What’s the best approach for dysplasia surveillance in IBD?

 

Chromoendoscopy

Chromoendoscopy is superior in both the detection and long-term management of dysplasia in IBD when compared to high-definition white-light examination. Chromoendoscopy not only enhances dysplasia detection but further improves the definition of these lesions which then facilitates endoscopic management.

Human beings have an innate visual perception limitation due to our inability to perceive depth in the red/green wavelength of light compared to the blue wavelength. All of the improvements in scope magnification and resolution bump up against this fact of our biology. Blue dye enhances our ability to perceive depth in this milieu and therefore detect and define flat lesions.

The superiority of chromoendoscopy when using standard definition colonoscopes has been demonstrated repeatedly and set the stage for the 2015 SCENIC international consensus statement and a seismic shift in our endoscopic management of dysplasia in patients with colitis. This evidence base remains relevant because only 77% of colonoscopies performed in the United States are performed using high-definition equipment. Nearly one-quarter of our patients lack access to the newer equipment and therefore without chromoendoscopy are being surveyed outside of current guidelines.

Since the SCENIC statement multiple studies comparing chromoendoscopy with newer higher resolution colonoscopes have been performed. The vast preponderance of evidence has shown either a trend toward superiority or the outright superiority of chromoendoscopy when compared with high-definition white-light examination in detection and long-term management of dysplasia.

Chromoendoscopy has allowed us to increase our visual vocabulary in describing dysplasia in the setting of colitis and, thus, open the door to further innovation and perhaps adoption of artificial intelligence going forward. Our ability to classify lesions encountered in colitis mucosa has become more precise with the expanded terminology the dye-enhanced high-definition view affords, with the Frankfurt Advanced Chromoendoscopic IBD Lesion Classification being the best and most detailed example.

It is no accident that advanced endoscopists have universally adopted chromoendoscopy for the management of dysplastic lesions whether by mucosal resection or submucosal dissection techniques. Chromoendoscopy is recommended by all society guidelines because of these inherent advantages.

Is high-definition white-light “good enough” for surveilling our patients with colitis? The overall incidence of CRC in IBD has been declining which makes each colonoscopy count more. We are performing up to 88 colonoscopies in patients with colitis to find a single cancer (compared to 8 in non-IBD surveillance patients). We need to be performing fewer and more precise chromoendoscopic examinations. We are otherwise failing to serve our IBD patients by performing too many negative procedures at too high a cost. Our patients deserve more than merely “good enough.”

James F. Marion, MD, is professor of medicine at the Icahn School of Medicine at Mount Sinai and director of education and outreach at The Susan and Leonard Feinstein Inflammatory Bowel Disease Center of The Mount Sinai Hospital, both in New York. He is on the advisory board for Janssen.
 

 

High-definition white light endoscopy

Longstanding ulcerative colitis and Crohn’s colitis increase the risk for developing colorectal cancer. The majority of neoplastic lesions are visible endoscopically, and therefore, dye spraying chromoendoscopy (DCE) may not be necessary for all inflammatory bowel disease (IBD) patients undergoing a routine dysplasia surveillance colonoscopy.

High-definition white light (HDWL) endoscopes have higher magnification capacities and pixel density than the standard definition (SD) systems and provide sharper images with fewer artifacts. Although DCE has been proven to be superior to SD, there have been no differences in detection of dysplasia for routine surveillance with use of HDWL compared to DCE.

The SCENIC guidelines key recommendation for optimizing detection and management of dysplasia in IBD is to use a HD colonoscope. Further, based on the recent ACG Practice Guidelines for Dysplasia Screening and Surveillance in 2019, HD colonoscopes are also recommended.

In a network meta-analysis of eight parallel-group randomized controlled trials (RCT), there was very low quality of evidence to support the use of DCE over HDWL. This was contrary to prior, non-RCT studies which suggested that both SD and HDWL were inferior to DCE. More recently, Iacucci and colleagues conducted a randomized noninferiority trial to determine detection rates of neoplastic lesions in IBD patients with longstanding colitis who had inactive disease and enrolled in HDWL, DCE, or virtual chromoendoscopy (VCE) groups. The conclusion was that VCE and HDWL was not inferior to DCE, and HDWL was sufficient in detection of all neoplastic lesions including dysplasia and adenocarcinoma. In another large multicenter, prospective RCT of nine tertiary hospitals in South Korea, the detection rates of colitis-associated dysplasia or all colorectal neoplasia were comparable in HDWL versus high-definition chromoendoscopy. Lastly, a meta-analysis of six RCTs concluded that, although DCE is superior to SD in identification of dysplasia, there was no benefit of DCE compared to HDWL.

In summary, HDWL colonoscopy should be the standard of care for routine dysplasia surveillance in IBD. DCE should be considered in patients who are found to have a dysplastic lesion by HDWL in order to better delineate the lesion margins, endoscopically resect or remove, and for future dysplasia surveillance colonoscopies in the higher-risk IBD patient. Overall, a close and careful examination of the entire colon with use of HDWL is sufficient in detection of dysplasia and for routine surveillance in IBD patients.

Anita Afzali, MD, MPH, AGAF, is medical director of the Inflammatory Bowel Disease Center and program director of the Advanced Inflammatory Bowel Disease Fellowship at Ohio State University in Hilliard, Ohio. She has no relevant conflicts of interest.



These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2021.

 

Chromoendoscopy

Chromoendoscopy is superior in both the detection and long-term management of dysplasia in IBD when compared to high-definition white-light examination. Chromoendoscopy not only enhances dysplasia detection but further improves the definition of these lesions which then facilitates endoscopic management.

Human beings have an innate visual perception limitation due to our inability to perceive depth in the red/green wavelength of light compared to the blue wavelength. All of the improvements in scope magnification and resolution bump up against this fact of our biology. Blue dye enhances our ability to perceive depth in this milieu and therefore detect and define flat lesions.

The superiority of chromoendoscopy when using standard definition colonoscopes has been demonstrated repeatedly and set the stage for the 2015 SCENIC international consensus statement and a seismic shift in our endoscopic management of dysplasia in patients with colitis. This evidence base remains relevant because only 77% of colonoscopies performed in the United States are performed using high-definition equipment. Nearly one-quarter of our patients lack access to the newer equipment and therefore without chromoendoscopy are being surveyed outside of current guidelines.

Since the SCENIC statement multiple studies comparing chromoendoscopy with newer higher resolution colonoscopes have been performed. The vast preponderance of evidence has shown either a trend toward superiority or the outright superiority of chromoendoscopy when compared with high-definition white-light examination in detection and long-term management of dysplasia.

Chromoendoscopy has allowed us to increase our visual vocabulary in describing dysplasia in the setting of colitis and, thus, open the door to further innovation and perhaps adoption of artificial intelligence going forward. Our ability to classify lesions encountered in colitis mucosa has become more precise with the expanded terminology the dye-enhanced high-definition view affords, with the Frankfurt Advanced Chromoendoscopic IBD Lesion Classification being the best and most detailed example.

It is no accident that advanced endoscopists have universally adopted chromoendoscopy for the management of dysplastic lesions whether by mucosal resection or submucosal dissection techniques. Chromoendoscopy is recommended by all society guidelines because of these inherent advantages.

Is high-definition white-light “good enough” for surveilling our patients with colitis? The overall incidence of CRC in IBD has been declining which makes each colonoscopy count more. We are performing up to 88 colonoscopies in patients with colitis to find a single cancer (compared to 8 in non-IBD surveillance patients). We need to be performing fewer and more precise chromoendoscopic examinations. We are otherwise failing to serve our IBD patients by performing too many negative procedures at too high a cost. Our patients deserve more than merely “good enough.”

James F. Marion, MD, is professor of medicine at the Icahn School of Medicine at Mount Sinai and director of education and outreach at The Susan and Leonard Feinstein Inflammatory Bowel Disease Center of The Mount Sinai Hospital, both in New York. He is on the advisory board for Janssen.
 

 

High-definition white light endoscopy

Longstanding ulcerative colitis and Crohn’s colitis increase the risk for developing colorectal cancer. The majority of neoplastic lesions are visible endoscopically, and therefore, dye spraying chromoendoscopy (DCE) may not be necessary for all inflammatory bowel disease (IBD) patients undergoing a routine dysplasia surveillance colonoscopy.

High-definition white light (HDWL) endoscopes have higher magnification capacities and pixel density than the standard definition (SD) systems and provide sharper images with fewer artifacts. Although DCE has been proven to be superior to SD, there have been no differences in detection of dysplasia for routine surveillance with use of HDWL compared to DCE.

The SCENIC guidelines key recommendation for optimizing detection and management of dysplasia in IBD is to use a HD colonoscope. Further, based on the recent ACG Practice Guidelines for Dysplasia Screening and Surveillance in 2019, HD colonoscopes are also recommended.

In a network meta-analysis of eight parallel-group randomized controlled trials (RCT), there was very low quality of evidence to support the use of DCE over HDWL. This was contrary to prior, non-RCT studies which suggested that both SD and HDWL were inferior to DCE. More recently, Iacucci and colleagues conducted a randomized noninferiority trial to determine detection rates of neoplastic lesions in IBD patients with longstanding colitis who had inactive disease and enrolled in HDWL, DCE, or virtual chromoendoscopy (VCE) groups. The conclusion was that VCE and HDWL was not inferior to DCE, and HDWL was sufficient in detection of all neoplastic lesions including dysplasia and adenocarcinoma. In another large multicenter, prospective RCT of nine tertiary hospitals in South Korea, the detection rates of colitis-associated dysplasia or all colorectal neoplasia were comparable in HDWL versus high-definition chromoendoscopy. Lastly, a meta-analysis of six RCTs concluded that, although DCE is superior to SD in identification of dysplasia, there was no benefit of DCE compared to HDWL.

In summary, HDWL colonoscopy should be the standard of care for routine dysplasia surveillance in IBD. DCE should be considered in patients who are found to have a dysplastic lesion by HDWL in order to better delineate the lesion margins, endoscopically resect or remove, and for future dysplasia surveillance colonoscopies in the higher-risk IBD patient. Overall, a close and careful examination of the entire colon with use of HDWL is sufficient in detection of dysplasia and for routine surveillance in IBD patients.

Anita Afzali, MD, MPH, AGAF, is medical director of the Inflammatory Bowel Disease Center and program director of the Advanced Inflammatory Bowel Disease Fellowship at Ohio State University in Hilliard, Ohio. She has no relevant conflicts of interest.



These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2021.

 

Chromoendoscopy

Chromoendoscopy is superior in both the detection and long-term management of dysplasia in IBD when compared to high-definition white-light examination. Chromoendoscopy not only enhances dysplasia detection but further improves the definition of these lesions which then facilitates endoscopic management.

Human beings have an innate visual perception limitation due to our inability to perceive depth in the red/green wavelength of light compared to the blue wavelength. All of the improvements in scope magnification and resolution bump up against this fact of our biology. Blue dye enhances our ability to perceive depth in this milieu and therefore detect and define flat lesions.

The superiority of chromoendoscopy when using standard definition colonoscopes has been demonstrated repeatedly and set the stage for the 2015 SCENIC international consensus statement and a seismic shift in our endoscopic management of dysplasia in patients with colitis. This evidence base remains relevant because only 77% of colonoscopies performed in the United States are performed using high-definition equipment. Nearly one-quarter of our patients lack access to the newer equipment and therefore without chromoendoscopy are being surveyed outside of current guidelines.

Since the SCENIC statement multiple studies comparing chromoendoscopy with newer higher resolution colonoscopes have been performed. The vast preponderance of evidence has shown either a trend toward superiority or the outright superiority of chromoendoscopy when compared with high-definition white-light examination in detection and long-term management of dysplasia.

Chromoendoscopy has allowed us to increase our visual vocabulary in describing dysplasia in the setting of colitis and, thus, open the door to further innovation and perhaps adoption of artificial intelligence going forward. Our ability to classify lesions encountered in colitis mucosa has become more precise with the expanded terminology the dye-enhanced high-definition view affords, with the Frankfurt Advanced Chromoendoscopic IBD Lesion Classification being the best and most detailed example.

It is no accident that advanced endoscopists have universally adopted chromoendoscopy for the management of dysplastic lesions whether by mucosal resection or submucosal dissection techniques. Chromoendoscopy is recommended by all society guidelines because of these inherent advantages.

Is high-definition white-light “good enough” for surveilling our patients with colitis? The overall incidence of CRC in IBD has been declining which makes each colonoscopy count more. We are performing up to 88 colonoscopies in patients with colitis to find a single cancer (compared to 8 in non-IBD surveillance patients). We need to be performing fewer and more precise chromoendoscopic examinations. We are otherwise failing to serve our IBD patients by performing too many negative procedures at too high a cost. Our patients deserve more than merely “good enough.”

James F. Marion, MD, is professor of medicine at the Icahn School of Medicine at Mount Sinai and director of education and outreach at The Susan and Leonard Feinstein Inflammatory Bowel Disease Center of The Mount Sinai Hospital, both in New York. He is on the advisory board for Janssen.
 

 

High-definition white light endoscopy

Longstanding ulcerative colitis and Crohn’s colitis increase the risk for developing colorectal cancer. The majority of neoplastic lesions are visible endoscopically, and therefore, dye spraying chromoendoscopy (DCE) may not be necessary for all inflammatory bowel disease (IBD) patients undergoing a routine dysplasia surveillance colonoscopy.

High-definition white light (HDWL) endoscopes have higher magnification capacities and pixel density than the standard definition (SD) systems and provide sharper images with fewer artifacts. Although DCE has been proven to be superior to SD, there have been no differences in detection of dysplasia for routine surveillance with use of HDWL compared to DCE.

The SCENIC guidelines key recommendation for optimizing detection and management of dysplasia in IBD is to use a HD colonoscope. Further, based on the recent ACG Practice Guidelines for Dysplasia Screening and Surveillance in 2019, HD colonoscopes are also recommended.

In a network meta-analysis of eight parallel-group randomized controlled trials (RCT), there was very low quality of evidence to support the use of DCE over HDWL. This was contrary to prior, non-RCT studies which suggested that both SD and HDWL were inferior to DCE. More recently, Iacucci and colleagues conducted a randomized noninferiority trial to determine detection rates of neoplastic lesions in IBD patients with longstanding colitis who had inactive disease and enrolled in HDWL, DCE, or virtual chromoendoscopy (VCE) groups. The conclusion was that VCE and HDWL was not inferior to DCE, and HDWL was sufficient in detection of all neoplastic lesions including dysplasia and adenocarcinoma. In another large multicenter, prospective RCT of nine tertiary hospitals in South Korea, the detection rates of colitis-associated dysplasia or all colorectal neoplasia were comparable in HDWL versus high-definition chromoendoscopy. Lastly, a meta-analysis of six RCTs concluded that, although DCE is superior to SD in identification of dysplasia, there was no benefit of DCE compared to HDWL.

In summary, HDWL colonoscopy should be the standard of care for routine dysplasia surveillance in IBD. DCE should be considered in patients who are found to have a dysplastic lesion by HDWL in order to better delineate the lesion margins, endoscopically resect or remove, and for future dysplasia surveillance colonoscopies in the higher-risk IBD patient. Overall, a close and careful examination of the entire colon with use of HDWL is sufficient in detection of dysplasia and for routine surveillance in IBD patients.

Anita Afzali, MD, MPH, AGAF, is medical director of the Inflammatory Bowel Disease Center and program director of the Advanced Inflammatory Bowel Disease Fellowship at Ohio State University in Hilliard, Ohio. She has no relevant conflicts of interest.



These remarks were made during one of the AGA Postgraduate Course sessions held at DDW 2021.