Experts release international consensus statement on surveillance, management of dysplasia in IBD
An international multidisciplinary group has developed unifying consensus recommendations on surveillance and management of dysplasia in inflammatory bowel disease, simultaneously published in Gastrointestinal Endoscopy and Gastroenterology.
As mounting data on newer endoscopic methods for detecting dysplasia in patients with IBD has caused variation in guideline recommendations, the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus (SCENIC) Guideline Development Panel aimed to develop a consensus statement addressing optimal methods on how surveillance colonoscopy for detecting dysplasia should be performed, and how dysplasia identified at colonoscopy should be managed.
“We recognized that there was variable practice in the surveillance methods for dysplasia detection in patients with IBD and there were also variable guidelines, both within the US and internationally,” Tonya Kaltenbach, MD, MS, from the Veterans Affairs Palo Alto, who served on the panel, told Healio Gastroenterology. The need for an international consensus statement, she said, came from “an interest to provide a uniform recommendation” — namely on the use of chromoendoscopy for the detection of dysplasia.
In addition to evidence, she added, factors like feasibility, values and preferences, cost and quality of life impact are also considered in guideline development, and the SCENIC panel therefore included stakeholders from various perspectives, including IBD experts, endoscopic imaging experts, pathologists, patient representatives, nurses and methodologists.
Detection of dysplasia on surveillance colonoscopy
The panelists agreed that regarding the optimal methods for detecting colon dysplasia in patients with IBD on surveillance colonoscopy, the following recommendations could be made:
- High definition is recommended for surveillance with white-light colonoscopy;
- Chromoendoscopy is recommended rather than white-light colonoscopy for standard-definition surveillance;
- Chromoendoscopy is suggested rather than white-light colonoscopy for high-definition surveillance;
- Narrow-band imaging is not suggested over white-light colonoscopy for standard- or high-definition surveillance; and
- Narrow-band imaging is not suggested over chromoendoscopy for image-enhanced high-definition surveillance.
The panelists did not reach consensus on whether endoscopists should perform random biopsies when using high-definition white-light colonoscopy or chromoendoscopy. They also did not endorse autofluorescence imaging over white-light colonoscopy for high-definition surveillance due to low-quality evidence, and did not include confocal laser endomicroscopy due to its inability to be practically applied in IBD surveillance.
Management of dysplasia identified on surveillance colonoscopy
The panelists agreed that regarding the optimal management of dysplasia identified on endoscopic surveillance of patients with IBD, the following recommendations could be made:
- Surveillance colonoscopy is recommended over colectomy after complete removal of endoscopically resectable polypoid dysplastic lesions;
- Surveillance colonoscopy is suggested over colectomy after complete removal of endoscopically resectable nonpolypoid dysplastic lesions; and
- Referral to an endoscopist with expertise in IBD surveillance using chromoendoscopy with high-definition colonoscopy is suggested for patients with pathology-confirmed endoscopically invisible dysplasia.
Implementation and learning resources
According to Kaltenbach, implementation has historically been the most significant obstacle to developing a standardized guideline for these practices, specifically due to reservations regarding chromoendoscopy and endoscopic removal of identified dysplastic lesions.
“One of the next steps that will be key to bringing about the widespread practice of chromoendoscopy to survey these patients is teaching,” she said, and emphasized that open access learning resources are critical in this regard.
Accordingly, the panel created free educational resources to assist endoscopy professionals as they incorporate the recommendations. ASGE's “Chromoendoscopy with Targeted Biopsy to Detect Nonpolypoid Colorectal Neoplasms” video is available at the ASGE Online Learning Center. Additional resources, such as an atlas of endoscopic images of dysplastic lesions and a learning algorithm, are also accessible via the consensus statement paper. – by Adam Leitenberger
Disclosure: Kaltenbach reports she is a consultant and has received research support from Olympus. Please see the study for a full list of authors’ relevant financial disclosures.