Digestive Endoscopy 2014; 26 (Suppl. 1): 43–51 doi: 10.1111/den.

12190

Review

Present and future perspectives of virtual

chromoendoscopy with i-scan and optical enhancement
technology
Helmut Neumann,1 Mitsuhiro Fujishiro,2 C. Mel Wilcox3 and Klaus Mönkemüller3
1
Department of Medicine 1, Interdisciplinary Endoscopy, University of Erlangen-Nuremberg, Erlangen, Germany;
2
Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo,
Tokyo, Japan; and 3Basil Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and
Hepatology, University of Alabama at Birmingham, Birmingham, USA

Despite being the current gold standard, white-light endoscopy
may miss a significant proportion of lesions within the colorec-
tum, thus leading to a misinterpretation of various disease find-
ings. Traditionally, dye-based chromoendoscopy is used to
improve both detection and characterization of lesions during
luminal gastrointestinal (GI) endoscopy. Recently introduced dye-
less chromoendoscopy (DLC) techniques have overcome many of
the limitations of dye-based chromoendoscopy, thereby poten-
tially improving lesion recognition and characterization. In detail,
DLC techniques allow for better detection of esophageal lesions,
gastric cancer and colorectal pathologies including colorectal
polyps and inflammatory bowel diseases. Moreover, DLC tech-
niques enable a more precise characterization of lesions through-
out the whole luminal GI tract, thereby potentially enabling more
accurate endoscopic therapies. In the present review we focus
on the newly introduced dye-less chromoendoscopy technique
i-scan and give an additional outlook on the recent development
of optical enhancement technology.
Key words: chromoendoscopy, inflammatory bowel disease
(IBD), i-scan, optical enhancement technology, polyp

INTRODUCTION six were cancers. These data were recently confirmed by Pohl
and coworkers in a randomized two-center trial including
E NDOSCOPIC IMAGING OF the gastrointestinal (GI)
tract is routinely carried out by using white-light endos-
copy. However, standard white-light endoscopy may miss a
more than 1000 patients.6 DBC with methylene blue has also
been shown to allow a more accurate diagnosis of the extent
and severity of the inflammatory activity in inflammatory
significant amount of lesions, especially within the colorec-
bowel diseases compared with conventional colonoscopy.7 In
tum, and may also lead to a misinterpretation of findings,
addition, DBC allowed for the early detection of intraepithe-
thereby resulting in delayed or suboptimal therapies.1,2 In an
lial neoplasia and colitis-associated cancer in patients with
attempt to overcome the limitations of white-light endos-
long-standing ulcerative colitis.7
copy, dye-based chromoendoscopy (DBC) techniques were
Moreover, the impact of DBC for detection and charac-
introduced more than one decade ago.3,4 DBC has been
terization of esophageal lesions, including esophageal squa-
proven to be feasible for improved detection and character-
mous cell cancer, non-erosive reflux disease and Barrett’s
ization rates of various GI lesions. In this context, one early
esophagus, has been demonstrated.8–11
study evaluated the efficacy of indigocarmine dye spraying
In terms of stomach lesions, indigocarmine DBC has rou-
in 52 patients undergoing screening colonoscopy.5 Among
tinely been used after detection of gastric lesions by white-
48 patients with mucosa of normal appearance, 27 patients
light endoscopy for an extended period of time, especially in
showed 178 lesions after staining with a mean size of 3 mm.
Japan, although there was no clear evidence that DBC could
On histological investigation, 67 lesions were adenomas and
actually improve detection and characterization of gastric
lesions. In this context, Kawahara et al. have recently shown
that indigocarmine dye-spraying significantly improved
Corresponding: Helmut Neumann, Department of Medicine 1,
University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen diagnostic accuracy of tumor extents and that a mixture of
91054, Germany. Email: helmut.neumann@uk-erlangen.de acetic acid and indigocarmine could lead to much higher
Received 17 June 2013; accepted 2 September 2013. accuracy in 108 already-known early gastric cancers.12

© 2013 The Authors 43

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44 H. Neumann et al. Digestive Endoscopy 2014; 26 (Suppl. 1): 43–51

Table 1 Summary of currently available dye-less chromoendoscopy (DLC) techniques

Technology Brand Company Specifications

Optical DLC NBI Olympus, Tokyo, Japan Evis Exera II & III
CBI Aohua Photoelectricity, Shanghai, China AQ-100
Virtual DLC i-scan Pentax, Tokyo, Japan EPKi, EPKi-5000, EPKi-7000
FICE Fujifilm, Tokyo, Japan EPX-4400

CBI, Compound Band Imaging; FICE, Fuji Intelligent Color Enhancement; NBI, narrow band imaging.

Additionally, intravital staining of the duodenum with
indigocarmine was shown to be useful for detecting mucosal
abnormalities, delineating their extent, and allowing targeted
biopsies.13 Taken together, DBC may unmask mucosal
lesions that are not easily identified by routine white-light
endoscopy. In addition, DBC facilitates visualization of the
margins of flat or depressed lesions and helps to predict
lesion histology for an optimized endoscopic therapy. Nev-
ertheless, DBC has some potential limitations, as the dye
does not always coat the surface evenly, thereby often result-
ing in overstained and less stained mucosal areas, which, in
turn, may affect the diagnosis and characterization of
lesions. In addition, there are additional costs for dye spray-
ing, including those for the dye and the spraying catheter.
Furthermore, the procedure requires a learning phase and the
mucosa should be well prepared, as mucus or residual stool
may result in false-positive findings.
In an attempt to overcome the limitations of DBC,
dye-less chromoendoscopy (DLC) techniques have been
introduced (Table 1). These are divided into optical chromo-
endoscopy techniques, including narrow band imaging
(NBI; Olympus, Tokyo, Japan) and Compound Band
Imaging (CBI; Aohua Photoelectricity, Shanghai, China),
and virtual chromoendoscopy techniques including Fujifilm
Intelligent Color Enhancement (FICE; Fujifilm, Tokyo,
Japan) and i-scan (Pentax, Tokyo, Japan). DLC is activated
simply by pushing a button on the handle of the endoscope,
thereby enabling high-contrast imaging of the mucosal
surface without any time delay or the need for special
equipment.
In the present review, we will focus on present and future
perspectives of virtual chromoendoscopy using i-scan and
give an outlook on the advent of the recently introduced
optical enhancement technology (Table 2).
TECHNIQUE OF VIRTUAL
CHROMOENDOSCOPY
Table 2 Potential applications and clinical advantages of virtual
chromoendoscopy using i-scan
Esophagus
• Early squamous cell cancer
• Gastric inlet patch
• Minimal change gastroesophageal reflux disease
• Barrett’s esophagus and early adenocarcinoma
Stomach
• Atrophic gastritis
• Gastric antral vascular ectasia (GAVE)
• Early gastric cancer
Duodenum
• Celiac disease
• Whipple’s disease
Colon
• Polyps
• Inflammatory bowel diseases
• Food allergies
time without any noticeable time delay. Currently, two
virtual chromoendoscopy techniques are available, including
FICE and i-scan. While FICE has no standardized image
settings, a recent international consensus recommended
uniform settings for i-scan, thereby allowing even the com-
parison of different studies.14 As a standard feature, the
i-scan system is integrated into the EPKi high-definition
video processor units (Pentax, Tokyo, Japan). A detailed
description of the technology was recently presented by
Kodashima and Fujishiro.15 In short, i-scan consists of three
different image algorithms: (i) surface enhancement (SE);
(ii) tone enhancement (TE); and (iii) contrast enhancement
(CE). Switching between different modes is done by pushing
a button on the handle of the endoscope. As explained by
Kodashima and Fujishiro, SE enhances light-dark contrast
by obtaining luminance intensity data for each pixel and
applying an algorithm that allows detailed observation of the

V IRTUAL CHROMOENDOSCOPY IS based on the

principle of digital post-processing. Accordingly, the
endoscopic image is reconstructed into virtual images in real
mucosal surface structure and lesion borders. In addition, CE
digitally adds blue color to relatively dark areas within the
endoscopic image by obtaining luminance intensity data for

© 2013 The Authors

Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 1): 43–51
each pixel and applying an algorithm that allows detailed
observation of subtle irregularities around the surface and a
detailed inspection of the mucosal vascular pattern morphol-
ogy. Last, TE dissects and analyses the individual red-green-
blue (RGB) components of a normal endoscopic image in
real time and then alters the color frequencies of each com-
ponent and recombines the components to a single, new
color image without visible delay for the examiner. Thereby,
TE enhances minute mucosal structures and subtle changes
in color.15
Based on current consensus, three i-scan settings are rec-
ommended as follows:14 (i) i-scan 1 for detection of lesions.
This algorithm uses only SE to refine imaging of subtle
surface abnormalities without altering the brightness of the
endoscopic picture. (ii) i-scan 2 mode was established for
characterization of lesions. This algorithm combines SE and
TE, thereby enhancing minute mucosal changes and vessel
structures. (iii) Last, i-scan 3 adds CE to the endoscopic
image (in addition to SE and TE) and is recommended for
demarcation of lesions as it digitally adds blue color to
darker edges within the endoscopic image.
PRESENT APPLICATIONS OF i-SCAN
TECHNOLOGY IN THE ESOPHAGUS
P ATIENTS WITH GASTROESOPHAGEAL reflux
disease (GERD) are divided into those with non-
erosive reflux disease (NERD), erosive reflux disease and
Barrett’s esophagus. Patients with NERD suffer from
typical reflux symptoms (e.g. heartburn) but show no
visible mucosal lesions during white-light endoscopy.16
Hoffman and coworkers evaluated the efficacy of i-scan
and chromoendoscopy with Lugol’s solution for differen-
tiation of reflux patients.17 In their study, the distal esopha-
gus of patients with heartburn was inspected with three
imaging modalities. High-definition white-light endoscopy
was followed by i-scan and Lugol’s solution dye-spraying.
The esophagus was evaluated for mucosal breaks and small
A B
Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society
i-scan: Optical enhancement technology 45
visible changes and, afterwards, targeted biopsies were
carried out. It was found that Lugol’s solution significantly
improved the identification of patients with esophagitis and
reduced misclassification, whereas i-scan and DBC helped
to identify reflux-associated lesions. These data were also
confirmed by a recent prospective study from Korea includ-
ing over 500 patients.18 White-light endoscopy identified
reflux esophagitis in approximately 22% of patients,
whereas i-scan identified reflux associated lesions in 30%
of patients. The detection rate of minimal change GERD
was significantly higher in the i-scan group as compared to
white-light endoscopy, but was not different for erosive
reflux esophagitis grade A and grade B according to the
Los Angeles classification (LA). Additionally, i-scan
showed better interobserver agreement than white-light
endoscopy. These data were also confirmed by Kim and
coworkers.19
PRESENT APPLICATIONS OF i-SCAN
TECHNOLOGY IN THE STOMACH
D IAGNOSES OF ATROPHIC gastritis, vascular lesions
such as gastric antral vascular ectasia (GAVE), and
gastric neoplasms represent potential candidates for appli-
cation of i-scan in the stomach (Figs 1,2). Currently, only
limited data are available on the use of i-scan for detection
of gastric lesions. However, in our experience, i-scan might
increase the detection of early gastric cancer in comparison
with white-light endoscopy.20 Additionally, our preliminary
results of i-scan revealed significantly higher accuracy in
the diagnoses of lateral tumor extent in 21 gastric neo-
plasms in comparison with white-light endoscopy (95.2%
vs 66.7%).21 Taken together, i-scan could potentially be
used for screening endoscopy to detect gastric lesions
and might also be useful for detailed inspection after detec-
tion of suspicious lesions. Nevertheless, well-designed, pro-
spective studies on this topic are still missing and highly
anticipated.
Figure 1 Intestinal-type intramucosal
gastric cancer at the lesser curvature of
the gastric body. (a) During white-light
endoscopy, correct identification of the
lesion is difficult. (b) i-scan endoscopy
enhances the lesion for better detec-
tion and characterization.
© 2013 The Authors
46 H. Neumann et al. Digestive Endoscopy 2014; 26 (Suppl. 1): 43–51

A B C

Figure 2 Intestinal-type intramucosal gastric cancer. (a) White-light endoscopy shows a small reddish depression in the lower gastric
body. (b) i-scan enhances the atrophic changes in the background as well as the tumor itself, which reveals that the tumor is located on
the atrophic border. (c) i-scan additionally reveals a clear demarcation line of the tumor to the surrounding tissue.

PRESENT APPLICATIONS OF i-SCAN instruments used for polypectomy, retrieval devices,

TECHNOLOGY FOR DUODENAL PATHOLOGIES physician and nurses fees, pathology assessments and
further surveillance. Therefore, the American Society for
O NLY LIMITED DATA are currently available on the
use of i-scan for the diagnosis of duodenal lesions.
One recent pilot study aimed to determine the diagnostic
Gastrointestinal Endoscopy (ASGE) recently introduced
a new concept for real-time endoscopic assessment of
the histology of diminutive polyps.25 The so-called PIVI
accuracy of i-scan for the evaluation of duodenal villous
(Preservation and Incorporation of Valuable endoscopic
patterns by using histology as the reference standard.22
Innovations) statement includes two new attractive para-
During endoscopy, duodenal villous patterns were evaluated
digms to reduce costs associated with diminutive colon
and classified as normal, partial villous atrophy, or marked
polyp resection. First, in order for colorectal polyps ≤5 mm
villous atrophy and the results were then compared with
in size to be resected and discarded, endoscopic technology
histology. For i-scan, an overall accuracy of 100% was dem-
should provide ≥90% agreement in assignment of post-
onstrated for the detection of marked villous atrophy pat-
polypectomy surveillance compared to decisions based on
terns, whereas the accuracy was 90% for determination of
pathological assessment of all identified polyps. Second, in
partial villous atrophy or normal villous patterns. Another
order for a technology used to guide the decision to leave
recent report highlighted the potential of i-scan for in vivo
suspected hyperplastic polyps ≤5 mm in size in place, the
diagnosis of Whipple’s disease.23 White-light endoscopy
technology should provide a negative predictive value
revealed pale yellow, shaggy mucosa with intermittent,
>90% for adenomatous polyp histology. One recent two-
superficial, erythematous eroded patches of the duodenum,
center trial examined whether i-scan was feasible to cor-
whereas i-scan additionally revealed edematous and
rectly identify hyperplastic and adenomatous colorectal
engorged duodenal villi filled with a white material repre-
lesions and also assessed the learning curve of this tech-
senting lymph. Moreover, concentric rings of the mucosa
nique.26 After a training set containing 20 images with
were visible, which have been identified to be specific for
known histology was reviewed to standardize image inter-
Whipple’s disease in previous studies using optical magni-
pretation, images from 110 colorectal lesions were ana-
fication endoscopy with 115-fold magnification.24
lyzed by using corresponding polypectomies as the
reference standard. Overall, four endoscopists with no prior
experience in i-scan image interpretation from two differ-
PRESENT APPLICATIONS OF i-SCAN
ent endoscopy centers evaluated the images. Overall accu-
TECHNOLOGY FOR COLORECTAL LESIONS
racy for the group was 74% for lesions 1 to 22, 80% for

C OLORECTAL CANCER IS the second most common

cause of cancer-related death in Europe and North
America and it is well accepted that screening colonoscopy
reduces colorectal cancer mortality by early detection and
endoscopic treatment (i.e. polypectomy). Nevertheless, the
unnecessary removal of non-adenomatous polyps results in
enormous costs for the health-care system related to the
lesions 23 to 44, 84% for lesions 45 to 66, 88% for lesions
67 to 88, and 94% for lesions 89 to 110. Accuracy of i-scan
for prediction of polyp histology was not dependent on
polyp size (≤5 mm, 6–10 mm, >10 mm) and the ability to
obtain high-quality images was stable over time and con-
stantly produced high-quality images. Whereas negative
predictive value was moderate in the first three sessions

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Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 1): 43–51
(50–80%) it increased for the subsequent 22 lesions (71–
83%). In the last teaching sessions, two investigators
reached the proposed negative predictive value ≥90%
according to the ASGE PIVI statement (80–100%). The
authors concluded that accurate interpretation of i-scan
images for prediction of hyperplastic and adenomatous
colorectal lesions follows a learning curve but can be
learned rapidly.
Another recent multicenter study including eight expert
endoscopists assessed interobserver agreement in the visu-
alization of the surfaces and margins of colorectal polyps
and in distinguishing neoplastic from non-neoplastic polyps
by using i-scan.27 A total of 400 images were stored for
analysis. Distinction between neoplastic and non-neoplastic
tissue was based on Kudo’s pit pattern classification, con-
sidering patterns I and II as non-neoplastic lesions and pat-
terns III, IV and V as neoplastic lesions (III and IV as
adenomatous and V as carcinomas). Overall, there was a
kappa agreement of 0.370 (P < 0.001) and 0.306 (P < 0.001)
regarding pit pattern and margins, respectively. The kappa
agreement for the differentiation between neoplastic and
non-neoplastic lesions was 0.446 (P < 0.001). Accordingly, a
good interobserver agreement was observed for the evalua-
tion of neoplastic and non-neoplastic lesions and a less good
agreement for the evaluation of pit pattern and margins. The
authors concluded that adequate training is required in order
to interpret images acquired with the i-scan technique.
One recent study compared the detection rate of mucosal
lesions using i-scan and the withdrawal time of the instru-
ment among non-expert and expert endoscopists during
screening colonoscopy for colorectal cancer.28 Overall, 542
colonoscopies were carried out. Notably, it was found that
i-scan enabled less experienced endoscopists to achieve
results comparable to those of experienced ones in detecting
mucosal lesions (Fig. 3).
Hoffman and coworkers prospectively compared high-
definition colonoscopy with i-scan versus standard video
colonoscopy.29 In their study, a total of 220 patients were
randomized in a 1:1 ratio. In this study, i-scan detected
A B
Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society
i-scan: Optical enhancement technology 47
significantly more patients with colorectal neoplasia (38%)
compared with standard resolution endoscopy (13%). More-
over, significantly more neoplastic (adenomatous and can-
cerous) lesions and more flat adenomas were detected by
using i-scan. Of interest, the final histological result could be
predicted with a nearly 99% accuracy. These data were also
confirmed by Testoni et al. showing that i-scan during the
withdrawal phase of colonoscopy significantly increased the
detection of colonic mucosal lesions, particularly the detec-
tion of small and non-protruding polyps.30 In contrast to
these studies, one prospective, randomized, back-to-back
trial was not able to show a significantly improved adenoma
detection rate when using i-scan.31 Patients were randomized
to the first withdrawal with either conventional high-
definition white-light or i-scan. In addition, all patients
underwent a second examination with high-definition white-
light as the criterion standard. The adenoma detection rates
during the first withdrawal of high-definition, i-scan 1 mode,
and i-scan 2 mode were 32%, 37%, and 33%, respectively
(P = 0.742), and the adenoma miss rates of each group were
23%, 19%, and 16%, respectively (P = 0.513). Based on the
multivariate analysis, the application of i-scan was not asso-
ciated with an improvement in adenoma detection and the
prevention of missed polyps. However, the prediction of
neoplastic and non-neoplastic colorectal lesions was more
precise in the i-scan group as compared with the high-
definition white-light group.
The group from Frankfurt tested the efficacy of high-
definition white-light endoscopy alone and in combination
with i-scan or methylene blue-aided chromoendoscopy in
screening for colorectal cancer.32 In 69 patients studied,
i-scan augmented the identification of lesions from 176 to
335 (P < 0.001) and chromoendoscopy to 646 (P < 0.001).
Additional detected lesions were mainly flat polyps and the
number of neoplasias detected was not significantly different
between groups (high-definition: 5, i-scan: 11, chromoen-
doscopy: 11), but all could be correctly predicted using
i-scan or chromoendoscopy. Of note, i-scan was able
to predict neoplasia as precisely as chromoendoscopy.
Figure 3 Non-polypoid lesion with a
mucus cap in the ascending colon visu-
alized by (a) high-definition white-light
endoscopy and (b) i-scan technology.
Surface characteristics and borders of
the lesion become more obvious by
using i-scan.
© 2013 The Authors
48 H. Neumann et al.
The potential of i-scan for real-time prediction of colorectal
polyp histology was also highlighted by a study from the
Modena group in Italy reporting on a sensitivity, specificity,
and accuracy of 95%, 82%, and 92%, respectively.33 Among
the subset of polyps with good or excellent quality images,
sensitivity and accuracy of i-scan significantly improved to
97% and 94%, respectively.
PRESENT APPLICATIONS OF i-SCAN
TECHNOLOGY FOR INFLAMMATORY
BOWEL DISEASE
A CCURATE ASSESSMENT OF disease activity and
extent in inflammatory bowel disease (IBD) appears to
be of paramount importance for optimized medical therapy.
Nevertheless, standard white-light endoscopy is likely an
insensitive test for diagnosis of IBD in the quiescent or even
mild phase of the disease.34,35 Therefore, multiple random
biopsies have to be taken because only histopathology is
currently able to predict the exact disease extent and severity
in IBD.36,37
One recent study evaluated whether i-scan has the poten-
tial to enhance assessment of disease severity and extent in
patients with mild or inactive IBD in comparison to high-
definition white-light endoscopy (HD-WL).38 Consecutive
patients with IBD were randomly assigned in a 1:1 ratio to
undergo colonoscopy with HD-WL (Group 1) or i-scan
(Group 2) and the mucosal vascular pattern and any mucosal
abnormalities were recorded. Average duration of the exami-
nation was 18 min in group A and 20.5 min in group B,
which was not statistically significant. When comparing the
endoscopic prediction of inflammatory extent and activity
with the histological results, an overall agreement of 51%
and 56% (group A) and 92% and 90% (group B) was found,
respectively. These differences were statistically significant.
Therefore, the present study indicated that i-scan has the
potential to significantly improve the diagnosis of severity
and extent of mucosal inflammation in patients with IBD and
may therefore open new implications for therapeutic inter-
ventions in patients suffering from IBD.
Moreover, one recent study reported on the potential of
i-scan for prediction of mucosal changes in patients with
suspected food allergy. Preliminary data suggested that
patients with intestinal food allergy present with lymphoid
hyperplasia, slight mucosal edema and blurred mucosal vas-
cular pattern. Based on these findings, i-scan could predict
food allergy with a sensitivity, specificity and accuracy of
85%, 89%, and 86%, respectively. Positive and negative pre-
dictive value for i-scan to predict food allergy were 92% and
80%, respectively.39
© 2013 The Authors
Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2014; 26 (Suppl. 1): 43–51
OPTICAL ENHANCEMENT TECHNOLOGY
N EW IMAGE-ENHANCED ENDOSCOPIC technol-
ogy using band-limited light, optical enhancement
(OE), was developed by HOYA Co. (Tokyo, Japan) and is
now equipped with the latest endoscopy system (Pentax
Video Processor EPK-i7000; HOYA Co.). The new technol-
ogy combines digital signal processing in a similar way to
i-scan and optical filters that limit the spectral characteristics
of the illumination light.
Previous i-scan technology uses white light alone as an
illumination light and digital post-processing of the reflec-
tion afterwards creates images yielding the virtual chromo-
endoscopic image. Although accumulating evidence has
shown the usefulness of i-scan in the clinical setting, emis-
sion of white light alone causes a potential limitation for the
current i-scan technology to obtain higher contrast images of
microvascular pattern on the mucosal surface in combination
with high magnification as shown by NBI with optical mag-
nification. The basic concept of OE is to overcome the dark-
ness of NBI which results in less usefulness for detectability
in wide-range observation in the full extended gastrointesti-
nal lumen. The new innovated optical filters achieve higher
overall transmittance by connecting the peaks of the hemo-
globin absorption spectrum (415 nm, 540 nm and 570 nm)
creating a continuous wavelength spectrum. There are two
modes with different OE filters (Mode 1 and Mode 2)
(Fig. 4). In the Mode 1 optical filter, the main wavelengths of
spectral transmission correspond to the peaks of the hemo-
globin absorption spectrum and the light between these
peaks is continuously slightly emitted by raising baseline
transmittance. In the Mode 2 optical filter, the main wave-
lengths of the short and mid-wavelength correspond to the
peaks of the hemoglobin absorption spectrum, and the main
R wavelength of the RGB signal is added on the long-wave
side. The light between these peaks is also continuously
slightly emitted by raising baseline transmittance to achieve
the maximum amount of illumination. Mode 1 is designed
mainly to improve visualization of microvessels with a suf-
ficient amount of light, and Mode 2 is designed to improve
contrast of white-light observation by bringing the color tone
of the overall image closer to that of natural color (white
color tone) with much more light than that of the Mode 1
filter. By using the optical filter (Mode 1 or Mode 2), the
microvascular patterns in addition to microsurface patterns
on the mucosal surface are clearly observed, which means
that the knowledge obtained by optical chromoendoscopy
could potentially be brought into the i-scan technology
(Figs 4–7). Representative cases of endoscopic images are
shown in Figures 2–4. From our pilot study by using OE
Mode 2 and Mode 1 we found that these methods may be
Digestive Endoscopy 2014; 26 (Suppl. 1): 43–51
A B
Figure 5 Superficial esophageal cancer with submucosal invasion. (a) White-light image. (b) Mode 2 image. (c) Mode 1 with magnifica-
tion image.
useful for detection and characterization of gastrointestinal
neoplasms, respectively.40
CONCLUSION
A LTHOUGH RECENTLY INTRODUCED, various
large and prospective studies have already shown the
benefit of i-scan for patient management during ongoing
endoscopy. Indications for image-enhanced endoscopy with
i-scan include diagnosis of minimal change esophagitis,
duodenal pathologies, colorectal adenomas and inflamma-
tory bowel disease. Future studies should now focus on the
detection of other esophageal pathologies including squa-
mous cell cancer and Barrett’s esophagus as well as gastric
Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society
i-scan: Optical enhancement technology 49
Figure 4 Characteristics of optical
filters and ex-vivo observation of
esophageal cancerous tissue.
C
lesions. The new optical enhancement technology offers a
new potential for enhanced diagnosis of lesions throughout
the whole luminal gastrointestinal tract. This new technology
is promising to overcome higher miss rates and lower accu-
racy of characterization. Accumulation of cases and well-
designed clinical trials in the near future are warranted and
highly anticipated.
CONFLICTS OF INTEREST
H ELMUT NEUMANN IS a recipient of the 2013 ASGE
Cook Medical Don Wilson Award. This work was
done during his awardee period at the Basil Hirschowitz
Endoscopic Center of Excellence, University of Alabama,
© 2013 The Authors
50 H. Neumann et al.
A B
Figure 6 Intestinal-type intramucosal gastric cancer. (a) White-light image. (b) Mode 2 image. (c) Mode 1 with magnification image.
A B
Figure 7 Laterally spreading-type intramucosal colon cancer. (a) White-light image. (b) Mode 2 image. (c) Mode 1 with magnification
image.
Birmingham, USA. Mitsuhiro Fujishiro has served as a lec-
turer for Eisai Pharmaceuticals Co., Ltd and his department
has obtained a donation from Dainihon Sumitomo Pharma-
ceuticals Co., Ltd. He is also a chief investigator in a coop-
erative study between The University of Tokyo and HOYA
Corporation regarding optical enhanced technology. The
other authors have no relevant conflicts of interest to disclose.
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