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Narrow Band Imaging (NBI)

A New Wave of Diagnostic Possibilities.

LIGHT ABSORPTION MAKES ALL THE DIFFERENCE

Olympus Narrow Band Imaging (NBI) has set a new standard for endoscopy. Now, the improved NBI with EVIS EXERA III takes imaging to a completely new level. This page provides an insight into this innovative technology, highlighting how NBI works and how to optimise images, plus various studies that analyse its overwhelming potential for the early detection of cancers.

Achieve More with NBI

Being a powerful optical image enhancement technology, Narrow Band Imaging improves the visibility of vascular and mucosal structures. This happens because narrow band light only consists of two wavelengths, namely 415 nm blue light and 540 nm green light.

NBI light is absorbed by vessels but reflected by mucosa. This offers a huge benefit: NBI achieves a maximum contrast of vessels and the surrounding mucosa. The shorter NBI light wavelength is only absorbed by superficial vessels. This facilitates the detection of tumors, as they are often highly vascularized. The longer 540 nm NBI light penetrates deeper and is absorbed by blood vessels located deeper within the mucosal layer. Thus, it is particularly helpful to display the deeper vasculature of suspect lesions.

NBI with EVIS EXERA III - More Power for Accurate Diagnosis

The cutting-edge EVIS EXERA III video endoscopy system from Olympus features improved NBI technology. Each component has been enhanced to achieve the best possible images. Combining a brighter light source, a more sensitive CCD, and 3D noise reduction, the whole system provides up to twice the viewable distance as compared to EVIS EXERA II, giving you much more flexibility and helping to speed up your endoscopic examination.

Esophagus

Targeted biopsy with NBI is a reliable and efficient method for the screening & surveillance of Barrett’s esophagus.

This conclusion arises from an international, randomized, crossover trial comparing HD-WLE and NBI with 123 patients by Sharma et al. , published in Gut. 2013, 62 (1), pp. 15–21.

The aim of the study was to compare high-definition white-light endoscopy (HD-WLE) applying the Seattle protocol and NBI targeted biopsy for detection of IM and neoplastic tissue in Barrett’s Esophagus. The authors examined the differences of HD-WLE and NBI biopsies with respect to (1) the proportion of patients with intestinal metaplasia and neoplasia; (2) the proportion of neoplastic area; and (3) the number of overall biopsies performed.

The results: For detection of IM, HD-WLE and NBI each yielded detection rates of 92%. While HD-WLE required a mean of 7.6 biopsies per patient, NBI only required 3.6 biopsies. For detection of dysplasia, the diagnostic yield of HD-WLE and NBI were equivalent. However, NBI required fewer biopsies than HD-WLE in patients with short-segment BO (3.0 vs. 3.9) and patients with long-segment BO (4.1 vs. 10.9).


Thus, NBI may improve the efficiency of Barrett’s Esophagus endoscopic screening and surveillance and even reduce pathology costs, thanks to fewer biopsies being taken.

NBI increases the detection rate of squamous cell carcinoma compared to WLE in both the H&N region and the esophagus.

This result was found by Manabu Muto et al. in a randomized controlled clinical study with 360 patients, comparing the real-time detection rate of superficial SCC and HNSCC with WLE and NBI in a back-to-back fashion. See details in the Journal of Clinical Oncology. 2010, 28 (9), pp. 1566–1572. (link to Muto et al.)


Esophageal cancer is the eighth most common cancer in the world with mostly a poor prognosis. This is mainly due to the fact that white-light endoscopy has a poor detection rate of early-stage cancers. Therefore, esophageal SCC and head & neck SCC (HNSCC) are often detected at a late stage. The aim of the study was to verify if NBI could improve the detection rates for squamous cell carcinoma of the head and neck region as well as the esophagus.


The results were promising. While primary NBI detected all (100%) of the superficial cancers in the H&N region, primary WLE detected only 8.0% (Table 1). In the esophagus, primary NBI detected 97% of the lesions while primary WLE reached only 55%. The detection rate of secondary NBI after primary WLE significantly increased in both the H&N region (8.0% vs. 77%) and esophagus (55% vs. 95%). In contrast, if NBI was followed by secondary WLE, the detection rate declined. Fifty-seven percent of superficial cancers in the H&N region and 23% in the esophagus even were detected only by NBI. There was only one lesion that was detected by WLE but was missed by secondary NBI.


In conclusion, NBI has a significantly higher detection rate for SCC than white-light endoscopy and may become the standard examination for the early detection of superficial cancer in the H&N region and the esophagus.

CREATE HIGH-QUALITY IMAGES

With a large number of innovative functions, EVIS EXERA III opens up entirely new possibilities for diagnosis. The following chapter will show you how to get the most out of the system’s latest technologies.


The cutting-edge EVIS EXERA III endoscopy system provides you with several versatile technologies to enhance image quality: HDTV, Dual Focus, NBI, Pre-Freeze, and caps. Read here why these technologies can take you to the next level of endoscopy – and which settings to choose for the best results.

Colon

In-situ optical diagnosis of diminutive and small polyps is accurate with NBI and may reduce the need for tissue sampling and thus pathology costs.

A meta-analysis by McGill et al. published in Gut 2013; 62 : 1704–1713 analyzed 28 studies on the real-time diagnostic performance of NBI colonoscopy. They found that real-time endoscopic diagnosis of colorectal polyps with NBI is highly accurate, with the area under the summary receiver operator curve exceeding >0.90. High-confidence predictions provide >90% sensitivity and NPV for adenomateous histology. Furthermore, surveillance interval predictions based upon the optical diagnosis were in agreement with pathology in more than 90% of patients.


In conclusion, the adaption of NBI optical diagnosis of colorectal polyps, particularly in high-confidence predictions, is promising for making colonoscopy more cost effective and efficient by potentially avoiding the need for pathological examination.

The NICE classification is a simple and accurate tool to differentiate between hyperplastic and adenomatous polyps using NBI.


Hewett et al. developed a simple tool to assess the histology of colorectal polyps: the NBI International Colorectal Endoscopic (NICE) Classification. Their randomized controlled multi-center study, published in Gastroenterology. 2012, 143 (3), pp. 599–607, does not only provide a simple tool for NBI-supported real-time assessment of colorectal polyps. It also shows that applying this classification scheme is accurate enough to consider the resect-and-discard policy which is a promising practice to save pathology costs.

The criteria of the NICE classification were rated both with experts and fellows followed by an overall prediction of histology. Surface pattern reached the highest values in accuracy, sensitivity, specificity, and negative predictive value. When combining the criteria, the presence of adenomateous features achieved an overall accuracy, sensitivity, and specificity of 92%, 92% and 95% respectively. The negative predictive value for adenomateous histology was 92%. These values further increased when low-confidence predictions were excluded.

In conclusion, if used with high-definition endoscopy, the NICE classification is suitable to differentiate between hyperplastic and adenomatous polyps. Fulfilling the minimum performance benchmarks for assessing the histology of diminutive colorectal polyps, it may substantially contribute to reduce the cost of colonoscopy.

Begin with Good Preparation

Especially when it comes to colonoscopy, good preparation is obligatory. If the bowel is poorly prepared, optical diagnoses are very difficult to make. Regardless of the technique you are using, there are some steps you can take to ensure a sound basis for the examination. First of all, ensure that the patient understands and adheres to the dietary restrictions. Secondly, when treating inpatients, make sure that you and your colleagues are acting in unison and that the patient receives all necessary information. And in case you choose a polyethylene glycol (PEG) regime instead of sodium phosphate, consider splitting the dose (2.0 to 4.0 l) to increase acceptance ( Kilgore et al. ).

Flushing Pumps

Flushing pumps can easily be attached to the endoscope to irrigate fluid either via the instrument or auxiliary water channel. This is very helpful to efficiently wash away any debris and remaining organic material during endoscopic examinations. The use of flushing pumps also facilitates the identification of bleeding sources. Furthermore, these accessories can rapidly fill organs with fluid for “underwater” endoscopy, also assisting in endoscopic ultrasound procedures. Underwater viewing enhances the clarity of structures.

HDTV

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The higher the image resolution, the greater the chance to detect lesions at an early stage. EVIS EXERA III offers a resolution of 1,920 × 1,080 pixels, which helps you to see significantly more. However, you should consider that your images have to pass through several stations before being displayed. At Olympus, we refer to this as the HDTV chain.

Dual Focus

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Using an innovative two-stage optical system, the EVIS EXERA III HQ190 endoscopes allow you to switch between two focus settings: "normal mode" and "near mode". The "normal mode" suits normal observation at a distance of 5.0-100mm and a 170° field of view, while the "near mode" allows to closely observe finest mucosal surfaces at a distance of 2.0-6.0 mm with 160 degrees field of view. The nice overlap of the depths of field as all as almost identical field of view does not only help to attain the desired view but also to stay in focus and achieve a good diagnostic image.

Moreover, different from the quite complicated handling of traditional zoom endoscopes, you can simply switch these modes by a push of a scope button. Apart from that, Dual Focus endoscopes are more flexible and easier to maneuver within the human being, as the optical zoom mechanism is significantly decreased in size.

Pre-Freeze

The new EVIS EXERA III CV-190 automatically buffers a continuous, rapid series of procedural images. When capturing a still image, the pre-freeze fundtion analyzes the previous images and displays and saves the sharpest image of the desired view. Thus, it helps to optain a clear visual record of the procedure in shortest possible time and minimizes re-takes.

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