Diagnostic accuracy of confocal laser endomicroscopy for the ex vivo characterization of peritoneal nodules during laparoscopic surgery



Intraoperative characterization of peritoneal nodules can be challenging. Probe-based confocal laser endomicroscopy (pCLE) is an innovative technique enabling real-time microscopic analysis. This study aimed to assess the role of pCLE in the discrimination of benign versus malignant peritoneal nodules during laparoscopic staging.

Materials and methods

During this prospective trial, pCLE was performed ex vivo on fresh samples of peritoneal nodules in 30 consecutive patients, after topical application of indocyanine green. The final diagnosis was obtained histologically, as per standard of care. pCLE image criteria for normal versus inflammatory versus malignant nodules were established (phase I); these criteria were tested retrospectively on selected videos by two examiners (phase II). The primary endpoints were values of accuracy in diagnosing malignant nodules.


pCLE criteria for malignant nodules defined in phase I were: strongly fluorescent irregular clusters of cancerous cells, nonfluorescent nuclei of cancerous cells, and substantially lower fluorescence of the extracellular matrix fluorescence compared with cancerous clusters. In phase II, the detection rate of these criteria was significantly higher in malignant compared with benign nodules. Overall sensitivity, specificity, positive and negative predictive values to detect malignant nodules were 75, 100, 100 and 89 %, respectively. Interobserver agreement was substantial (kappa 0.69).


These preliminary results suggest that pCLE is a valuable tool to discriminate between benign and malignant peritoneal nodules, with a high positive predictive value.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Vercauteren T, Meining A, Lacombe F, Perchant A (2008) Real time autonomous video image registration for endomicroscopy: fighting the compromises. Three-Dimens Multidimens Microsc Image Acquis Process XV 6861:68610C

  2. 2.

    Becker V, Vieth M, Bajbouj M, Schmidt RM, Meining A (2008) Confocal laser scanning fluorescence microscopy for in vivo determination of microvessel density in Barrett’s esophagus. Endoscopy 40:888–891

  3. 3.

    Caillol F, Filoche B, Gaidhane M, Kaheleh M (2013) Refined probe-based confocal laser endomicroscopy classification for biliary strictures: the Paris classification. Dig Dis Sci 58:1784–1789

  4. 4.

    Shahid MW, Buchner AM, Coron E (2012) Diagnostic accuracy of probe-based confocal laser endomicroscopy in detecting residual colorectal neoplasia after EMR: a prospective study. Gastrointest Endosc 75:525–533

  5. 5.

    Napoléon B, Lemaistre AI, Pujol B, Caillol F, Lucidarme D, Bourdariat R, Morellon-Mialhe B, Fumex F, Lefort C, Lepilliez V, Palazzo L, Monges G, Filoche B, Giovannini M (2015) A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy. Endoscopy 47:26–32

  6. 6.

    Tontini GE, Mudter J, Vieth M, Atreya R, Günther C, Zopf Y, Wildner D, Kiesslich R, Vecchi M, Neurath MF, Neumann H (2015) Confocal laser endomicroscopy for the differential diagnosis of ulcerative colitis and Crohn’s disease: a pilot study. Endoscopy 47:437–443

  7. 7.

    Sharma P, Meining AR, Coron E, Lightdale CJ, Wolfsen HC, Bansal A, Bajbouj M, Galmiche JP, Abrams JA, Rastogi A, Gupta N, Michalek JE, Lauwers GY, Wallace MB (2011) Real-time increased detection of neoplastic tissue in Barrett’s esophagus with probe-based confocal laser endomicroscopy: final results of an international multicenter, prospective, randomized, controlled trial. Gastrointest Endosc 74:465–472

  8. 8.

    Thiberville L, Moreno-Swirc S, Vercauteren T, Peltier E, Cavé C, Bourg Heckly G (2007) In vivo imaging of the bronchial wall microstructure using fibered confocal fluorescence microscopy. Am J Respir Crit Care Med 175:22–31

  9. 9.

    Wellikoff AS, Holladay RC, Downie GH, Chaudoir CS, Brandi L, Turbat-Herrera EA (2015) Comparison of in vivo probe-based confocal laser endomicroscopy with histopathology in lung cancer: a move toward optical biopsy. Respirology 20:967–974

  10. 10.

    Wu K, Liu JJ, Adams W, Sonn GA, Mach KE, Pan Y, Beck AH, Jensen KC, Liao JC (2011) Dynamic real-time microscopy of the urinary tract using confocal laser endomicroscopy. Urology 78:225–231

  11. 11.

    Zlatev DV, Altobelli E, Liao JC (2015) Advances in imaging technologies in the evaluation of high-grade bladder cancer. Urol Clin North Am 42:147–157

  12. 12.

    Grobmyer SR, Fong Y, D’Angelica M, Dematteo RP, Blumgart LH, Jarnagin WR (2004) Diagnostic laparoscopy prior to planned hepatic resection for colorectal metastases. Arch Surg 139:1326–1330

  13. 13.

    Oberschmid B, Dietrich A, Wittekind C (2012) Frozen sections diagnostics in visceral surgery. Stomach and intestines. Pathologie 33:407–412

  14. 14.

    Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, Moher D, Rennie D, de Vet HC, Lijmer JG (2003) The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 138:W1–W12

  15. 15.

    Wang KK, Carr-Lock DL, Singh SK, Neumann H, Bertani H, Galmiche JP, Arsenescu RI, Caillol F, Chang KJ, Chaussade S, Coron E, Costamagna G, Dlugosz A, Ian Gan S, Giovannini M, Gress FG, Haluszka O, Ho KY, Kahaleh M, Konda VJ, Prat F, Shah RJ, Sharma P, Slivka A, Wolfsen HC, Zfass A (2015) Use of probe-based confocal laser endomicroscopy (pCLE) in gastrointestinal applications. A consensus report based on clinical evidence. U Euro Gastroenterol J 3:230–254

  16. 16.

    Anderson MA, Appalaneni V, Ben-Menachem T, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Fisher LR, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan K, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Shergill AK, Dominitz JA, Cash BD (2013) American Society for gastrointestinal endoscopy (ASGE) standards of practice committee. The role of endoscopy in the evaluation and treatment of patients with biliary neoplasia. Gastrointest Endosc 77:167–174

  17. 17.

    ASGE Technology Committee, Chauhan SS, Abu Dayyeh BK, Bhat YM, Gottlieb KT, Hwang JH, Komanduri S, Konda V, Lo SK, Manfredi MA, Maple JT, Murad FM, Siddiqui UD, Banerjee S, Wallace MB (2014) Confocal laser endomicroscopy. Gastrointest Endosc 80:928–938

  18. 18.

    Von Delius S, Feussner H, Wilhelm D, Karagianni A, Henke J, Schmid RM, Meining A (2007) Transgastric in vivo histology in the peritoneal cavity using miniprobe-based confocal fluorescence microscopy in an acute porcine model. Endoscopy 39:407–411

  19. 19.

    Meining A, Bajbouj M, Delius S, Prinz C (2007) Confocal laser scanning microscopy for in vivo histopathology of the gastrointestinal tract. Arab J Gastroenterol 8(1):1–4

  20. 20.

    Hong JH, Song SH, Kim SE (2011) Diffuse intraabdominal fibrosis and inflammation mimicking peritoneal carcinomatosis recurred after surgery for borderline ovarian tumor misdiagnosed by 18F-fluorodeoxyglucose-positron emission tomography. Eur J Gynaecol Oncol 32:231–233

Download references


We would like to thank Pauline La Fay, Siddharth Maskara from Mauna Kea Technologies, Bérengère Bardou from Endocontrol for additional logistical support during the trial and BPI France for financial support.

Author information

Correspondence to David Fuks.

Ethics declarations


The study was funded by BPI France: #I0911038 W Prof. Brice Gayet is a consultant for Mauna Kea Technologies. Mr. Pierangelo, Dr. Fuks, Dr. Validire, Prof. Gayet have received funding from Mauna Kea Technologies to support congress registration and travel fees. Dr. Benali has no conflict of interest or financial ties to disclose.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (MOV 18891 kb)

Supplementary material 1 (MOV 18891 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Pierangelo, A., Fuks, D., Benali, A. et al. Diagnostic accuracy of confocal laser endomicroscopy for the ex vivo characterization of peritoneal nodules during laparoscopic surgery. Surg Endosc 31, 1974–1981 (2017) doi:10.1007/s00464-016-5172-7

Download citation


  • Confocal laser endomicroscopy
  • Fluorescence
  • Peritoneal carcinosis
  • Extracellular matrix