detection (CADe) using various false positive (FP) thresholds and determining the best threshold for each model.
Methods
Colonoscopy videos were collected prospectively and reviewed by three expert endoscopists (gold standard), trainees, CADe (CAD EYE; Fujifilm Corp.), and Deep-GI. Polyp detection sensitivity (PDS), polyp miss rates (PMR), and false-positive alarm rates (FPR) were compared among the three groups using different FP thresholds for the duration of bounding boxes appearing on the screen.
Results
In total, 170 colonoscopy videos were used in this study. Deep-GI showed the highest PDS (99.4% vs. 85.4% vs. 66.7%, p<0.01) and the lowest PMR (0.6% vs. 14.6% vs. 33.3%, p<0.01) when compared to CADe and trainees, respectively. Compared to CADe, Deep-GI demonstrated lower FPR at FP thresholds of ≥0.5 (12.1 vs. 22.4) and ≥1 second (4.4 vs. 6.8) (both p<0.05). However, when the threshold was raised to ≥1.5 seconds, the FPR became comparable (2 vs. 2.4, p=0.3), while the PMR increased from 2% to 10%.
Conclusions
Compared to CADe, Deep-GI demonstrated a higher PDS with significantly lower FPR at ≥0.5- and ≥1-second thresholds. At the ≥1.5-second threshold, both systems showed comparable FPR with increased PMR.

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Cell block created from pancreatic duct lavage is another jigsaw puzzle to diagnose early pancreatic ductal adenocarcinoma: Rungsun Rerknimitr; Clin Endosc 2023;56(3):313-314. Published online April 21, 2023; DOI: https://doi.org/10.5946/ce.2023.029

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Real-time semantic segmentation of gastric intestinal metaplasia using a deep learning approach: Vitchaya Siripoppohn, Rapat Pittayanon, Kasenee Tiankanon, Natee Faknak, Anapat Sanpavat, Naruemon Klaikaew, Peerapon Vateekul, Rungsun Rerknimitr; Clin Endosc 2022;55(3):390-400. Published online May 9, 2022; DOI: https://doi.org/10.5946/ce.2022.005

Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: Previous artificial intelligence (AI) models attempting to segment gastric intestinal metaplasia (GIM) areas have failed to be deployed in real-time endoscopy due to their slow inference speeds. Here, we propose a new GIM segmentation AI model with inference speeds faster than 25 frames per second that maintains a high level of accuracy.
Methods
Investigators from Chulalongkorn University obtained 802 histological-proven GIM images for AI model training. Four strategies were proposed to improve the model accuracy. First, transfer learning was employed to the public colon datasets. Second, an image preprocessing technique contrast-limited adaptive histogram equalization was employed to produce clearer GIM areas. Third, data augmentation was applied for a more robust model. Lastly, the bilateral segmentation network model was applied to segment GIM areas in real time. The results were analyzed using different validity values.
Results
From the internal test, our AI model achieved an inference speed of 31.53 frames per second. GIM detection showed sensitivity, specificity, positive predictive, negative predictive, accuracy, and mean intersection over union in GIM segmentation values of 93%, 80%, 82%, 92%, 87%, and 57%, respectively.
Conclusions
The bilateral segmentation network combined with transfer learning, contrast-limited adaptive histogram equalization, and data augmentation can provide high sensitivity and good accuracy for GIM detection and segmentation.

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Applications of artificial intelligence in gastroscopy: a narrative review
Hu Chen, Shi-yu Liu, Si-hui Huang, Min Liu, Guang-xia Chen
Journal of International Medical Research.2024;[Epub] CrossRef
Computer‐aided diagnosis in real‐time endoscopy for all stages of gastric carcinogenesis: Development and validation study
Eun Jeong Gong, Chang Seok Bang, Jae Jun Lee
United European Gastroenterology Journal.2024; 12(4): 487. CrossRef
As how artificial intelligence is revolutionizing endoscopy
Jean-Francois Rey
Clinical Endoscopy.2024; 57(3): 302. CrossRef
Accuracy of artificial intelligence-assisted endoscopy in the diagnosis of gastric intestinal metaplasia: A systematic review and meta-analysis
Na Li, Jian Yang, Xiaodong Li, Yanting Shi, Kunhong Wang, Chih-Wei Tseng
PLOS ONE.2024; 19(5): e0303421. CrossRef
Real-time gastric intestinal metaplasia segmentation using a deep neural network designed for multiple imaging modes on high-resolution images
Passin Pornvoraphat, Kasenee Tiankanon, Rapat Pittayanon, Natawut Nupairoj, Peerapon Vateekul, Rungsun Rerknimitr
Knowledge-Based Systems.2024; 300: 112213. CrossRef
A Benchmark Dataset of Endoscopic Images and Novel Deep Learning Method to Detect Intestinal Metaplasia and Gastritis Atrophy
Jie Yang, Yan Ou, Zhiqian Chen, Juan Liao, Wenjian Sun, Yang Luo, Chunbo Luo
IEEE Journal of Biomedical and Health Informatics.2023; 27(1): 7. CrossRef
Real-time gastric intestinal metaplasia diagnosis tailored for bias and noisy-labeled data with multiple endoscopic imaging
Passin Pornvoraphat, Kasenee Tiankanon, Rapat Pittayanon, Phanukorn Sunthornwetchapong, Peerapon Vateekul, Rungsun Rerknimitr
Computers in Biology and Medicine.2023; 154: 106582. CrossRef
Diagnostic value of artificial intelligence-assisted endoscopy for chronic atrophic gastritis: a systematic review and meta-analysis
Yanting Shi, Ning Wei, Kunhong Wang, Tao Tao, Feng Yu, Bing Lv
Frontiers in Medicine.2023;[Epub] CrossRef
Recent Advances in Applying Machine Learning and Deep Learning to Detect Upper Gastrointestinal Tract Lesions
Malinda Vania, Bayu Adhi Tama, Hasan Maulahela, Sunghoon Lim
IEEE Access.2023; 11: 66544. CrossRef
Colon histology slide classification with deep-learning framework using individual and fused features
Venkatesan Rajinikanth, Seifedine Kadry, Ramya Mohan, Arunmozhi Rama, Muhammad Attique Khan, Jungeun Kim
Mathematical Biosciences and Engineering.2023; 20(11): 19454. CrossRef
Clinical Decision Support System for All Stages of Gastric Carcinogenesis in Real-Time Endoscopy: Model Establishment and Validation Study
Eun Jeong Gong, Chang Seok Bang, Jae Jun Lee, Hae Min Jeong, Gwang Ho Baik, Jae Hoon Jeong, Sigmund Dick, Gi Hun Lee
Journal of Medical Internet Research.2023; 25: e50448. CrossRef

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Perception of Gastrointestinal Endoscopy Personnel on Society Recommendations on Personal Protective Equipment, Case Selection, and Scope Cleaning During Covid-19 Pandemic: An International Survey Study: Parit Mekaroonkamol, Kasenee Tiankanon, Rapat Pittayanon, Wiriyaporn Ridtitid, Fariha Shams, Ghias Un Nabi Tayyab, Julia Massaad, Saurabh Chawla, Stanley Khoo, Siriboon Attasaranya, Nonthalee Pausawasdi, Qiang Cai, Thawee Ratanachu-ek, Pradermchai Kongkham, Rungsun Rerknimitr; Clin Endosc 2022;55(2):215-225. Published online September 29, 2021; DOI: https://doi.org/10.5946/ce.2021.051

Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: The Thai Association for Gastrointestinal Endoscopy published recommendations on safe endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to assess the practicality and applicability of the recommendations and the perceptions of endoscopy personnel on them.
Methods
A validated questionnaire was sent to 1290 endoscopy personnel globally. Of these, the data of all 330 responders (25.6%) from 15 countries, related to the current recommendations on proper personal protective equipment (PPE), case selection, scope cleaning, and safety perception, were analyzed. Ordinal logistic regression was used to determine the relationships between the variables.
Results
Despite an overwhelming agreement with the recommendations on PPE (94.5%) and case selection (95.5%), their practicality and applicability on PPE recommendations and case selection were significantly lower (p=0.001, p=0.047, p<0.001, and p=0.032, respectively). Factors that were associated with lower sense of safety in endoscopy units were younger age (p=0.004), less working experience (p=0.008), in-training status (p=0.04), and higher national prevalence of COVID-19 (p=0.003). High prevalent countries also had more difficulty implementing the guidelines (p<0.001) and they considered the PPE recommendations less practical and showed lower agreement with them (p<0.001 and p=0.008, respectively). A higher number of in-hospital COVID-19 patients was associated with less agreement with PPE recommendations (p=0.039).
Conclusions
Using appropriate PPE and case selection in endoscopic practice during a pandemic remains a challenge. Resource availability and local prevalence are critical factors influencing the adoption of the current guidelines.

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Cracking Difficult Biliary Stones: Phonthep Angsuwatcharakon, Rungsun Rerknimitr; Clin Endosc 2021;54(5):660-668. Published online March 16, 2021; DOI: https://doi.org/10.5946/ce.2020.256-IDEN

Abstract PDF PubReader ePub

Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. However, there are difficult stones that cannot be removed using these standard methods. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. A few decades ago, mechanical lithotripsy was usually required to manage these stones. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. EPLBD can reduce the procedural time by shortening the stone removal process. It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications.

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Cholangioscopy as a rescue for a post-cholecystectomy adherent stone formed around a migrated surgical clip in the common bile duct
Chukwunonso Ezeani, Samuel O. Igbinedion, Kwabena Asafo-Agyei, Erik A. Holzwanger, Sultan Mahmood, Mandeep S. Sawhney, Tyler M. Berzin, Moamen Gabr, Douglas K. Pleskow
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Clinical Gastroenterology and Hepatology.2023; 21(1): 33. CrossRef
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L.L. Generdukayev, D.A. Blagovestnov, Yu.S. Teterin, P.A. Yartsev
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Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope
A. K. Uribe Rivera, B. Seeliger, C. A. Saldivar, E. Houghton, F. Rodríguez, P. Acquafresca, M. Palermo, M. E. Giménez
Surgical Endoscopy.2023; 37(10): 7774. CrossRef
Outcomes of balloon vs basket catheter for clearance of choledocholithiasis: a systematic review and meta-analysis
Ruchi Sharma, Vikram Sharma, Umang Singhal, Madhusudhan Sanaka
Endoscopy International Open.2022; 10(11): E1447. CrossRef

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Current Status of Colorectal Cancer and Its Public Health Burden in Thailand: Kasenee Tiankanon, Satimai Aniwan, Rungsun Rerknimitr; Clin Endosc 2021;54(4):499-504. Published online March 15, 2021; DOI: https://doi.org/10.5946/ce.2020.245-IDEN

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Colorectal cancer (CRC) accounts for approximately 10.3% of new cancer cases in Thailand and is currently the 3rd most prevalent cancer found among the Thai population. Starting in 2017, the Thai government announced the national CRC screening program as a response to this important issue. Among the 70 million people currently residing in Thailand, 14 million require screening, while there are approximately a total of 1,000 endoscopists available to perform colonoscopy. Due to the limited resources and shortage of endoscopists in Thailand, applying a population-based one-step colonoscopy program as a primary screening method is not feasible. To reduce colonoscopy workload, with the help of others, including village health volunteers, institution-based health personnel, reimbursement coders, pathologists, and patients due for CRC screening, a two-step approach of one-time fecal immunochemical test (FIT), which prioritizes and filters out subjects for colonoscopy, is chosen. Moreover, additional adjustments to the optimal FIT cutoff value and the modified Asia-Pacific Colorectal Screening risk score, including body weight, were proposed to stratify the priority of colonoscopy schedule. This article aims to give an overview of the past and current policy developmental strategies and the current status of the Thailand CRC screening program.

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Integrated Care Model by the Village Health Volunteers to Prevent and Slow down Progression of Chronic Kidney Disease in a Rural Community, Thailand
Ampornpan Theeranut, Nonglak Methakanjanasak, Sunee Lertsinudom, Pattama Surit, Nichanun Panyaek, Saisamon Leeladapattarakul, Peangtikumporn Nilpetch, Pattapong Kessomboon, Chalongchai Chalermwat, Watcharapong Rintara, Wudipong Khongtong, Pawich Paktipat,
Journal of Primary Care & Community Health.2024;[Epub] CrossRef
Cost-Effectiveness of Increasing Access to Colorectal Cancer Diagnosis: Analysis From Thailand
Peeradon Wongseree, Zeynep Hasgul, Mohammad S. Jalali
Value in Health Regional Issues.2024; 43: 101010. CrossRef
Dynamics of colorectal cancer screening in low and middle-income countries: A modeling analysis from Thailand
Peeradon Wongseree, Zeynep Hasgul, Borwornsom Leerapan, Cherdsak Iramaneerat, Pochamana Phisalprapa, Mohammad S. Jalali
Preventive Medicine.2023; 175: 107694. CrossRef
An Assessment of Physicians’ Recommendations for Colorectal Cancer Screening and International Guidelines Awareness and Adherence: Results From a Thai National Survey
Nonthalee Pausawasdi, Pongkamon Tongpong, Tanawat Geeratragool, Phunchai Charatcharoenwitthaya
Frontiers in Medicine.2022;[Epub] CrossRef
Cytotoxic effect of metformin on butyrate-resistant PMF-K014 colorectal cancer spheroid cells
Kesara Nittayaboon, Kittinun Leetanaporn, Surasak Sangkhathat, Sittirak Roytrakul, Raphatphorn Navakanitworakul
Biomedicine & Pharmacotherapy.2022; 151: 113214. CrossRef

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Practical Approaches for High-Risk Surgical Patients with Acute Cholecystitis: The Percutaneous Approach versus Endoscopic Alternatives: Rungsun Rerknimitr, Khanh Cong Pham; Clin Endosc 2020;53(6):678-685. Published online January 9, 2020; DOI: https://doi.org/10.5946/ce.2019.186

Abstract PDF PubReader ePub

In high-risk surgical patients with acute cholecystitis who are not candidates for early laparoscopic cholecystectomy, gallbladder (GB) drainage is an alternative treatment option. Percutaneous transhepatic gallbladder drainage (PTGBD) is a recommended first line intervention because of its high efficacy and feasibility in most centers. However, with the advent of endoscopic accessories and technology, endoscopic GB drainage has been chosen as a more favorable choice by endoscopists. Endoscopic transpapillary gallbladder drainage (ETGBD) can be performed under either fluoroscopic or peroral cholangioscopic guidance via endoscopic retrograde cholangiopancreatography by the transpapillary placement of a long double-pigtail stent. In a patient with common bile duct stones, this procedure is accompanied with stone removal. ETGBD is especially useful for acute cholecystitis patients who are contraindicated for PTGBD or those with severe coagulopathy, thrombocytopenia, and abnormal anatomy. Moreover, the advantage of ETGBD is its preservation of the external GB structure. Thereby it would not disturb the future cholecystectomy. Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic, fully covered metallic, or lumen-apposing metal stents transmurally has emerged as a modality for GB drainage with higher technical and clinical success rates. EUS-GBD can provide a more permanent GB drainage than PTGBD and ETGBD.

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Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines
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Maria Arechederra, Maria Rullán, Daniel Oyón, Matias A. Ávila, Jesús M. Urman, Carmen Berasain
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The Success Rate Is Lower but Completion Rate of Laparoscopic Cholecystectomy Is higher in Endoscopic Transpapillary Gallbladder Drainage than Percutaneous Gallbladder Drainage for Acute Cholecystitis
Toshiro Masuda, Hiroshi Takamori, Ken-ichi Ogata, Katsuhiro Ogawa, Kenji Shimizu, Ryuichi Karashima, Hidetoshi Nitta, Katsutaka Matsumoto, Tetsuya Okino, Hideo Baba
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Azhar Hussain, Vishnu Charan Suresh Kumar, Hafiz Muzaffar Akbar Khan
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Markus Zachäus, Michael Bartels, Andreas Flade, Andreas Schubert-Hartmann, Regina Lamberts, Alireza Sepehri-Shamloo, Ulrich Paul Halm
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Wiriyaporn Ridtitid, Thanawat Luangsukrerk, Panida Piyachaturawat, Nicha Teeratorn, Phonthep Angsuwatcharakon, Pradermchai Kongkam, Rungsun Rerknimitr
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Endosonography-Guided Versus Percutaneous Gallbladder Drainage Versus Cholecystectomy in Fragile Patients with Acute Cholecystitis—A High-Volume Center Study
Hayato Kurihara, Francesca M. Bunino, Alessandro Fugazza, Enrico Marrano, Giulia Mauri, Martina Ceolin, Ezio Lanza, Matteo Colombo, Antonio Facciorusso, Alessandro Repici, Andrea Anderloni
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Moeko KATO, Toshiro MASUDA, Takihiro KAMIO, Hiroshi TAKAMORI
Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association).2022; 83(10): 1800. CrossRef
Endoscopic Ultrasound-Guided Gallbladder Drainage Versus Percutaneous Transhepatic Gallbladder Drainage for Acute Cholecystitis with High Surgical Risk: An Up-to-Date Meta-Analysis and Systematic Review
Yunxiao Lyu, Ting Li, Bin Wang, Yunxiao Cheng, Liang Chen, Sicong Zhao
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Endoscopic Transmural Necrosectomy: Timing, Indications, and Methods: Rungsun Rerknimitr; Clin Endosc 2020;53(1):49-53. Published online September 18, 2019; DOI: https://doi.org/10.5946/ce.2019.131

Abstract PDF PubReader ePub

Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.

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Safety and efficacy of the EndoRotor device for the treatment of walled-off pancreatic necrosis after EUS-guided cystenterostomy: A systematic review and meta-analysis
Daryl Ramai, Zohaib Ahmed, Saurabh Chandan, Antonio Facciorusso, Smit S. Deliwala, Yaseen Alastal, Ali Nawras, Marcello Maida, Monique T. Barakat, Andrea Anderloni, Douglas G. Adler
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Step-up approach in severe necrotizing pancreatitis: Combination of video-assisted retroperitoneal debridement and endoscopic necrosectomy
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Controversies in EUS-guided treatment of walled-off necrosis
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The endoscopic ultrasound features of pancreatic fluid collections and their impact on therapeutic decisions: an interobserver agreement study
Carlo Fabbri, Todd H. Baron, Giulia Gibiino, Paolo Giorgio Arcidiacono, Cecilia Binda, Andrea Anderloni, Gianenrico Rizzatti, Manuel Pérez-Miranda, Andrea Lisotti, Loredana Correale, Joan B. Gornals, Ilaria Tarantino, Maria Chiara Petrone, Paolo Cecinato,
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Whether clean or dirty, endoscopic treatment is recommended for symptomatic walled-off necrosis
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Unfortunately, a “Back Light System” As a Global Positioning System Failed to Guide the Route in 25-G Fine-Needle Aspiration: Rungsun Rerknimitr, Phonthep Angsuwatcharakon; Clin Endosc 2019;52(4):295-296. Published online July 30, 2019; DOI: https://doi.org/10.5946/ce.2019.104

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The Association of “GOOP” on Gross Examination of Fine Needle Aspiration Samples and On-Site Adequacy
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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

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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 Detection of Early Upper Gastrointestinal Cancer
Wei Han, Rui Kong, Nan Wang, Wen Bao, Xinli Mao, Jie Lu
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Usefulness of Probe-Based Confocal Laser Endomicroscopy for Esophageal Squamous Cell Neoplasm
Sang Kil Lee
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