Endoscopic Surveillance Program Research Articles

A nationwide database study on colectomy and colorectal cancer in ulcerative colitis: what is the role of appendectomy?

Although has been suggested that an appendectomy has a positive effect on the disease course in patients with ulcerative colitis (UC), recent studies indicate a potential increase in risk of colectomy and colorectal cancer (CRC). This study aimed to evaluate the rates of colectomy and CRC after appendectomy in UC patients using a nationwide prospective database [the Initiative on Crohn and Colitis Parelsnoer Institute - Inflammatory Bowel Disease (ICC PSI-IBD) database]. All UC patients were retrieved from the ICC PSI-IBD database between January 2007 and May 2018. Primary outcomes were colectomy and CRC. Outcomes were compared in patients with and without appendectomy, with a separate analysis for timing of appendectomy (before or after UC diagnosis). A total of 826 UC patients (54.7% female; median age 46years, range 18-89 years) were included. Sixty-three (7.6%) patients had previously undergone appendectomy: 24 (38.1%) before and 33 (52.4%) after their diagnosis of UC. In multivariate analysis, appendectomy after UC diagnosis was associated with a significantly lower colectomy rate compared with no appendectomy [hazard ratio (HR) 0.16, 95% C: 0.04-0.66, P=0.011], and the same nonsignificant trend was seen in patients with an appendectomy before UC diagnosis (HR 0.35, 95% CI 0.08-1.41, P=0.138). Appendectomy was associated with delayed colectomy, particularly when it was performed after diagnosis of UC (P=0.009). No significant differences were found in the CRC rate between patients with and without appendectomy (1.6% vs 1.2%; P=0.555). Appendectomy in established UC is associated with an 84% decreased risk of colectomy and a delay in surgery. Since the colon is in situ for longer, the risk of developing CRC remains, which underscores the importance of endoscopic surveillance programmes.

Endoscopic eradication therapy for Barrett's oesophagus: state of the art.

Barrett's oesophagus is the only identifiable precursor lesion to oesophageal adenocarcinoma. The stepwise progression of Barrett's oesophagus to dysplasia and invasive carcinoma provides the opportunity to intervene and reduce the morbidity and mortality associated with this lethal cancer. Several studies have demonstrated the efficacy and safety of endoscopic eradication therapy (EET) for the management of Barrett's oesophagus related neoplasia. The primary goal of EET is to achieve complete eradication of intestinal metaplasia (CE-IM) followed by enrolment of patients in surveillance protocols to detect recurrence of Barrett's oesophagus and Barrett's oesophagus related neoplasia. EET depends on early and accurate detection and diagnosis of Barrett's oesophagus related neoplasia. All visible lesions should be resected followed by ablation of the remaining Barrett's epithelium. After treatment, patients should be enrolled in endoscopic surveillance programmes. For nondysplastic Barrett's oesophagus, surveillance alone is recommended. For low-grade dysplasia, both surveillance and ablation are reasonable options and should be decided on an individual basis according to patient risk factors and preferences. EET is preferred for high-grade dysplasia and intramucosal carcinoma. For T1b oesophageal adenocarcinoma, esophagectomy remains the standard of care, but endoscopic therapy can be considered in select cases. EET is now standard of care and endorsed by societal guidelines for the treatment of Barrett's oesophagus related neoplasia. Future studies should focus on risk stratification models using a combination of clinical data and biomarkers to identify ideal candidates for EET, and to predict recurrence. Optimal therapy for T1b cancer and surveillance strategy after CE-IM are topics that require further study.

Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus.

Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.

Protocolo de prevención y vigilancia endoscópica de la displasia/cáncer colorrectal en la enfermedad inflamatoria intestinal

The colorectal cancer (CRC) prevention in inflammatory bowel disease (IBD) comprises all those measures directed to: long-term control of inflammatory activity in colon, chemo-prevention and the adequate adherence of physicians and patients to endoscopic screening and surveillance (ES) programs recommended by updated consensus clinical practice guidelines (CPG). In the IBD, dysplasia and intra-epithelial neoplasia are the oncogenic precursors of CRC. In the most cases, dysplasia lesions can be discovered by endoscopy. The rroutine use of dye-based pancolonic chromoendoscopy or virtual chomoendoscopty with yargered biopsies/resection is recomended in order to optimize its detection and diagnosis. A good prognosis is related with a complete resection of dysplasia lesions, allowing an endoscopic follow-up according to consensus protocols. Colectomy is indicated either when complete resection (by polypectomy and / or advanced endoscopy techniques) is impossible, or when there are signs of neoplastic invasiveness. Recommendations of the GPC of Asociación Española de Gastroenterología (AEG) and Sociedad Española de Medicina Familiar y Comunitaria (SemFYC) 2018 and Grupo Español de Trabajo en Enfermedad de Crohn y Colitis ulcerosa (GETECCU) 2019, are summarized in the current report.

1756 Evolution of Esophageal Lichen Planus to Esophageal Leukoplakia

INTRODUCTION: To describe a case of esophageal lichen planus which appeared to evolve to leukoplakia (aka epidermoid metaplasia). CASE DESCRIPTION/METHODS: A 70 yo female with a prior history of lichen planus, presented from another institution for ongoing care related to proximal esophageal stricturing. The patient had well-documented lichen planus involving the oral and vaginal mucosae and axillary areas. Dysphagia had been ongoing for greater than a decade and prior endoscopic exams revealed the proximal esophagus to be of small caliber with proximal esophageal strictures/rings. Biopsies had shown nonspecific change. On some occasions an ultrathin gastroscope was required to traverse the proximal esophagus. The patient underwent numerous sessions of Savary dilation and given oral lichen planus, it was assumed that this process was also responsible for the proximal esophageal pathology. She was treated with periodic esophageal dilation and topical budesonide. Recently after the above therapy, dysphagia had resolved, and the patient was ingesting a normal diet. The esophagus was found to be of more normal caliber endoscopically (strictures were no longer evident) and prominent whitish proximal esophageal plaques were now noted (Figure 1). Proximal esophageal biopsies now revealed hyperorthokeratosis with hypergranulosis, but no inflammatory process or Civatte bodies (apoptotic keratinocytes). As such, recent endoscopic and pathologic findings were thought to be most consistent with esophageal leukoplakia/epidermoid metaplasia. Topical budesonide was continued for her oral lichen planus, but it was now recommended that it be administered in a "swish and spit" manner. Given the association of esophageal leukoplakia with squamous dysplasia and squamous cell carcinoma, the patient was placed in an endoscopic surveillance program. She has recently remained asymptomatic from the esophageal perspective. DISCUSSION: Lichen planus and leukoplakia (epidermoid metaplasia) involving the esophagus are distinct clinical, endoscopic and pathologic processes- both of which appear to have a female predominance, and potential association with squamous cell carcinoma. The esophageal disease in patient under discussion appeared to evolve from one of these processes to the other, raising the specter of an association between these disorders.

A Pilot Low-Inflammatory Dietary Intervention to Reduce Inflammation and Improve Quality of Life in Patients With Familial Adenomatous Polyposis: Protocol Description and Preliminary Results.

Patients with familial adenomatous polyposis (FAP) depend on a lifelong endoscopic surveillance programme and prophylactic surgery, and usually suffer nutritional problems. Intestinal inflammation has been linked to both FAP and colorectal cancer. Epidemiological studies show a relationship between diet and inflammation. Preventive dietary recommendations for FAP patients are so far lacking. We have designed a nonrandomized prospective pilot study on FAP patients to assess whether a low-inflammatory diet based on the Mediterranean diet principles and recipes, by interacting with the microbiota, reduces gastrointestinal markers of inflammation and improves quality of life. This report describes the scientific protocol of the study and reports the participants’ adherence to the proposed dietary recommendations. Thirty-four FAP patients older than 18 years, bearing the APC pathogenic variant, who underwent prophylactic total colectomy with ileo-rectal anastomosis were eligible into the study. During the 3-month dietary intervention, they reported improvements in their consumption of Mediterranean foods (vegetables, fruits, fish, and legumes), and a reduction in pro-inflammatory foods (red/processed meat and sweets); this led to a significant increase in their adherence to the Mediterranean diet. The improvement was accompanied by a decrease in the number of diarrhoeal discharges. These preliminary results are encouraging with regard to feasibility, dietary outcome measures, and safety.

Endoscopic findings and esophageal cancer incidence among Fanconi Anemia patients participating in an endoscopic surveillance program

Background and aimsThe primary clinical characteristics of Fanconi Anemia (FA) include typical physical features, progressive bone marrow failure, and an increased incidence of neoplasms, including esophageal carcinoma. Currently, there are no data regarding endoscopic findings or the interval time to malignancy in these patients. Data about the contribution of Human Papilloma Virus (HPV) to esophageal carcinoma is conflicting. Our objective is to document the upper gastrointestinal (GI) findings at baseline, document cancer incidence, and evaluate the role of HPV among these cancers. MethodsWe reviewed endoscopic and clinical data of FA subjects who participated in active surveillance before cancer diagnosis. Incident esophageal cancers were stained for HPV p16 protein. ResultsEight FA patients were included (men 62.5%; median age at first endoscopy 20 years, median endoscopies number: 5.5). At baseline, 8/8 had endoscopic evidence for reflux esophagitis. In 3/8 the reflux esophagitis was mild and in 5/8 it was moderate or severe. During the follow up time (median time 4.5 years 2/8 developed Barrett’s esophagus and 2/8 patients had incident esophageal squamous cell carcinoma during follow up, at intervals of eight and eighteen months from the previous upper endoscopy. Both cancers stained negative for HPV P16. ConclusionsFA subjects have both an extremely high risk for esophageal cancer within short intervals and a very high prevalence of reflux esophagitis with various severities. Active surveillance programs in specialized centers including annual upper endoscopies should be considered in these patients.

Surveillance of premalignant gastric lesions: a multicentre prospective cohort study from low incidence regions

ObjectiveInternational guidelines recommend endoscopic surveillance of premalignant gastric lesions. However, the diagnostic yield and preventive effect require further study. We therefore aimed to assess the incidence of neoplastic progression and...

Volumetric laser endomicroscopy in the management of Barrett's esophagus

The incidence of esophageal adenocarcinoma is on the rise despite widespread appreciation that the precursor lesion is Barrett's esophagus. Studies have shown that some patients known to have Barrett's esophagus develop cancer despite their enrollment in conventional endoscopic surveillance programs. This highlights the need for advanced endoscopic imaging to help identify early neoplasia and prevent its progression to esophageal cancer. Recently, a wide-field, second-generation optical coherence tomography endoscopic platform called volumetric laser endomicroscopy (VLE) was cleared by the Food and Drug Administration and made commercially available for advanced imaging in Barrett's esophagus. The current review discusses current literature on VLE imaging in Barrett's esophagus. Based on ex-vivo studies, criteria have been established for identifying Barrett's esophagus-associated neoplasia. In addition, recent studies, case series, and case reports have demonstrated that VLE is well tolerated, efficacious, and can target neoplasia. VLE is a new advanced imaging platform for Barrett's esophagus with considerable promise to target Barrett's esophagus-associated neoplasia. The following are needed to establish VLE's clinical role: studies showing incremental yield of dysplasia detection using VLE, studies to determine VLE's in-vivo diagnostic accuracy for identifying and classifying Barrett's esophagus-associated neoplasia, and studies on the cost-efficacy of VLE.

The Role of Esophagogastroduodenoscopy Surveillance for Patients with Barrett Esophagus.

Approximately 10% to 15% of patients who experience chronic gastroesophageal reflux disease have Barrett esophagus, which is associated with an increased risk of esophageal adenocarcinoma. If symptoms persist after 8weeks of adhering to treatment and lifestyle modifications, or if alarm symptoms develop, patients should be referred for screening upper endoscopy. Those with evidence of Barrett esophagus with dysplasia should be monitored in an endoscopic surveillance program, and those with high-grade dysplasia should consider surgical treatment.

Findings at surveillance colonoscopy following surgery for colorectal cancer.

Colonoscopic surveillance following potentially curative surgery for colorectal cancer aims to detect treatable metachronous neoplasia. The timing and findings of colonoscopies for patients enrolled in an endoscopic surveillance programme were examined in this study. A retrospective clinical audit was undertaken of 174 consecutive patients undergoing surgery for first-presentation colorectal cancer, looking at the findings of subsequent surveillance colonoscopies. Sixty-nine patients were fit for ongoing surveillance, with the median time to first colonoscopy being 14 months, and significant metachronous pathology was identified in 25%, comprising low-risk adenomas, high-risk adenomas, sessile serrated adenomas and one Dukes A carcinoma. Twenty-seven patients underwent a second colonoscopy, with a median interval of 34 months between the investigations, and adenomas were identified in 30% of patients at the second surveillance colonoscopy. All polyps were colonoscopically resectable. Colonoscopy at 1 and 4 years following bowel cancer resection may detect treatable pathology in a significant proportion of those patients fit for ongoing surveillance.

How Do We Manage Gastric Intestinal Metaplasia? A Survey of Clinical Practice Trends for Gastrointestinal Endoscopists in the United States.

Gastric intestinal metaplasia (GIM) is an accepted pathologic precursor to gastric adenocarcinoma (GAC). While surveillance of GIM in Europe and Asia is common, only limited recommendations related to endoscopic surveillance of GIM exist in the United States. To understand the clinical practice patterns of US gastroenterologists in the management and endoscopic surveillance of GIM. A 23 item survey was developed to explore endoscopists' opinions regarding the surveillance of GIM and knowledge of current guidelines. Eight clinical vignettes were developed to address specific clinical scenarios where endoscopic surveillance of GIM might be considered. There were 227 respondents, with 60% working primarily in the private sector and 40% in academic medicine. While 68% of the respondents refer to major society guidelines for guidance in patient management, almost 78% of endoscopist responders believe that there are no specific US guidelines pertaining to surveillance of GIM. Only two-thirds of respondents believe that based on current data, patients at increased risk of GAC should be a part of an endoscopic surveillance program, while 15% believe all patients with GIM should receive endoscopic surveillance. Respondents use a wide range of biopsy techniques and surveillance intervals for patients with GIM, with no consistent pattern of practice identified. There is variability in the knowledge and practice patterns of US endoscopists related to surveillance of gastric intestinal metaplasia. In the absence of detailed US GI society guidelines, many endoscopists perform surveillance endoscopy on patients with GIM using variable biopsy techniques and surveillance intervals.

Screening and surveillance for Barrett esophagus.

Screening and surveillance for Barrett esophagus.

Metachronous cancer after endoscopic submucosal dissection of gastric neoplasia.

559 Background: Metachronous recurrence after endoscopic resection (ER) of gastric cancer is known to be high. However, recurrence rate of metachrous lesions after ER of gastric adenoma has not been studied well. The aim of the study was to compare the metachronous recurrence between gastric carcinoma and adenoma patients. Methods: Four hundred eight carcinoma and 539 adenoma patients were enrolled in this study, and median follow-up period was 27 months (IQR: 16-45 months). Clinicopathological characteristics were assessed. At the follow-up endoscopy, the whole gastric mucosa was examined thoroughly to detect any gastric neoplasia. All suspicious lesions were evaluated histologically on endoscopic biopsies. Surveillance endoscopic schedule was as follows: every 3–6 months within 1 year, then once every year. Results: Forty three metachronous recurrence was diagnosed in in carcinoma patients and 45 in adenoma patients. There was no significant difference in the incidence of recurrent metachronous neoplasm between carcinoma and adenoma patients (p=0.728, log-rank test). After excluding metachronous adenoma, cancer recurrence was not different either between two groups (p=0.943). After adjusting for age, sex, multiplicity, and Helicobacter pylori status, the risk of the metachronous development of gastric cancer in adenoma patients was similar with that in carcinoma patients (HR, 0.96; 95% CI, 0.63-1.45). Conclusions: Metachronous gastric cancer after ER of gastric adenoma was as high as that of gastric carcinoma. Similar endoscopic surveillance program should be applied for both gastric carcinoma and adenoma patients after ER.

Targeting care in Barrett’s oesophagus

Barretts oesophagus represents the most significant risk factor for the development of oesophageal adenocarcinoma (OAC), although the majority of patients will not develop cancer. However, early detection of OAC and its precursors significantly improves outcome and underlines the importance of endoscopic surveillance programmes. Clearly there is a discrepancy between the small number of people who need to undergo surveillance because they are at significant progression risk, and the large number that do. Research is therefore now concentrated on risk stratification. Currently such stratification is currently based on clinical findings, endoscopic diagnosis and histopathological grade. Histopathology can be imperfect and is likely to require molecular confirmation of different grades, thus molecular stratification is becoming more important in this regard and p53 immunohistochemistry is already clinically useful, with other molecular biomarkers likely to prove beneficial in the future. The hope is that non-endoscopic methods, such as the Cytosponge may be able to combine molecular biomarkers with histopathology and therefore perhaps benefit a population screening as well as a surveillance programme.

Prospective Long-Term Assessment of Sedation-Related Adverse Events and Patient Satisfaction for Upper Endoscopy and Colonoscopy

Background: Fear of pain and sedation-related adverse events are impediments for patients to attend endoscopic screening or surveillance programs. Objective: To investigate the long-term effect of different sedation protocols in patients undergoing screening or surveillance endoscopy. Moreover, motivation of patients to decline endoscopic procedures was evaluated by focusing on the patient's satisfaction, fear and pain in relation to type of sedation used. Methods: Design: A prospective, double-blind controlled trial data collection was performed by using a standardized clinical questionnaire followed by a telephone interview 3-4 weeks after the initial endoscopic procedure. Setting: The study was conducted at the Department of Medicine I at the University Hospital of Erlangen-Nuremberg. Data collection was performed during June 2012 till April 2013. Patients: Overall, 307 patients were prospectively evaluated (44.3% female, mean age 51 ± 17.4 years; mean BMI 25.5 ± 5.7). 247 patients (80.5%) were outpatients, 60 inpatients (19.5%). Interventions: Endoscopic procedures were divided into five groups: (i) procedures in the upper gastrointestinal tract, (ii) complete colonoscopies, (iii) ileocolonoscopies, (iv) incomplete colonoscopies, and (v) other procedures. Main outcome measurements: Patient satisfaction, fear and pain were measured in a structured and standardized clinical interview using a 6-point numerical rating scale, where 1 was ‘very satisfied/no pain' and 6 was ‘very unsatisfied/unsupportable pain'. Results: Different types of sedation were assessed: propofol in monosedation (6.5%), combination of propofol + meperidine (41.0%), combination of midazolam + meperidine (48.5%) and other combinations (3.9%). Patient satisfaction was significantly reduced regarding fear and pain during the endoscopic procedure (p = 0.001 and p = 0.0001, respectively). All patients receiving propofol monosedation indicated significantly less pain in comparison to other sedation groups (p < 0.0001). Moreover, sedation with midazolam + meperidine increased the fear during the procedure significantly in comparison to monosedation with propofol (p = 0.082). Propofol/meperidine in combination and midazolam/meperidine increased the probability for cardiovascular events in comparison to monosedation with propofol (p = 0.005; p = 0.039). Finally, we observed significantly lower doses of propofol when used in monosedation than propofol in combination with meperidine (p = 0.066). Limitation: Single-center study at a tertiary referral center. Conclusions: Propofol in monosedation should preferably be used for patient sedation in screening and surveillance endoscopies. Whether this approach could also improve participation rates in screening and surveillance endoscopies requires further investigations.

Surveillance of Barrett's esophagus and mortality from esophageal adenocarcinoma: a population-based cohort study.

Barrett's esophagus (BE) is associated with an increased risk of developing esophageal adenocarcinoma (EAC). Patients with a known diagnosis of BE are usually advised to participate in an endoscopic surveillance program, but its clinical value is unproven. Our objective was to compare patients participating in a surveillance program for BE before EAC diagnosis with those not participating in such a program, and to determine predictive factors for mortality from EAC. All patients diagnosed with EAC between 1999 and 2009 were identified in the nationwide Netherlands Cancer Registry. These data were linked to Pathologisch-Anatomisch Landelijk Geautomatiseerd Archief, the Dutch Pathology Registry. Prior surveillance was evaluated, and multivariable Cox proportional hazards regression analysis was performed to identify predictors for all-cause mortality at 2-year and 5-year follow-up. In total, 9,780 EAC patients were included. Of these, 791 (8%) patients were known with a prior diagnosis of BE, of which 452 (57%) patients participated in an adequate endoscopic surveillance program, 120 (15%) patients in an inadequate program, and 219 (28%) patients had a prior BE diagnosis without participating. Two-year (and five-year) mortality rates were lower in patients undergoing adequate surveillance (adjusted hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.64-0.92) when compared with patients with a prior BE diagnosis who were not participating. Other factors associated with lower mortality from EAC were lower tumor stage (stage I vs. IV, HR=0.19, 95% CI=0.16-0.23) and combining surgery with neoadjuvant chemo/radiotherapy (HR=0.66, 95% CI=0.58-0.76). Participation in a surveillance program for BE, but only if adequately performed, reduces mortality from EAC. Nevertheless, it remains to be determined whether such a program is cost-effective, as more than 90% of all EAC patients were not known to have BE before diagnosis.

The Role of the Pathologist in the Diagnosis and Treatment of Dysplasia in Inflammatory Bowel Disease

It has been clearly demonstrated that patients suffering from long-standing inflammatory bowel disease (IBD) (ulcerative colitis and Crohn’s disease) are at increased risk of developing colorectal cancer (CRC). The exact magnitude of this risk is difficult to measure and ranges widely according to different reports. Several reasons could explain this variability including (1) selection bias: population based vs specialized centers; (2) practice patterns, different threshold among physicians to perform colectomies; (3) widespread use of medications that have been proven to reduce the risk of colorectal cancer (5ASA); and (4) rigorous endoscopic surveillance programs. In a meta-analysis of 116 studies that included almost 55,000 patients, Eaden at al demonstrated that the risk of developing CRC associated with IBD was 2, 8, and 18% after 10, 20, and 30 years, respectively. Even when the variation in cancer risk among several institutions is considered, there appears to be a trend towards a decreased incidence in CRC in the most recent reports.

Current and Future Status for Evaluation of Dysplasia and Carcinoma in IBD

Endoscopic surveillance is an important method to identify colorectal neoplasia in patients with inflammatory bowel disease. Advances in endoscopic techniques using pancolonic chromoendoscopy have improved the detection of dysplasia compared to white-light endoscopy, which has the potential to decrease the risk of colorectal cancer. Currently, pancolonic chromoendoscopy is readily available for use, and in the future, it will likely become the standard of care for endoscopic surveillance. Pancolonic chromoendoscopy followed by confocal laser endomicroscopy may further increase the yield on surveillance endoscopy, although confocal laser endomicroscopy is not readily available outside of a limited number of institutions. Other endoscopic tools such as narrow band imaging have not been shown to be beneficial over white-light endoscopy. Emerging tools such as stool DNA testing show promise as an adjunct to colonoscopy but are still in the early stages of development. For management, patients with well-demarcated circumscribed dysplastic lesions should be resected endoscopically, followed by a continued endoscopic surveillance program. Patients with lesions that cannot be resected completely or that have features suggestive of invasive carcinoma on either endoscopy or histology should undergo colectomy. Patients with flat high-grade dysplasia should undergo colectomy. Patients with flat low-grade dysplasia should have a discussion about the risks and benefits of undergoing colectomy versus continuing in an endoscopic surveillance program. If they opt for surveillance, these patients should have more frequent follow-up surveillance examinations (every 3 to 6months) with pancolonic chromoendoscopy.

Barrett's oesophagus: epidemiology, cancer risk and implications for management

Although endoscopic surveillance of patients with Barrett's oesophagus has been widely implemented, its effectiveness is debateable. The recently reported low annual oesophageal adenocarcinoma risk in population studies, the failure to...