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Northeast Florida Medicine
Vol. 66, No. 4 2015
35
Inflammatory Bowel Disease
Difficulties with adopting CE into clinical practice in-
clude lack of endoscopist experience, reliability of image
interpretation, and the additional time needed to perform
the procedure. These issues were addressed in a study that
looked at the implementation of a chromoendoscopy
surveillance program for UC.
27
Six endoscopists without
experience in chromoendoscopy had similar rates of dys-
plasia detection compared to “experts” in the field after
only 15 chromoendoscopy cases were completed.
UC surveillance CE is recommended for those with
expertise in the technique,
12,25
but the dye-spraying process
adds time to the procedure when paired with the usual
process of obtaining multiple non-targeted biopsies. How-
ever, surveillance with random biopsies, as is the standard
of care, results in very low dysplasia detection rates and is
generally reimbursed at the same rate as colonoscopy with
biopsy. If this technique were abandoned in favor of directed
CE biopsies, overall procedure time is likely to be affected
very little and cost savings realized by restricting biopsies
to targeted lesions. Unfortunately, narrow band imaging,
a convenient technology installed in many colonoscopies,
has not been shown to increase dysplasia detection in UC.
28
The New Era: SCENIC Guidelines
In an effort to provide, in the era of high definition
colonoscopy and chromoendoscopy, updated guidelines
for adoption into surveillance colonoscopy for chronic
ulcerative colitis, an international multidisciplinary group
was convened that consisted of inflammatory bowel disease
specialists and interventional endoscopists.The Surveillance
for Colorectal Neoplasia Detection and Management
in Inflammatory Bowel Disease Patients: International
Consensus Guidelines (SCENIC) provides new recommen-
dations for the application of standard colonoscopy and
chromoendoscopy to surveillance and better classification
of lesions found.
14
High definition colonoscopies are recommended for
surveillance. Chromoendoscopy is recommended if stan-
dard definition and suggested if high definition scopes are
used. The panel could not reach a consensus on random
biopsies. Currently, biopsies can be done with standard
colonoscopy and with chromoendoscopy.
The SCENIC guidelines emphasized whether a lesion
seen at colonoscopy is polypoid or non-polypoid (little or
no protrusion above the mucosa) endoscopically resectable
or unresectable. The terms of “dysplasia associated lesion
or mass (DALM)” and “adenoma like lesion (ALM)” were
abandoned. Resectable lesions were defined as having distinct
margins that can be completely removed by endoscopy and
with biopsies of the surrounding tissue without dysplasia.
The authors recommended that such lesions do not require
colectomy but can be followed with closer surveillance (i.e.
every six months). While endoscopic removal of polypoid
lesions is generally accepted, the additional recommendation
that non-polypoid (flat) dysplasia be resected and safely fol-
lowed by surveillance, rather that colectomy, is controversial.
SCENIC did set up a framework for further investigation that
is needed to advance the field. Despite these consensus group
recommendations, chromoendoscopyhas failed tobe endorsed
for all surveillance procedures.
29
Some academic centers have
adopted it for high-risk patients with a history dysplasia, colon
polyps or pseudopolyps, PSC and others on a case by case basis.
Conclusion
Long-standing extensive ulcerative colitis increases
the risk of CRC. Available methods of surveillance with
conventional colonoscopy result in low rates of dysplasia
detection. Chromoendoscopy has ushered in a new era
of improved dysplasia detection among individuals with
ulcerative colitis at risk for colorectal cancer.The technique
is simple, easy to learn and leads to improved dysplasia
detection. However, many questions remain to be answered
including whether all UC patients at risk for CRC should
have chromoendoscopy, the natural history of the lesions
that are found, and whether the technique leads to lower
rates of CRC. For now, for endoscopists with experience
in chromoendoscopy, it is reasonable to at least apply the
technique to high risk patients such as those with prior
dysplasia, polyps and/or PSC.
v
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