The learning curve, interobserver, and intraobserver agreement of endoscopic confocal laser endomicroscopy in the assessment of mucosal barrier defects.
OBJECTIVE
Confocal laser endomicroscopy can dynamically assess intestinal mucosal barrier defects and increased intestinal permeability (IP). These are functional features that do not have corresponding appearance on histopathology. As such, previous pathology training may not be beneficial in learning these dynamic features. This study aims to evaluate the diagnostic accuracy, learning curve, inter- and intraobserver agreement for identifying features of increased IP in experienced and inexperienced analysts and pathologists.


METHODS
A total of 180 endoscopic confocal laser endomicroscopy (Pentax EC-3870FK; Pentax, Tokyo, Japan) images of the terminal ileum, subdivided into 6 sets of 30 were evaluated by 6 experienced analysts, 13 inexperienced analysts, and 2 pathologists, after a 30-minute teaching session. Cell-junction enhancement, fluorescein leak, and cell dropout were used to represent increased IP and were either present or absent in each image. For each image, the diagnostic accuracy, confidence, and quality were assessed.


RESULTS
Diagnostic accuracy was significantly higher for experienced analysts compared with inexperienced analysts from the first set (96.7% vs 83.1%, P < .001) to the third set (95% vs 89.7, P = .127). No differences in accuracy were noted between inexperienced analysts and pathologists. Confidence (odds ratio, 8.71; 95% confidence interval, 5.58-13.57) and good image quality (odds ratio, 1.58; 95% confidence interval, 1.22-2.03) were associated with improved interpretation. Interobserver agreement κ values were high and improved with experience (experienced analysts, 0.83; inexperienced analysts, 0.73; and pathologists, 0.62). Intraobserver agreement was >0.86 for experienced observers.


CONCLUSIONS
Features representative of increased IP can be rapidly learned with high inter- and intraobserver agreement. Confidence and image quality were significant predictors of accurate interpretation. Previous pathology training did not have an effect on learning.
Gastroenterology and Liver Services, Bankstown Hospital, Sydney South West Local Health District, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Jeff
J
Chang
Gastroenterology and Liver Services, Bankstown Hospital, Sydney South West Local Health District, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Matthew
M
Ip
Gastroenterology and Liver Services, Bankstown Hospital, Sydney South West Local Health District, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Michael
M
Yang
Gastroenterology and Liver Services, Bankstown Hospital, Sydney South West Local Health District, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Brendon
B
Wong
Department of Histopathology, Douglass Hanly Moir Pathology, Sydney, New South Wales, Australia; Faculty of Medicine, The University of Notre Dame, Sydney, New South Wales, Australia.
Theresa
T
Power
Department of Histopathology, Douglass Hanly Moir Pathology, Sydney, New South Wales, Australia; Faculty of Medicine, The University of Notre Dame, Sydney, New South Wales, Australia.
Lisa
L
Lin
Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia.
Wei
W
Xuan
Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Immunology Division, The Garvan Institute of Medical Research, Sydney, New South Wales, Australia.
Tri Giang
TG
Phan
Gastroenterology and Liver Services, Bankstown Hospital, Sydney South West Local Health District, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Immunology Division, The Garvan Institute of Medical Research, Sydney, New South Wales, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia.
Rupert W
RW
Leong
D002983:Clinical Competence; D016099:Endoscopy, Gastrointestinal; D006801:Humans; D015212:Inflammatory Bowel Diseases / Q000000981:diagnostic imaging* / Q000473:pathology / Q000503:physiopathology; D007413:Intestinal Mucosa / Q000000981:diagnostic imaging* / Q000378:metabolism* / Q000473:pathology; D059032:Learning Curve; D018613:Microscopy, Confocal / Q000592:standards; D015588:Observer Variation; D010539:Permeability