2011 Debate on Chromoendoscopy for IBD colitis surveillance
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Chromoendoscopy and other advanced endoscopic imaging techniques are becoming the standard of care in the surveillance of dysplasia. At the 2011 Australian Gastroenterology Week, the use of advanced imaging techniques was compared against four quadrant random biopsies at a breakfast debate.
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2011 Debate on Chromoendoscopy for IBD colitis surveillance
- 1. Rupert WL Leong Director of Endoscopy Senior Staff Specialist Gastroenterologist Concord & Bankstown Hospitals Conjoint Associate Professor UNSW AIBDA Symposium Colorectal Cancer Surveillance What should we be doing? New endoscopy techniques and targeted biopsies are now the standard of care
- 8. Why newer endoscopic techniques are required? Sporadic Cancer Normal Colon Aberrant crypt foci Adenoma Carcinoma Normal Colon Inflammation Flat Dysplasia Carcinoma IBD Cancer
- 10. Chromoendoscopy
- 15. Does it work? Yes
- 21. Dysplasia Yield Conventional Chromoendoscopy P Kiesslich Gastro. 2003 (n = 163) 3X <0.005 35min 44min ns Rutter Gut 2004 (n = 100) 3.5X 0.02 11min 10min ns Hurlstone Endos. 2005 (n = 350) 10X <0.0001 13min 24min Marion AJG 2008 (n = 102) 230X <0.0002 15min 22min
- 28. Rupert WL Leong Director of Endoscopy Senior Staff Specialist Gastroenterologist Concord & Bankstown Hospitals Conjoint Associate Professor UNSW AIBDA Symposium Colorectal Cancer Surveillance What should we be doing? New endoscopy techniques and targeted biopsies are now the standard of care
- 33. Procedure/ Withdrawal Times Conventional Chromoendoscopy P Kiesslich Gastro. 2003 (n = 163) 3X <0.005 35min 44min ns Rutter Gut 2004 (n = 100) 3.5X 0.02 11min 10min ns Hurlstone Endos. 2005 (n = 350) 10X <0.0001 13min 24min Marion AJG 2008 (n = 102) 230X <0.0002 15min 22min
Editor's Notes
- Therefore, random biopsies need to be taken throughout the bowel previously exposed to inflammation. It’s been calculated that taking at least 33 quadrantic random biopsies at 10cm intervals are required to yield a 90% confidence of picking up a dysplastic lesion if present. However, only 2% of gastroenterologists take >20 biopsies, let alone 33 biopsies; 50% only take 6 – 10 biopsies. Even when surveillance colonoscopies occur, a significant number of patients still present with symptomatic bowel cancer. Routine colonoscopy and random biopsies may not be adequate to pick up cancers and this review was from St Mark’s hospital, one of the leaders in IBD.
- However, finding dysplasia in IBD poses a major challenges to endoscopists. Because dysplasia in IBD develops in flat mucosa which is difficult to see in comparison to sporadic polyps.
- What new endoscopic technologies offer include: - improved resolution of tissue imaging plus magnification to increase the sensitivity of finding lesions - the use of special light properties that interact with tissue to differentiate lesions, - and technologies that allow for immediate in situ histology.
- CE is low in cost, requires no special equipment apart from a spray catheter and a wide variety of contrast agents can be used. In IBD surveillance they tend to be methylene blue or indigo carmine.
- Prospective randomised study
- Take home points: - despite protocol 4 quadrant random biopsies, on average only 29 biopsies per person - random biopsies are rarely positive - pre-dye targeted biopsies are good; 4.6% yield (15 – 20mm lesions) - yield in dye targeted = an additional 7 cases or a 3.5 fold increase in detection, smaller dysplastic lesions
- In another prospective study from the UK recruiting 350 patients into a conventional colonoscopy arm and another 350
- In another prospective study from the UK recruiting 350 patients into a conventional colonoscopy arm and another 350
- Although you may be in the minority of gastroenterologists in Australia that do not use advanced imaging techniques, this debate emphasises on what you SHOULD be doing. Based on that, ladies and gentleman, I hope that you would all agree that
- Although you may be in the minority of gastroenterologists in Australia that do not use advanced imaging techniques, this debate emphasises on what you SHOULD be doing. Based on that, ladies and gentleman, I hope that you would all agree that
- So how is CE performed? 1. Strict patient selection: symptoms in remission and or optimised medical therapy to induce remission whenever possible. 2. Unmasking the mucosa with an excellent bowel prep, removing mucus and using washes. 3. IV buscopan or glucagon can be used to reduce peristalsis. Air insufflation is required. 4. Full length staining refers to pan-chromoendoscopy of the whole colon, starting at the caecum. 5. Add dye in a segmental fashion every 20 – 30cm. On average 60 – 100ml of solution is required. 6. Crypt pattern is detected using magnifying colonoscopy 7. Endoscopic targeting of lesions is required