High-Definition Chromoendoscopy Superior to High-Definition White-Light Endoscopy in Surveillance of Inflammatory Bowel Diseases in a Randomized Trial

doi:10.1016/j.cgh.2020.04.049

Clinical Gastroenterology and Hepatology

Volume 18, Issue 9, August 2020, Pages 2101-2107

https://doi.org/10.1016/j.cgh.2020.04.049 Get rights and content

Background & Aims

There is debate over the optimal method for colonoscopic surveillance of patients with inflammatory bowel diseases. Guidelines recommend chromoendoscopy, but the value of chromoendoscopy in high-definition colonoscopy has not been proven. Furthermore, the value of random biopsies is controversial.

Methods

We performed a prospective study of 305 patients with ulcerative colitis or Crohn’s colitis referred for surveillance colonoscopy at a university hospital in Sweden, from March 2011 through April 2016. Patients randomly assigned to a group that received high-definition chromoendoscopy with indigo carmine (HD-CE; n = 152), collection of 32 random biopsies, and targeted biopsies or polypectomies or to a group that received high-definition white light endoscopy (HD-WLE; n = 153), collection of 32 random biopsies, and targeted biopsies or polypectomies. The primary endpoint was number of patients with dysplastic lesions.

Results

Dysplastic lesions were detected in 17 patients with HD-CE and 7 patients with HD-WLE (P = .032). Dysplasias in random biopsies (n = 9760) were detected in 9 patients: 6 (3.9%) in the HD-CE group and 3 (2.0%) in the HD-WLE group (P = .72). Of the 9 patients with dysplasia, 3 patients (33%) had primary sclerosing cholangitis—only 18% of patients (54/305) included in the study had primary sclerosing cholangitis. The number of dysplastic lesions per 10 min of withdrawal time was 0.066 with HD-CE and 0.027 with HD-WLE (P = .056).

Conclusions

In a randomized trial, we found HD-CE with collection of random biopsies to be superior to HD-WLE with random biopsies for detection of dysplasia per colonoscopy. These results support the use of chromoendoscopy for surveillance of patients with inflammatory bowel diseases. ClinicalTrials.gov no: NCT01505842.

Section snippets

Methods

This single-center, prospective, randomized, controlled trial compared WLE (HD-WLE group) and CE (HD-CE group) with HD colonoscopes and was performed at Karolinska University Hospital in Stockholm, Sweden.

The study population comprised consecutive adult patients with IBD, referred for surveillance colonoscopy from March 2011 to April 2016. The inclusion and exclusion criteria were based on Swedish guidelines for IBD surveillance. The inclusion criteria were: (1) extensive ulcerative colitis or

Results

In total, 305 patients were included. Of these, 152 patients were randomized to HD-CE, and 153 to HD-WLE. In the per-protocol analysis, 42 (14%) patients were excluded (Figure 1, Supplementary File 2). The number of exclusions did not differ between the HD-CE and the HD-WLE-group (n = 20 vs 22; P = .76). There were no significant differences in patient-related characteristics, including risk factors for colorectal cancer (Table 1).

The characteristics of the macroscopic lesions are presented in

Discussion

In this randomized controlled trial including 305 patients, HD-CE was superior to HD-WLE in the detection of dysplasia in patients with long-standing IBD.

Previous research found that CE was superior to WLE in the detection of dysplasia in IBD when using standard resolution endoscopes.⁶^,⁷ Our results support that this is also the case when using HD endoscopes. In 2 recent meta-analysis⁶^,⁷ that included 3 randomized controlled studies,12, 13, 14, 15 HD-CE was compared with HD-WLE in subgroup

CRediT Authorship Contributions

Equal; Software: Lead; Validation: Equal; Visualization: Equal; Writing – original draft: Lead; Writing – review & editing: Equal)

Bjarki Alexandersson, (Data curation: Lead; Formal analysis: Lead; Methodology: Yousef Hamad, MD (Data curation: Supporting; Writing – review & editing: Supporting)

Anna Andreasson, PhD (Data curation: Supporting; Formal analysis: Supporting; Methodology: Supporting; Software: Supporting; Supervision: Supporting; Validation: Supporting; Visualization: Supporting;

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Managing Risk of Dysplasia and Colorectal Cancer in Inflammatory Bowel Disease
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Mitigating colorectal cancer (CRC) risk is a pillar in caring for patients with inflammatory bowel disease (IBD). Over the last decade, there have been significant advances in understanding the natural history of colitis-associated dysplasia (CAD) and its management. The identification of patient- and disease-specific risk factors has enabled a tailored approach to initiating colonoscopy screening and surveillance programs. Improved video endoscopy systems and the development of advanced endoscopic resection techniques have evolved the role of endoscopy in CAD. Modern-era endoscopic instruments can better detect and effectively intervene with CAD, reducing CRC risk. As a result, the last decade has brought forth substantial changes to how endoscopic technologies are applied to IBD surveillance. This review will go over the latest updates in the stratification and management of CAD and CRC risk for patients with IBD, as well as discuss the exciting future in this topic area.
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Citation Excerpt :
Based on a pooled analysis, the prevalence of dysplasia identified on random biopsies only (“invisible dysplasia”) was 19.6% (range: 11.5%–31.2%) with SD-WLE, 9.8% (range: 6%–15%) with dye-based chromoendoscopy with indigo carmine (mix of SD-WLE and HD-WLE), and 9.4% (range: 4.1%–19.9%) with HD-WLE. Based on the same pooled analysis, fewer than 1%–1.5% of patients undergoing surveillance with HD-WLE or HD-chromoendoscopy would be misclassified as not having dysplasia if random biopsies were not obtained, although some studies report estimates as high as 6%.77,83 The randomized controlled trial that compared HD-WLE and HD-chromoendoscopy reported invisible dysplasia in only 3.9% vs 2.0% of patients, respectively; the vast majority of invisible dysplasia was LGD (89%; only 1 patient with HGD), and one-third of the patients with invisible dysplasia had concomitant PSC.
Patients with inflammatory bowel disease (IBD) are at increased risk of developing colorectal cancer (CRC), despite decreases in CRC incidence in recent years. Chronic inflammation is the driver of neoplastic progression, resulting in dysplastic precursor lesions that may arise in multiple areas of the colon through a process of field cancerization. Colitis-associated CRC shares many molecular similarities with sporadic CRC, and preclinical investigations have demonstrated a potential role for the microbiome in concert with the host immune system in the development of colitis-associated colorectal cancer (CAC). Some unique molecular differences occur in CAC, but their role in the pathogenesis and behavior of inflammation-associated cancers remains to be elucidated. Nonconventional types of dysplasia have been increasingly recognized, but their natural history is not well defined, and they have not been incorporated into surveillance algorithms. The concept of cumulative inflammatory burden highlights the importance of considering histologic inflammation over time as an important risk factor for CAC. Dysplasia is arguably the most important risk factor for developing CAC, and advances have been made in the endoscopic detection and removal of precancerous lesions, thereby deferring or avoiding surgical resection. Some of the agents used to treat IBD are chemopreventive. It is hoped that by gaining better control of the underlying inflammation with newer medications and better endoscopic detection and management, a more sophisticated appreciation of clinicopathologic risk factors, and growing awareness of the genetic, immunologic, and environmental causes of colitis- associated neoplasia, that colitis-associated colorectal neoplasia will become even more predictable and manageable in the coming years.
SCENIC update 2021: Is chromoendoscopy still standard of care for inflammatory bowel disease surveillance?
2022, Gastrointestinal Endoscopy
Surveillance and management of colorectal dysplasia and cancer in inflammatory bowel disease: Current practice and future perspectives
2021, European Journal of Internal Medicine
Citation Excerpt :
Non-inferiority in neoplasia detection was reported for surveillance with only targeted biopsies versus target and random biopsies in a RCT study, although no data on long-term outcomes were reported. [53] The yield of random biopsies is higher in patients with concomitant PSC (3.7% per-colonoscopy and 0.3% per biopsy), [51, 52, 54, 55] prior dysplasia, or a tubular colon. [52] The added value of random biopsies in these high-risk patients should be balanced against additional costs and potential risks, e.g. of surgical procedures.
Patients with inflammatory bowel disease (IBD) are at increased risk of developing colorectal cancer (CRC). Current guidelines recommend frequent surveillance colonoscopies for patients with at least left-sided ulcerative colitis, or Crohn's disease involving more than 30% of the colon. Surveillance allows for early detection and treatment of colorectal dysplasia and cancer. The first colonoscopy should be performed 8 to 10 years after onset of disease symptoms. European and British guidelines employ a risk-stratification algorithm that assigns patients to surveillance intervals of one, three or five years, whereas American guidelines recommend to perform surveillance every 1 to 3 years based on the (combined) presence of risk factors. Patients with concomitant primary sclerosing cholangitis are at an additionally increased risk, and should undergo annual surveillance starting immediately after the diagnosis. The current practice of surveillance is based on limited evidence, is resource intensive and cannot preclude the occurrence of interval carcinomas. Fortunately, advances in endoscopic techniques for mucosal visualisation, along with better control of inflammation, have resulted in a declining incidence of CRC in patients with IBD. Furthermore, advanced endoscopic resection techniques can be expected to result in a shift from surgical to endoscopic management of dysplastic lesions. In this review, we provide an up-to-date overview of colitis-associated CRC pathophysiology, epidemiology, surveillance practices, and management of dysplasia.
Recommendations of the Spanish Working Group on Crohn's disease and Ulcerative Colitis (Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa — GETECCU) on dysplasia screening in inflammatory bowel disease patients
2021, Gastroenterologia y Hepatologia
Los pacientes con enfermedades inflamatorias intestinales de localización colónica tienen mayor riesgo de desarrollar cáncer colorrectal que la población general, por lo que precisan de técnicas endoscópicas de cribado con intervalos de seguimiento basados en los diferentes factores de riesgo descritos.
En el presente documento de posicionamiento analizamos la evidencia científica vigente para las diferentes técnicas endoscópicas disponibles en la actualidad, cómo debe realizarse su implementación en las unidades de endoscopia, y se describe con detalle cómo debe ser técnicamente su realización, a qué pacientes y con qué intervalo debe realizarse, y finalmente, cuál debe ser nuestra actitud ante el hallazgo de displasia, proponiendo un algoritmo de seguimiento específico.
Colonic inflammatory bowel diseases have a higher risk of developing colorectal cancer compared to the general population, which is why they require endoscopic screening techniques with specific follow-up intervals based on the different risk factors described on the literature.
This position paper analyzes the current scientific evidence for the different endoscopic techniques available today, how their implementation should be carried out in endoscopic units and describes in detail how their implementation should be carried out, in which patients and with what interval, and finally, what should be the response to finding dysplasia, proposing a specific follow-up algorithm.
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: Conflicts of interest The authors disclose no conflicts.

: Funding Supported by grants provided by the Stockholm County Council (ALF project).

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Original ArticleEndoscopyHigh-Definition Chromoendoscopy Superior to High-Definition White-Light Endoscopy in Surveillance of Inflammatory Bowel Diseases in a Randomized Trial

Background & Aims

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

CRediT Authorship Contributions

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastroenterology

Increased risk of intestinal cancer in Crohn's disease: a meta-analysis of population-based cohort studies

Am J Gastroenterol

The role of endoscopy in inflammatory bowel disease

Gastrointest Endosc

Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders

J Crohns Colitis

Original Article
Endoscopy
High-Definition Chromoendoscopy Superior to High-Definition White-Light Endoscopy in Surveillance of Inflammatory Bowel Diseases in a Randomized Trial