Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 752 


 
Table of Contents   
ORIGINAL ARTICLE  
Year : 2019  |  Volume : 25  |  Issue : 2  |  Page : 89-96
Use of image-enhanced endoscopy in the characterization of colorectal polyps: Still some ways to go


1 Gastroenterology Divisions, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Medicine, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Gastroenterology Divisions, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Gastroenterology Division, McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada

Click here for correspondence address and email

Date of Web Publication27-Dec-2018
 

   Abstract 


Background/Aim: Instrument-based image-enhanced endoscopy (IEE) is of benefit in detecting and characterizing lesions during colonoscopy. We aimed to study the ability of community-based gastroenterologists to differentiate between neoplastic and non-neoplastic lesions using IEE modalities and to identify predictors of correct classification and the confidence of the optical diagnosis made.
Materials and Methods: An electronic survey was sent to practicing gastroenterologists using electronic tablets during a gastroenterology meeting. Demographic and professional information was gathered and endoscopic images of various colonic lesions were shown and they were requested to classify the images based in white light, flexible spectral imaging color enhancement (FICE), iScan, and narrow band imaging (NBI).
Results: Overall, 71 gastroenterologists responded to the survey, 76% were males and the majority were aged between 36 and 45 years (44%). Most of the respondents practiced both hepatology and gastroenterology (56%) and most of them had never received any training on IEE (66%). Correct identification of lesions using regular white light endoscopy was low (range 28%–84%). None of the IEE modalities increased the percentage of correct diagnoses apart from one NBI image where it increased from 28% (95%CI: 17%–38%) to 56% (95%CI: 44%–68%) (P < 0.01). Those who identified themselves as practicing mainly luminal gastroenterology were more confident 72% (95%CI: 60%–84%) compared with hepatologists 36% (95%CI: 25%–48%), or those who practiced both 48% (95%CI: 39%–56%) despite no difference in the percentage in correct answers.
Conclusion: There remain areas of improvement in the performance of endoscopists in practice and would recommend more dedicated training programs, which could make use of asynchronous technological platforms.

Keywords: Colonoscopy, flexible spectral imaging color enhancement, image-enhanced endoscopy, iScan, narrow band imaging, polyps

How to cite this article:
Alharbi OR, Alballa NS, AlRajeh AS, Alturki LS, Alfuraih IM, Jamalaldeen MR, Almadi MA. Use of image-enhanced endoscopy in the characterization of colorectal polyps: Still some ways to go. Saudi J Gastroenterol 2019;25:89-96

How to cite this URL:
Alharbi OR, Alballa NS, AlRajeh AS, Alturki LS, Alfuraih IM, Jamalaldeen MR, Almadi MA. Use of image-enhanced endoscopy in the characterization of colorectal polyps: Still some ways to go. Saudi J Gastroenterol [serial online] 2019 [cited 2019 Jul 23];25:89-96. Available from: http://www.saudijgastro.com/text.asp?2019/25/2/89/248780





   Introduction Top


Although the age-adjusted rates, distribution, and histological characteristics of polyps might vary between populations,[1],[2] the majority of polyps that are encountered during colonoscopy are in the left colon, diminutive (<5 mm), and significant proportions are hyperplastic.[3] There is an effort to curtail the rising costs of health care by attempting to identify the histology of polyps in vivo and undertaking a “resect and discard” policy (which would decrease the cost of post polypectomy histological examination); this only is applicable to diminutive polyps in the rectosigmoid area. Although dye-based image-enhanced endoscopy (IEE) is of benefit in the detection and characterization of lesions during colonoscopy, its application and performance is considered cumbersome and has limited its widespread uptake.[4] In contrast, instrument-based IEE like iScan (Pentax, Tokyo, Japan), narrow band imaging (NBI) (Olympus Inc., Tokyo, Japan), and flexible spectral imaging color enhancement (FICE) (Fujinon Inc., Saitama, Japan) has the advantage of ease of implementation and the technology is already embedded in the instruments.

IEE is an essential instrument in the application of a “resect and discard” approach; although these technologies have been promising, they are only as good as the endoscopists interpreting the findings. In a study looking into the gastroenterologists in community practice, only 25% of gastroenterologists assessed polyps with >90% accuracy.[5] Thus, there is a need for training in the use of these IEE modalities as well as monitoring and auditing[3],[6] to guarantee that the required quality benchmarks of 90% agreement between the endoscopists judgment and histopathology, and 90% negative predictive value (NPV) are achieved.[7]

The primary aim of the study was to assess the ability of community-based gastroenterologists to differentiate between neoplastic and non-neoplastic lesions using IEE modalities; the secondary aim was to identify predictors of correct classification and the confidence of the optical diagnosis made.


   Materials and Methods Top


This is a cross-sectional study where an electronic survey was sent to practicing gastroenterologists who are members of the Saudi Gastroenterology Association (SGA) through emails. Also, the survey was conducted using electronic tablets during the SGA annual meeting which was held on the 11th and 12th of February 2017.

The questionnaire was comprised of two segments. The first collected demographic and professional information of the participants: age, sex, level of training (fellow in training, specialist, or independent consultant), practice setting (government hospital, private hospital, or both settings), main practice (gastroenterology, hepatology, or both), the number of years in practice, the annual number of endoscopies they would perform if they had received training in IEE (iScan, NBI, FICE), and whether they thought it was important.

The second section showed a series of thirty endoscopic images, of various adenomas, lesions with cancer and hyperplasia.[8],[9],[10] The participants were requested to classify the images based in white light endoscopy into a hyperplastic polyp, adenoma, or cancer. At a later time in the survey, they were shown the same image using an IEE modality and asked again to classify the images based in white light endoscopy into a hyperplastic polyp, adenoma, or cancer.

Statistical analysis

Descriptive statistics were computed for continuous variables, including means, standard deviations, minimum and maximum values, frequencies for categorical variables and 95% confidence intervals (CIs). When hypothesis testing was conducted, the paired t-test and Fisher's exact test, where appropriate, were used. In comparing more than one group, a one-way analysis of variance was used to test for differences among the groups. A statistical significance threshold of P = 0.05 was adopted. No attempt at imputation was made for missing data. A sample size calculation was performed to detect a 50% difference in the success interpreting images with a power of 80% and type I error of 5%; a sample size of 62 gastroenterologists was required.[11],[12],[13]

STATA 11.2 (Stata Corp., College Station, TX, USA) was used for all analyses.


   Results Top


Demographics

In total, 71 gastroenterologists responded to the survey, 76% were males and the majority were aged between 36 and 45 years (44%). Independent consultants comprised 58% of the participants, whereas 21% were specialists and 21% fellows in training. The majority of the gastroenterologists practiced in the government sector (76%) and 10% in both private and government sectors. Most of the respondents practiced both hepatology and gastroenterology (56%) and 73% were practicing for <10 years [Table 1].
Table 1: Demographics of physicians who participated in the study

Click here to view


The respondents believed that knowledge and training is mandatory for the use of IEE (91%). When asked if they required training on IEE, the majority (80%) thought they did require training, whereas the remainder did not think so.

NBI was used by 44%, 8.5% used iScan, 14% used both NBI and iScan, 4% used FICE, and 1% used both FICE and NBI, whereas 28% used only white light without any IEE [Figure 1].
Figure 1: Different image enhancement modalities used by the participants in the study

Click here to view


The majority of physicians responded that they had never received any training on IEE (66%), whereas 20% were trained with NBI, 8% trained with NBI and iScan, 3% had training with all three modalities (NBI, FICE, and iScan), 2% trained with iScan only, and 1% trained with FICE only.

Correct identification of lesions

When comparing the correct identification of lesions using regular white light endoscopy, it was observed that the scores were overall low, ranging from 28% to 84%. [Table 2] demonstrates a paired comparison on the total correct answers on the images taken using IEE modalities (NBI, FICE, iScan) when compared with the same image taken by white light endoscopy.
Table 2: Paired sample comparison on total correct answers on images taken using various enhance imaging modalities

Click here to view


None of the IEE modalities that were used increased the percentage of physicians who made a correct diagnosis apart from one of the images of NBI, where the percentage increased from 28% (95% CI: 17%–38%) to 56% (95% CI: 44%–68%; P < 0.01).

Relationship between correct identification of lesions and the confidence of the endoscopist

In general, the level of confidence by which the study participants made their diagnosis was low (range 32% to 72%). There was no correlation between the percentage of correct identification of lesions and the confidence of the endoscopist when making that diagnosis. This was also the case when stratified by sex, age, practice setting, number of years in practice, or level of training.

It was noted that those who identified themselves as practicing mainly luminal gastroenterology were more confident 72% (95% CI: 60%–84%) compared with hepatologists 36% (95% CI: 25%–48%), or those who practice both 48% (95% CI: 39%–56%) despite no difference in the percentage in correct answers in identifying lesions [Table 3].
Table 3: Relationship of correctly identifying lesions and the confidence with which that judgment was made

Click here to view


Also, those who thought that training in IEE was not necessary tended to have a lower confidence in their diagnoses 26% (95% CI: 3%–48%) compared with those who thought it was 55% (95% CI: 48%–62%), again despite no difference in the percentage in correct answers in identifying lesions [Table 4]. There was no effect of the annual number of procedures performed, the type of IEE used, or the training received [Table 4].
Table 4: Relationship of correctly identifying lesions and the confidence with which that judgment was made based on receiving training, perception for the need of training and annual procedure volume

Click here to view



   Discussion Top


Real-time optic diagnosis using IEE modalities can prevent unnecessary polypectomy to decrease the cost related to the histopathological examinations of polyps. However, before applying this strategy in routine clinical practice, a gastroenterologist must achieve a certain diagnostic threshold in differentiating adenomas from non-adenomas.

Although current IEE technologies have advanced compared with earlier versions of scopes and their performance of IEE has been very encouraging in clinical trials, there remains some caution when it comes to the in vivo diagnosis of diminutive polyps to the degree that the European Society of Gastrointestinal Endoscopy (ESGE) has suggested that these technologies (NBI, FICE, and iScan) could be used, under strictly controlled conditions, for the diagnosis of diminutive polyps.[14] They also required that the diagnosis be reported using validated scales, photodocumented, and only performed by endoscopists who are adequately trained, experienced, and audited periodically.[14] This stems from the fact that the performance of IEE outside of clinical trials and academic/specialized centers has been inconsistent.[3],[15]

We included in our study standard IEE modalities that are widely available, but the advances in the field of IEE have been relatively fast where even newer technologies, such as blue laser imaging (BLI) (Fujifilm Co, Tokyo, Japan) and linked color imaging (LCI)[16],[17],[18] (Lasereo system, Fujifilm, Tokyo, Japan), iScan optical enhancement,[19] and second-generation (2G) NBI[4] are being rolled out. We still do not have a clear sense of the performance of the older technologies and their impact in real clinical practice let alone these newer IEE modalities. Thus, we felt a need to assess the ability of community practicing gastroenterologists in identifying lesions correctly with the use of IEE compared with regular white light endoscopy as well as trying to identify factors that would affect this competency.

When applied properly, NBI could differentiate between neoplastic and non-neoplastic colorectal polyps in real time with a sensitivity of 91.0% (95%CI: 87.6%–93.5%), a specificity of 82.6% (95%CI: 79.0%–85.7%), and an area under the receiver-operating characteristics curve of 92% (95%CI: 90%–94%),[20] with similar figures also being reported for iScan and FICE.[21] With these test characteristics, a correct surveillance interval for the follow-up procedure using IEE correlated with that derived from pathological assessment in 92% of patients.[20] Unfortunately, these figures were far from what we had found in our survey, which stress the need to be cautious when generalizing these results into community practice.[5] Even for white light endoscopy, the correct identification of polyps was relatively low, which emphasizes the need for improving basic skills prior to any IEE.

Even today, there remains some ambiguity in the amount and type of training required, and earlier studies indicating that it might be taxing (up to 100 video recordings between training and assessment) to achieve competence[22] in IEE, whereas others gave a notion that it could be done with minimal effort (20 min).[23] Most probably the reality lies in between these extremes, but what seems to be for sure is that this learning requires constant practice and “relearning”[22] to maintain these skills.

Not receiving training (whatever that training form maybe) is a hindrance to any gain that would be anticipated for this technology. Although 66% of the respondents did not receive any form of training in IEE, a significant proportion had the technology available and were using it in practice, which indicates that there is a will to use these tools in clinical practice.

Part of learning is the knowledge of what one knows and what is required to reach a desired or needed knowledge or skill to be attained, this self-awareness will aid in this process, while overconfidence will hinder this process. In our study, it was interesting that those who identified as mainly gastroenterologists were more confident about their diagnoses compared with their counterparts, while they were not different in correctly identifying lesions. It is not clear what the driving factor for the overconfidence in this group was, but it is a cognitive bias that might be linked to certain personality traits; other cognitive bias that have been found in physicians include a lower tolerance to risk, the anchoring effect, and information and availability biases.[24] Also, it has been known that relatively incompetent people consistently overestimate their abilities.[25] It has been demonstrated that physicians have a lack of perception of the difficulty of tasks at hand and this is reflected in a stable level of confidence despite a change in the difficulty of the task that was requested from them to achieve.[26] The knowledge of one's gaps and acquisition of that knowledge is at the core of the value of “Life Long Learning,” which is instilled in healthcare practitioners during their training, and thus knowing the unknown is an essential aspect.[27]

In a meta-analysis, factors associated with a better performance when using digital IEE included being at an academic medical center (NPV 91.8%; 95% CI: 89%–94%), being an expert (NPV 93%; 95% CI: 91%–96%), and when the assessment was made with high confidence (NPV 93%; 95% CI: 90%–96%),[28] thus, pinning the importance of confidence which is a natural byproduct of learning and practice.

Educational programs have been conducted in the field of dye-based IEE for the surveillance colonoscopies in patients with inflammatory bowel disease and had impact on trainees' practices,[29] and the plateau is reached after 15 cases,[30] and has been found to be reproducible even outside of clinical trials.[31] Programs for the detection of diminutive polyps have been performed with encouraging results as demonstrated with a NPV of 94.7% (95% CI: 92.6%–96.8%) achieved by 26 endoscopists after a period of training in NBI,[6] but the need for continuous auditing appears to be required to maintain that level of competency.[6] Such programs would need to be given on a larger scale, if the use of these IEE technologies were to be widespread.

A study on 10 gastroenterologists found that with some training in NBI, and no prior experience with IEE, they achieved a NPV of 95% for adenomas and a 93% agreement with histology but could not find any factors that could affect the quality of the optical diagnosis made.[32] Of note, the study had a small number of participants and they were enrolled from two academic centers and 2 of 10 had been involved in clinical studies in IEE technologies.[32] All these factors limit the generalizability of that study to a community-based practice. A second study of five gastroenterologists, who were already involved in an endoscopy-related randomized trial,[33] achieved the quality threshold of a 90% NPV and maintained that when they were trained on the initiation of the study as well as getting a mid-study refresher.[15]

To overcome the human element of variation in the differentiation between hyperplastic polyps and neoplastic lesions, the use of computer-aided diagnosis with a deep neural network is being developed, and has produced results that are promising where this system was able to differentiate between hyperplastic and neoplastic lesions with a sensitivity of 96.3%, specificity of 78.1%, a positive predictive value of 89.6%, and a NPV of 91.5%,[34] which was similar to expert endoscopists but better than novices.[34] How these new computer-aided detection and diagnosis systems will function in the future is unclear[35] but might act as “a second reader” for the endoscopist.[36]

An interesting advancement in the technology for IEE is in LCI where it was found in a small study that trainees had better scores in characterizing lesions compared with the white light or BLI-bright, which is interesting as these modalities usually require a level of expertise,[37],[38] whether this would be sustained when adapted at a community level remains to be seen.

Although the interpretation of still images does not translate to the performance of IEE in real-time endoscopy, where other variables such as the preparation quality, patient comfort and scope position, all might affect the real-time performance of IEE. The use of electronic surveys to investigate the ability of endoscopists in correctly identifying lesions is well established. A study involving 60 Japanese gastroenterologists using IEE demonstrated that they achieved a diagnostic accuracy of 88% for superficial colorectal neoplasms using still images.[39]

Limitations in our study include the fact that this was a self-administered questionnaire and is limited by the relatively small number of respondents and also is susceptible to recall bias in terms of annual volume of endoscopies. Also, the definition of receiving training on IEE is not standardized, but nonetheless, the self-perception of being trained is an important aspect when realizing the need for proper initial training and maintenance of these skills[15] as well as self-audit which has been demonstrated to be important if one is to achieve and maintain the quality thresholds needed[7] and whether these variables should be taken into credentialing of endoscopists by their institutions, as a matter of debate.

In conclusion, there remain areas of improvement in the performance of endoscopists in practice and would recommend more dedicated training programs, which could make use of asynchronous technological platforms, with frequent feedback and well-validated scales and classification to familiarize the gastroenterologists about IEE modalities, if we are to maximize these technological advances. This study does stress that a tool is as good as its user in akin to “beauty is in the eye of the beholder.”

Ethical approval statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and within the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Institutional Review Board (IRB) No. E-17-2257.

Informed consent statement

Informed consent was obtained from all individual participants included in the study.

Acknowledgements

The authors extend their sincere appreciation to the Deanship of Scientific Research at King Saud University for funding this research through the Research Group Project number RGP-279.

Financial support and sponsorship

The authors extend their sincere appreciation to the Deanship of Scientific Research at King Saud University for funding this research through the Research Group Project number RGP-279.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Almadi MA, Alharbi O, Azzam N, Wadera J, Sadaf N, Aljebreen AM. Prevalence and characteristics of colonic polyps and adenomas in 2654 colonoscopies in Saudi Arabia. Saudi J Gastroenterol 2014;20:154-61.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Strum WB. Colorectal Adenomas. N Engl J Med 2016;374:1065-75.  Back to cited text no. 2
    
3.
Paggi S, Rondonotti E, Amato A, Fuccio L, Andrealli A, Spinzi G, et al. Narrow-band imaging in the prediction of surveillance intervals after polypectomy in community practice. Endoscopy 2015;47:808-14.  Back to cited text no. 3
    
4.
Ho SH, Uedo N, Aso A, Shimizu S, Saito Y, Yao K, et al. Development of image-enhanced endoscopy of the gastrointestinal tract: A review of history and current evidences. J Clin Gastroenterol 2018;52:295-306.  Back to cited text no. 4
    
5.
Ladabaum U, Fioritto A, Mitani A, Desai M, Kim JP, Rex DK, et al. Real-time optical biopsy of colon polyps with narrow band imaging in community practice does not yet meet key thresholds for clinical decisions. Gastroenterology 2013;144:81-91.  Back to cited text no. 5
    
6.
Patel SG, Schoenfeld P, Kim HM, Ward EK, Bansal A, Kim Y, et al. Real-time characterization of diminutive colorectal polyp histology using narrow-band imaging: Implications for the resect and discard strategy. Gastroenterology 2016;150:406-18.  Back to cited text no. 6
    
7.
Rex DK, Kahi C, O'Brien M, Levin TR, Pohl H, Rastogi A, et al. The american society for gastrointestinal endoscopy PIVI (preservation and incorporation of valuable endoscopic innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011;73:419-22.  Back to cited text no. 7
    
8.
Atlas of Spectral Endoscopic Images. Available from: http://en.fujifilmla.com/products/endoscopy/catalogs/pdf/index/fice-atlas-esp.pdf. [Last accessed on 2018 Jun 30].  Back to cited text no. 8
    
9.
EndoAtlas Clinical data and endoscopic training tools from renowned physicians. Available from: https://www.endoatlas.net/ea. [Last accessed on 2018 Jun 30].  Back to cited text no. 9
    
10.
I-scan Atlas for Gastroenterology. Available from: https://www.pentaxmedical.com/pentax/download/fstore/uploadFiles/Pdfs/Product%20Datasheets/video%20equipment/i-scan%20Atlas%20GI_05.2016.pdf. [Last accessed on 2018 Jun 30].  Back to cited text no. 10
    
11.
RStudio Team. RStudio: Integrated Development for R. Boston, MA, RStudio, Inc.; 2016. URL http://www.rstudio.com/.  Back to cited text no. 11
    
12.
R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2017. URL https://www.R-project.org/.  Back to cited text no. 12
    
13.
Stephane Champely. pwr: Basic Functions for Power Analysis. R package version 1.2-2; 2018. https://CRAN.R-project.org/package=pwr.  Back to cited text no. 13
    
14.
Kaminski MF, Hassan C, Bisschops R, Pohl J, Pellisé M, Dekker E, et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy 2014;46:435-49.  Back to cited text no. 14
    
15.
McGill SK, Soetikno R, Rastogi A, Rouse RV, Sato T, Bansal A, et al. Endoscopists can sustain high performance for the optical diagnosis of colorectal polyps following standardized and continued training. Endoscopy 2015;47:200-6.  Back to cited text no. 15
    
16.
Hammad H, Kaltenbach T, Soetikno R. Image-enhanced endoscopy: How far do we need to go? Gastrointest Endosc 2017;86:698-9.  Back to cited text no. 16
    
17.
Goda Y, Mori H, Kobara H, Nishiyama N, Kobayashi N, Yachida T, et al. Therapeutic application of linked color imaging for colorectal endoscopic mucosal resection. Endoscopy 2018;50:E8-9.  Back to cited text no. 17
    
18.
Wu CH, Chen TH, Hsu CM, Su MY, Chiu CT, Wu RC, et al. Linked-color imaging combined with the NICE classification system for optical diagnosis of colon polyps: New image-enhanced endoscopic technology for pathological prediction. Ther Clin Risk Manag 2017;13:1317-21.  Back to cited text no. 18
    
19.
Klenske E, Zopf S, Neufert C, Nägel A, Siebler J, Gschossmann J, et al. I-scan optical enhancement for the in vivo prediction of diminutive colorectal polyp histology: Results from a prospective three-phased multicentre trial. PloS One 2018;13:e0197520.  Back to cited text no. 19
    
20.
McGill SK, Evangelou E, Ioannidis JP, Soetikno RM, Kaltenbach T. Narrow band imaging to differentiate neoplastic and non-neoplastic colorectal polyps in real time: A meta-analysis of diagnostic operating characteristics. Gut 2013;62:1704-13.  Back to cited text no. 20
    
21.
Wanders LK, East JE, Uitentuis SE, Leeflang MM, Dekker E. Diagnostic performance of narrowed spectrum endoscopy, autofluorescence imaging, and confocal laser endomicroscopy for optical diagnosis of colonic polyps: A meta-analysis. Lancet Oncol 2013;14:1337-47.  Back to cited text no. 21
    
22.
Singh R, Bhat YM, Thurairajah PH, Shetti MP, Jayanna M, Nind G, et al. Is narrow band imaging superior to high-definition white light endoscopy in the assessment of diminutive colorectal polyps? J Gastroenterol Hepatol 2013;28:472-8.  Back to cited text no. 22
    
23.
Raghavendra M, Hewett DG, Rex DK. Differentiating adenomas from hyperplastic colorectal polyps: Narrow-band imaging can be learned in 20 minutes. Gastrointest Endosc 2010;72:572-6.  Back to cited text no. 23
    
24.
Saposnik G, Redelmeier D, Ruff CC, Tobler PN. Cognitive biases associated with medical decisions: A systematic review. BMC Med Inform Eecis Mak 2016;16:138.  Back to cited text no. 24
    
25.
Croskerry P, Norman G. Overconfidence in clinical decision making. Am J Med 2008;121:S24-9.  Back to cited text no. 25
    
26.
Meyer AN, Payne VL, Meeks DW, Rao R, Singh H. Physicians' diagnostic accuracy, confidence, and resource requests: A vignette study. JAMA Intern Med 2013;173:1952-8.  Back to cited text no. 26
    
27.
Dhaliwal G. Known unknowns and unknown unknowns at the point of care. JAMA Intern Med 2013;173:1959-61.  Back to cited text no. 27
    
28.
Committee AT, Abu Dayyeh BK, Thosani N, Konda V, Wallace MB, Rex DK, et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2015;81:502 e1-e16.  Back to cited text no. 28
    
29.
Kaltenbach TR, Soetikno RM, DeVivo R, Laine LA, Barkun A, McQuaid KR, et al. Optimizing the quality of endoscopy in inflammatory bowel disease: Focus on surveillance and management of colorectal dysplasia using interactive image- and video-based teaching. Gastrointest Endosc 2017;86:1107-17.e1.  Back to cited text no. 29
    
30.
Leong RW, Butcher RO, Picco MF. Implementation of image-enhanced endoscopy into solo and group practices for dysplasia detection in Crohn's disease and ulcerative colitis. Gastrointest Endosc Clin N Am 2014;24:419-25.  Back to cited text no. 30
    
31.
Carballal S, Maisterra S, Lopez-Serrano A, Gimeno-García AZ, Vera MI, Marín-Garbriel JC, et al. Real-life chromoendoscopy for neoplasia detection and characterisation in long-standing IBD. Gut 2018;67:70-8.  Back to cited text no. 31
    
32.
Pohl H, Bensen SP, Toor A, Gordon SR, Levy LC, Anderson PB, et al. Quality of optical diagnosis of diminutive polyps and associated factors. Endoscopy 2016;48:817-22.  Back to cited text no. 32
    
33.
Kaltenbach T, Rastogi A, Rouse RV, McQuaid KR, Sato T, Bansal A, et al. Real-time optical diagnosis for diminutive colorectal polyps using narrow-band imaging: The VALID randomised clinical trial. Gut 2015;64:1569-77.  Back to cited text no. 33
    
34.
Chen PJ, Lin MC, Lai MJ, Lin JC, Lu HH, Tseng VS. Accurate classification of diminutive colorectal polyps using computer-aided analysis. Gastroenterology 2018;154:568-75.  Back to cited text no. 34
    
35.
Oka S, Tanaka S, Sano Y, Saitoh Y, Shimoda R, Tajiri H. Advanced diagnostic endoscopy in the lower gastrointestinal tract: A review of JGES core sessions. Dig Endosc 2018;30:192-7.  Back to cited text no. 35
    
36.
Byrne MF, Shahidi N, Rex DK. Will computer-aided detection and diagnosis revolutionize colonoscopy? Gastroenterology 2017;153:1460-4.e1.  Back to cited text no. 36
    
37.
Suzuki T, Hara T, Kitagawa Y, Takashiro H, Nankinzan R, Sugita O, et al. Linked-color imaging improves endoscopic visibility of colorectal nongranular flat lesions. Gastrointest Endosc 2017;86:692-7.  Back to cited text no. 37
    
38.
Togashi K, Nemoto D, Utano K, Isohata N, Kumamoto K, Endo S, et al. Blue laser imaging endoscopy system for the early detection and characterization of colorectal lesions: A guide for the endoscopist. Therap Adv Gastroenterol 2016;9:50-6.  Back to cited text no. 38
    
39.
Sakamoto T, Nakajima T, Matsuda T, Murakami Y, Ishikawa H, Yao K, et al. Comparison of the diagnostic performance between magnifying chromoendoscopy and magnifying narrow-band imaging for superficial colorectal neoplasms: An online survey. Gastrointest Endosc 2018;87:1318-23.  Back to cited text no. 39
    

Top
Correspondence Address:
Dr. Majid A Almadi
Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh - 11461

Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjg.SJG_417_18

Rights and Permissions


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
  
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed779    
    Printed28    
    Emailed0    
    PDF Downloaded74    
    Comments [Add]    

Recommend this journal