SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease

Abstract

Patients with ulcerative colitis or Crohn’s colitis have an increased risk of colorectal cancer (CRC). Most cases are believed to arise from dysplasia, and surveillance colonoscopy therefore is recommended to detect dysplasia. Detection of dysplasia traditionally has relied on both examination of the mucosa with targeted biopsies of visible lesions and extensive random biopsies to identify invisible dysplasia. Current U.S. guidelines recommend obtaining at least 32 random biopsy specimens from all segments of the colon as the foundation of endoscopic surveillance.1Farraye F.A. Odze R.D. Eaden J. et al.AGA Medical Position Statement on the Diagnosis and Management of Neoplasia in Inflammatory Bowel Disease.Gastroenterology. 2010; 138: 738-745Abstract Full Text Full Text PDF PubMed Scopus (406) Google Scholar, 2Farraye F.A. Odze R.D. Eaden J. et al.AGA Technical Review on the diagnosis and management of colorectal dysplasia in inflammatory bowel disease.Gastroenterology. 2010; 138: 746-774Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar, 3Leighton J.A. Shen B. Baron T.H. et al.ASGE Guidelines: endoscopy in the diagnosis and treatment of inflammatory bowel disease.Gastrointest Endosc. 2006; 63: 558-565Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 4Itzkowitz S.H. Present D.H. Crohn's and Colitis Foundation of America Colon Cancer in IBD Study GroupConsensus conference: colorectal cancer screening and surveillance in inflammatory bowel disease.Inflamm Bowel Dis. 2005; 11: 314-321Crossref PubMed Scopus (515) Google Scholar However, much of the evidence that provides a basis for these recommendations is from older literature, when most dysplasia was diagnosed on random biopsies of colon mucosa.5Bernstein C.N. Shanahan F. Weinstein W.M. Are we telling patients the truth about surveillance colonoscopy in ulcerative colitis?.Lancet. 1994; 343: 71-74Abstract PubMed Scopus (517) Google Scholar With the advent of video endoscopy and newer endoscopic technologies, investigators now report that most dysplasia discovered in patients with inflammatory bowel disease (IBD) is visible.6Rutter M.D. Saunders B.P. Wilkinson K.H. et al.Most dysplasia in ulcerative colitis is visible at colonoscopy.Gastrointest Endosc. 2004; 6: 334-339Abstract Full Text Full Text PDF Scopus (139) Google Scholar, 7Rubin D.T. Rothe J.A. Hetzel J.T. et al.Are dysplasia and colorectal cancer endoscopically visible in patients with ulcerative colitis?.Gastrointest Endosc. 2007; 65: 998-1004Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar Such a paradigm shift may have important implications for the surveillance and management of dysplasia. The evolving evidence regarding newer endoscopic methods to detect dysplasia has resulted in variation among guideline recommendations from organizations around the world.1Farraye F.A. Odze R.D. Eaden J. et al.AGA Medical Position Statement on the Diagnosis and Management of Neoplasia in Inflammatory Bowel Disease.Gastroenterology. 2010; 138: 738-745Abstract Full Text Full Text PDF PubMed Scopus (406) Google Scholar, 2Farraye F.A. Odze R.D. Eaden J. et al.AGA Technical Review on the diagnosis and management of colorectal dysplasia in inflammatory bowel disease.Gastroenterology. 2010; 138: 746-774Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar, 3Leighton J.A. Shen B. Baron T.H. et al.ASGE Guidelines: endoscopy in the diagnosis and treatment of inflammatory bowel disease.Gastrointest Endosc. 2006; 63: 558-565Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 4Itzkowitz S.H. Present D.H. Crohn's and Colitis Foundation of America Colon Cancer in IBD Study GroupConsensus conference: colorectal cancer screening and surveillance in inflammatory bowel disease.Inflamm Bowel Dis. 2005; 11: 314-321Crossref PubMed Scopus (515) Google Scholar, 8Van Assche G. Dignass A. Bokemeyer B. et al.Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 3: special situations.J Crohns Colitis. 2013; 7: 1-33Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar, 9Cairns S.R. Scholefield J.H. Steele R.J. et al.Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002).Gut. 2010; 59: 666-689Crossref PubMed Scopus (884) Google Scholar, 10Cancer Council Australia Colonoscopy Surveillance Working PartyClinical Practice Guidelines for Surveillance Colonoscopy—in adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Cancer Council Australia, Sydney2011Google Scholar We therefore sought to develop unifying consensus recommendations addressing 2 issues: (1) How should surveillance colonoscopy for detection of dysplasia be performed? (2) How should dysplasia identified at colonoscopy be managed? An international multidisciplinary group representing a wide spectrum of stakeholders and attitudes regarding IBD surveillance (Appendix 1, available online at www.giejournal.org) developed these recommendations following a process that adhered to suggested standards for guideline development from the Institute of Medicine and others and that incorporated the GRADE methodology.11Graham R. Mancher M. Wolman D.M. et al.Clinical Practice Guidelines We Can Trust. National Academy of Sciences, Washington, DC2011Crossref Google Scholar, 12Woolf S.H. Schunemann H.J. Eccles M.P. et al.Developing Clinical Practice Guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations.Implementation Sci. 2012; 7: 1-12Crossref Scopus (162) Google Scholar, 13Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar, 14Schunemann H.J. Wiercioch W. Etxeandia I. et al.Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise.CMAJ. 2014; 186: E123-E142Crossref PubMed Scopus (379) Google Scholar Details regarding the development process are provided in Figure 1 and Appendix 2. A systematic review was performed for each focused clinical question. The search strategy is shown in Appendix 3, and the full synthesis of evidence reviewed by panelists is presented in Appendix 4. All appendices are available online at www.giejournal.org. The strength of recommendation, provided for each recommendation, reflects the level of confidence that desirable effects of an intervention outweigh undesirable effects. Strong recommendations mean panelists are confident that the desirable effects outweigh the undesirable effects; therefore, most informed patients would choose the recommended management, and clinicians would provide the intervention to most patients. Conditional recommendations mean the desirable and undesirable effects of the intervention are closely balanced or appreciable uncertainty exists regarding the balance; therefore, informed patients’ choices will vary according to their values and preferences, with many not wanting the intervention, and clinicians must ensure that patients’ care is in keeping with their values and preferences.13Guyatt G.H. Oxman A.D. Vist G.E. et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar A subgroup of panelists developed a set of terms for colonoscopic findings in IBD surveillance to establish uniformity in communication. Descriptive phrases, modified from the Paris Classification,15The Paris classification of superficial neoplastic lesions: esophagus, stomach, and colon.Gastrointest Endosc. 2003; 58: S3-S43Abstract Full Text Full Text PDF PubMed Scopus (1749) Google Scholar were recommended for adoption (Table 1). Modifications included the addition of terms for ulceration and border of the lesion. It was agreed that the terms dysplasia-associated lesion or mass (DALM), adenoma-like, and non-adenoma-like should be abandoned. The term endoscopically resectable indicates that (1) distinct margins of the lesion could be identified, (2) the lesion appears to be completely removed on visual inspection after endoscopic resection, (3) histologic examination of the resected specimen is consistent with complete removal, and (4) biopsy specimens taken from mucosa immediately adjacent to the resection site are free of dysplasia on histologic examination.Table 1Terminology for reporting findings on colonoscopic surveillance of patients with inflammatory bowel disease (modified from Paris Classification15The Paris classification of superficial neoplastic lesions: esophagus, stomach, and colon.Gastrointest Endosc. 2003; 58: S3-S43Abstract Full Text Full Text PDF PubMed Scopus (1749) Google Scholar)TermDefinitionVisible dysplasiaDysplasia identified on targeted biopsies from a lesion visualized at colonoscopy PolypoidLesion protruding from the mucosa into the lumen ≥2.5 mmPedunculatedLesion attached to the mucosa by a stalkSessileLesion not attached to the mucosa by a stalk: entire base is contiguous with the mucosa NonpolypoidLesion with little (<2.5 mm) or no protrusion above the mucosaSuperficial elevatedLesion with protrusion but <2.5 mm above the lumen (less than the height of the closed cup of a biopsy forceps)FlatLesion without protrusion above the mucosaDepressedLesion with at least a portion depressed below the level of the mucosa General descriptorsUlceratedUlceration (fibrinous-appearing base with depth) within the lesionBorder Distinct borderLesion’s border is discrete and can be distinguished from surrounding mucosa Indistinct borderLesion’s border is not discrete and cannot be distinguished from surrounding mucosaInvisible dysplasiaDysplasia identified on random (non-targeted) biopsies of colon mucosa without a visible lesion Open table in a new tab The goal of this section is to define the optimal method(s) of detecting colon dysplasia in patients with IBD. Detection of dysplasia, which is the immediate goal of surveillance colonoscopy, was chosen as the primary endpoint, with the understanding that detection of dysplasia is not clearly documented to improve clinical outcomes such as CRC incidence or mortality. Only histologic diagnoses of low-grade or high-grade dysplasia were considered; diagnoses of indefinite for dysplasia were excluded. Current guideline recommendations regarding the need for serial surveillance colonoscopy in patients with IBD were accepted, and other issues such as the appropriate surveillance interval or risk stratification1Farraye F.A. Odze R.D. Eaden J. et al.AGA Medical Position Statement on the Diagnosis and Management of Neoplasia in Inflammatory Bowel Disease.Gastroenterology. 2010; 138: 738-745Abstract Full Text Full Text PDF PubMed Scopus (406) Google Scholar, 2Farraye F.A. Odze R.D. Eaden J. et al.AGA Technical Review on the diagnosis and management of colorectal dysplasia in inflammatory bowel disease.Gastroenterology. 2010; 138: 746-774Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar, 3Leighton J.A. Shen B. Baron T.H. et al.ASGE Guidelines: endoscopy in the diagnosis and treatment of inflammatory bowel disease.Gastrointest Endosc. 2006; 63: 558-565Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 4Itzkowitz S.H. Present D.H. Crohn's and Colitis Foundation of America Colon Cancer in IBD Study GroupConsensus conference: colorectal cancer screening and surveillance in inflammatory bowel disease.Inflamm Bowel Dis. 2005; 11: 314-321Crossref PubMed Scopus (515) Google Scholar, 8Van Assche G. Dignass A. Bokemeyer B. et al.Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 3: special situations.J Crohns Colitis. 2013; 7: 1-33Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar, 9Cairns S.R. Scholefield J.H. Steele R.J. et al.Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002).Gut. 2010; 59: 666-689Crossref PubMed Scopus (884) Google Scholar, 10Cancer Council Australia Colonoscopy Surveillance Working PartyClinical Practice Guidelines for Surveillance Colonoscopy—in adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Cancer Council Australia, Sydney2011Google Scholar were not addressed. Recommendations are listed in Table 2 and appear individually hereafter with the proportion of panelists in agreement, the strength of the recommendation, and the quality of evidence. A summary of the evidence and discussion regarding the recommendation follows each statement.Table 2Summary of recommendations for surveillance and management of dysplasia in patients with inflammatory bowel diseaseDetection of dysplasia on surveillance colonoscopy1.When performing surveillance with white-light colonoscopy, high definition is recommended rather than standard definition (strong recommendation, low-quality evidence).2.When performing surveillance with standard-definition colonoscopy, chromoendoscopy is recommended rather than white-light colonoscopy (strong recommendation, moderate-quality evidence).3.When performing surveillance with high-definition colonoscopy, chromoendoscopy is suggested rather than white-light colonoscopy (conditional recommendation, low-quality evidence).4.When performing surveillance with standard-definition colonoscopy, narrow-band imaging is not suggested in place of white-light colonoscopy (conditional recommendation, low-quality evidence).5.When performing surveillance with high-definition colonoscopy, narrow-band imaging is not suggested in place of white-light colonoscopy (conditional recommendation, moderate-quality evidence).6.When performing surveillance with image-enhanced high-definition colonoscopy, narrow-band imaging is not suggested in place of chromoendoscopy (conditional recommendation, moderate-quality evidence).Management of dysplasia discovered on surveillance colonoscopy7.After complete removal of endoscopically resectable polypoid dysplastic lesions, surveillance colonoscopy is recommended rather than colectomy (strong recommendation, very low-quality evidence).8.After complete removal of endoscopically resectable nonpolypoid dysplastic lesions, surveillance colonoscopy is suggested rather than colectomy (conditional recommendation, very low-quality evidence).9.For patients with endoscopically invisible dysplasia (confirmed by a GI pathologist) referral is suggested to an endoscopist with expertise in IBD surveillance using chromoendoscopy with high-definition colonoscopy (conditional recommendation, very low-quality evidence). Open table in a new tab Statement 1: When performing surveillance with white-light colonoscopy, high definition is recommended rather than standard definition. (80% agreement; strong recommendation; low-quality evidence) High-definition (1080 system) endoscopy provides image signals of higher pixel density than standard definition (480 system), with faster line scanning on high-definition monitors, leading to sharper images with fewer artifacts.16Subramanian V. Ragunath K. Advanced endoscopic imaging: a review of commercially available technologies.Clin Gastroenterol Hepatol. 2014; 12: 368-376Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar A high-definition system includes a high-definition endoscope, processor, cabling, and monitor. A retrospective observational study found that dysplasia was discovered in approximately twice as many patients undergoing high-definition colonoscopy (n = 203) compared with a cohort undergoing standard-definition colonoscopy (n = 154): adjusted prevalence ratio = 2.2 (95% confidence interval [CI], 1.1-4.5).17Subramanian V. Ramappa V. Telakis E. et al.Comparison of high definition with standard white light endoscopy for detection of dysplastic lesions during surveillance colonoscopy in patients with colonic inflammatory bowel disease.Inflamm Bowel Dis. 2013; 19: 350-355Crossref PubMed Scopus (18) Google Scholar Given that most dysplastic lesions are visible,6Rutter M.D. Saunders B.P. Wilkinson K.H. et al.Most dysplasia in ulcerative colitis is visible at colonoscopy.Gastrointest Endosc. 2004; 6: 334-339Abstract Full Text Full Text PDF Scopus (139) Google Scholar, 7Rubin D.T. Rothe J.A. Hetzel J.T. et al.Are dysplasia and colorectal cancer endoscopically visible in patients with ulcerative colitis?.Gastrointest Endosc. 2007; 65: 998-1004Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar the improved visualization and lack of negative effects with high-definition endoscopy justified a strong recommendation for its use. In addition, patients likely would strongly desire high-definition colonoscopy because of the belief that visualization and examination are improved. The cost of purchasing new high-definition endoscopic equipment is a consideration. However, high-definition colonoscopy already is widely used in endoscopic units. Statement 2: When performing surveillance with standard-definition colonoscopy, chromoendoscopy is recommended rather than white-light colonoscopy. (85% agreement; strong recommendation; moderate-quality evidence) Chromoendoscopy involves the application of dye to the colon mucosa, thereby providing contrast enhancement to improve visualization of epithelial surface detail. Methylene blue and indigo carmine, the agents most commonly used, are applied to the colon mucosa via a catheter or the colonoscope biopsy or water jet channel,18Soetikno R. Subramanian V. Kaltenbach T. et al.The detection of nonpolypoid (flat and depressed) colorectal neoplasms in patients with inflammatory bowel disease.Gastroenterology. 2013; 144: 1349-1352.e6Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar and accentuate the changes in epithelial surface topography.19Kaltenbach T. Sano Y. Friedland S. et al.American Gastroenterological Association (AGA) Institute Technology Assessment on Image Enhanced Endoscopy.Gastroenterology. 2008; 134: 327-340Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar We identified 8 trials that used standard-definition colonoscopy and compared chromoendoscopy with white-light colonoscopy alone (Table 3).20Kiesslich R. Fritsch J. Holtmann M. et al.Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis.Gastroenterology. 2003; 124: 880-888Abstract Full Text Full Text PDF PubMed Scopus (555) Google Scholar, 21Kiesslich R. Goetz M. Lammersdorf K. et al.Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis.Gastroenterology. 2007; 132: 874-882Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar, 22Chiorean M.V. Helper D.J. Saxena R. et al.Targeted biopsies using chromoendoscopy can replace random biopsies in patients with IBD at high risk for colorectal neoplasia.Gastroenterology. 2012; 142: S339Google Scholar, 23Rutter M.D. Saunders B.P. Schofield G. et al.Pancolonic indigo carmine dye spraying for the detection of dysplasia in ulcerative colitis.Gut. 2004; 53: 256-260Crossref PubMed Scopus (363) Google Scholar, 24Marion J.F. Waye J.D. Present D.H. et al.Chromoendoscopy-targeted biopsies are superior to standard colonoscopic surveillance for detecting dysplasia in inflammatory bowel disease patients: a prospective endoscopic trial.Am J Gastroenterol. 2008; 103: 2342-2349Crossref PubMed Scopus (141) Google Scholar, 25Matsumoto T. Nakamura S. Jo Y. et al.Chromoscopy might improve diagnostic accuracy in cancer surveillance for ulcerative colitis.Am J Gastroenterol. 2003; 98: 1827-1833Crossref PubMed Scopus (73) Google Scholar, 26Hlavaty T. Huorka M. Koller T. et al.Colorectal cancer screening in patients with ulcerative and Crohn's colitis with use of colonoscopy, chromoendoscopy and confocal endomicroscopy.Eur J Gastroenterol Hepatol. 2011; 23: 680-689Crossref PubMed Scopus (25) Google Scholar, 27Gunther U. Kusch D. Heller F. et al.Surveillance colonoscopy in patients with inflammatory bowel disease: Comparison of random biopsy vs. targeted biopsy protocols International.J Colorectal Dis. 2011; 26: 667-672Crossref PubMed Scopus (29) Google Scholar The proportion of patients with dysplasia was 0% to 10% greater with chromoendoscopy in the individual studies, but the difference was not significant in any study. Meta-analysis revealed a significantly greater proportion of patients with dysplasia by using chromoendoscopy (relative risk [RR] = 1.8 [1.2-2.6] and absolute risk increase = 6% [3%-9%]). Meta-analysis of the 2 randomized, parallel-group trials also confirmed a significant increase with chromoendoscopy in the proportion of patients with dysplasia (RR = 2.3 [1.1-4.6], absolute increase = 8% [2%-15%]). The number of dysplastic lesions identified was greater with chromoendoscopy in all studies (Table 3), and in the 4 tandem studies in which all patients had both chromoendoscopy and white-light examination, the number of dysplastic areas discovered increased almost 2-fold (RR = 1.9, 1.4-2.7) with chromoendoscopy. Chromoendoscopy significantly increased the duration of colonoscopy by a mean of 11 minutes (range 9-12 minutes).Table 3Proportion of patients with dysplasia and number of visible dysplastic lesions identified in studies comparing chromoendoscopy versus white-light colonoscopyStudyStudy typePatients with dysplasia/all patientsRR (95% CI)Absolute risk increase (95% CI)No. of visible dysplastic lesionsChromoendoscopyWhite-lightChromoendoscopyWhite-lightKiesslich20Kiesslich R. Fritsch J. Holtmann M. et al.Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis.Gastroenterology. 2003; 124: 880-888Abstract Full Text Full Text PDF PubMed Scopus (555) Google ScholarRandomized parallel-group13/846/812.1 (0.8-5.2)8% (-2% to 18%)3210Kiesslich21Kiesslich R. Goetz M. Lammersdorf K. et al.Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis.Gastroenterology. 2007; 132: 874-882Abstract Full Text Full Text PDF PubMed Scopus (290) Google ScholarRandomized parallel-group11/804/732.5 (0.8-7.5)8% (-1% to 17%)192Marion24Marion J.F. Waye J.D. Present D.H. et al.Chromoendoscopy-targeted biopsies are superior to standard colonoscopic surveillance for detecting dysplasia in inflammatory bowel disease patients: a prospective endoscopic trial.Am J Gastroenterol. 2008; 103: 2342-2349Crossref PubMed Scopus (141) Google ScholarProspective tandem22/10212/1021.8 (0.96-3.5)10% (0% to 20%)3513Rutter23Rutter M.D. Saunders B.P. Schofield G. et al.Pancolonic indigo carmine dye spraying for the detection of dysplasia in ulcerative colitis.Gut. 2004; 53: 256-260Crossref PubMed Scopus (363) Google ScholarProspective tandem7/1002/1003.5 (0.8-16.4)5% (-1% to 11%)92Matsumoto25Matsumoto T. Nakamura S. Jo Y. et al.Chromoscopy might improve diagnostic accuracy in cancer surveillance for ulcerative colitis.Am J Gastroenterol. 2003; 98: 1827-1833Crossref PubMed Scopus (73) Google ScholarProspective tandem12/5712/571.0 (0.5-2.0)0% (-2% to 2%)188Hlvaty26Hlavaty T. Huorka M. Koller T. et al.Colorectal cancer screening in patients with ulcerative and Crohn's colitis with use of colonoscopy, chromoendoscopy and confocal endomicroscopy.Eur J Gastroenterol Hepatol. 2011; 23: 680-689Crossref PubMed Scopus (25) Google ScholarProspective tandem and additional cohort4/302/453.0 (0.6-15.4)9% (-5% to 23%)62Gunther27Gunther U. Kusch D. Heller F. et al.Surveillance colonoscopy in patients with inflammatory bowel disease: Comparison of random biopsy vs. targeted biopsy protocols International.J Colorectal Dis. 2011; 26: 667-672Crossref PubMed Scopus (29) Google ScholarRetrospective two-group2/500/505.0 (0.3-101.6)4% (-3% to 11%)20Chiorean22Chiorean M.V. Helper D.J. Saxena R. et al.Targeted biopsies using chromoendoscopy can replace random biopsies in patients with IBD at high risk for colorectal neoplasia.Gastroenterology. 2012; 142: S339Google ScholarProspective tandemNo per-patient data given (N = 63)4118SCENIC meta-analysis1.8 (1.2-2.6)6% (3%-9%)RR, Relative risk; CI, confidence interval; SCENIC, Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations. Open table in a new tab RR, Relative risk; CI, confidence interval; SCENIC, Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations. An economic analysis concluded that chromoendoscopy with targeted biopsies was less costly and more effective than white-light colonoscopy with random biopsies,28Konijeti GG, Shrime MG, Ananthakrishnan A, et al. Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis. Gastrointest Endosc. Epub 2013 Nov 18.Google Scholar suggesting that chromoendoscopy should be used in place of white-light endoscopy when surveillance colonoscopy is performed. The cost-effectiveness of chromoendoscopy increased with increasing surveillance interval, suggesting that varying the surveillance interval based on the risk of CRC may be appropriate and could increase the cost effectiveness of surveillance colonoscopy. However, when surveillance is performed, even if performed less frequently than currently recommended in lower-risk patients, the best technique should be used. Although chromoendoscopy increases the yield of dysplasia compared with standard-definition white-light colonoscopy, whether the additional lesions identified with chromoendoscopy are associated with the same increased risk for CRC as the visible and invisible dysplasia identified in older studies is not known. Data from the Surveillance, Epidemiology and End-Results Medicare-linked database of patients ≥67 years old revealed that interval cancers 6 to 36 months after colonoscopy occurred in a much higher proportion of patients with IBD (15.1% with Crohn’s disease and 15.8% with ulcerative colitis) than patients without IBD (5.8%),29Wang Y.R. Cangemi J.R. Loftus Jr., E.V. et al.Rate of early/missed colorectal cancers after colonoscopy in older patients with or without inflammatory bowel disease in the United States.Am J Gastroenterol. 2013; 108: 444-449Crossref PubMed Scopus (61) Google Scholar suggesting that clinically relevant areas of neoplasia may be missed with current colonoscopic surveillance. Potential barriers to use of chromoendoscopy also were considered. These include the additional preparation and time required for chromoendoscopy, need to train endoscopists in this technique, need to develop quality measures and assess performance after training, procedure-related costs, and barriers to reimbursement (eg, lack of procedure code for chromoendoscopy in the United States). These issues were discussed in detail by a subgroup of the panel, and their report will appear in a separate publication. Statement 3: When performing surveillance with high-definition colonoscopy, chromoendoscopy is suggested rather than white-light colonoscopy. (84% agreement; conditional recommendation; low-quality evidence) A prospective, tandem study that used high-definition colonoscopy in 75 patients with IBD found that dysplasia was identified in significantly more patients undergoing chromoendoscopy than white-light colonoscopy alone: 16 (21%) versus 7 (9%); P = .007.30Picco M.F. Pasha S. Leighton J.A. et al.Procedure time and the determination of polypoid abnormalities with experience: implementation of a chromoendoscopy program for surveillance colonoscopy for ulcerative colitis.Inflamm Bowel Dis. 2013; 19: 1913-1920PubMed Google Scholar Ten dysplastic lesions were identified on the initial white-light examination, and an additional 12 were discovered on the subsequent chromoendoscopic examination. Despite the significant difference in favor of chromoendoscopy, the strength of this recommendation is conditional because of its reliance on only one relatively small observational study whose primary aim was to assess chromoendoscopy training and performance. Statement 4: When performing surveillance with standard-definition colonoscopy, narrow-band imaging (NBI) is not suggested in place of white-light colonoscopy. (84% agreement; conditional recommendation; low-quality evidence) Currently available endoscope-based image-enhancement technologies include NBI (Olympus, Tokyo, Japan), i-scan (Pentax, Tokyo, Japan), and Fuji Intelligent Chromo Endoscopy (Fujinon, Tokyo, Japan).16Subramanian V. Ragunath K. Advanced endoscopic imaging: a review of commercially available technologies.Clin Gastroenterol Hepatol. 2014; 12: 368-376Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar NBI, which uses filters to provide narrow bands of blue and green light wavelengths,16Subramanian V. Ragunath K. Advanced endoscopic imaging: a review of commercially available technologies.Clin Gastroenterol Hepatol. 2014; 12: 368-376Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar is the only one of these technologies that has been studied in IBD surveillance and thus the only one considered in this recommendation. A randomized, crossover study of 42 patients found no significant difference between NBI and standard-definition white-light colonoscopy in the proportion of patients with dysplasia (8 [19%] vs 7 [17%]).31Dekker E. van