Subsequent Surveillance Research Articles

Excision of a juxtapapillary duodenal diverticulum causing biliary obstruction: report of three cases

We report three cases of biliary obstruction caused by a juxtapapillary duodenal diverticulum that were treated by excision of the diverticulum. A 72-year-old man, a 77-year-old woman, and an 81-year-old woman each presented with recurrent obstructive jaundice. Diagnostic imaging revealed a juxtapapillary duodenal diverticulum compressing the common bile duct (CBD). Following cholecystectomy, the diverticulum between the intrapancreatic CBD and pancreatic parenchyma was isolated and excised successfully in each case. The patients have been followed up for 34, 31, and 22 months, respectively. In one patient, choledocholithiasis developed 33 months after the surgery, necessitating endoscopic sphincterotomy. Duodenal diverticulectomy is a useful procedure to relieve biliary obstruction caused by a juxtapapillary duodenal diverticulum. However, it remains unclear whether excision of the diverticulum is preferred to biliodigestive anastomosis from the point of view of long-term prognosis. Subsequent surveillance is necessary.

Pathologic findings from the National Surgical Adjuvant Breast and Bowel Project: twelve-year observations concerning lobular carcinoma in situ.

The current report represents a 12-year clinicopathologic update of an earlier 5-year analysis of 180 patients with lobular carcinoma in situ (LCIS) who were treated with local excision and subsequent surveillance only. Nineteen pathologic characteristics of LCIS were assessed as potential predictors of invasive and noninvasive ipsilateral breast tumor recurrence (IBTR) and contralateral breast tumor recurrence (CBTR) as well as mortality. Overall, only 26 IBTRs (14.4%) and 14 CBTRs (7.8%) were observed. Nine IBTRs (5.0% of the total cohort) and 10 CBTRs (5.6% of the total cohort) were invasive carcinomas. Eight of 9 IBTRs (88.9%) and 6 of 8 invasive CBTRs (75%) that had histologic sections available for review were of the lobular invasive type. Ninety-six percent of all IBTRs and 100% of invasive IBTRs occurred within the same site as the index LCIS. The numbers of invasive IBTRs were comparable within and after 5 years (5 invasive IBTRs vs. 4 IBTRs). Recurrences of invasive CBTR occurred later than recurrences of invasive IBTR, with 70% of invasive CBTRs recognized after 5 years compared with 44% of invasive IBTRs. It was found that Grade 2-3 LCIS was significantly predictive for invasive IBTR when combined with the number of recurrences of ductal carcinoma in situ (DCIS) alone or with LCIS. Only 2 patients in the cohort (1.1%) succumbed to breast carcinoma; 1 patient had a prior invasive IBTR, and the other patient had an invasive CBTR. The reasons for the lower frequency of invasive recurrences and the higher proportions of the lobular invasive phenotype than noted by others are discussed along with the impact of the findings on the nomenclature, precursor nature, and treatment of LCIS. LCIS is a more indolent form of in situ breast carcinoma than DCIS, with which it shares other features of its natural history, particularly very low mortality rates. There is no compelling reason to surgically treat LCIS other than conservatively. The values of other adjuvant modalities in the management of LCIS are discussed. The authors acknowledge that their findings are based on relatively few events and, even at 12 years, may be regarded as "preliminary". Nonetheless, their findings may reflect the true biologic nature of LCIS.

Screening for abdominal aortic aneurysm: a consensus statement.

Screening for abdominal aortic aneurysm: a consensus statement.

Endoscopic response predicts for survival and organ preservation after primary chemoradiotherapy for esophageal cancer

Purpose To determine the role of endoscopic surveillance in predicting organ preservation and survival after primary chemoradiotherapy (CRT) for esophageal cancer. Methods and materials Fifty-six consecutive patients with nonmetastatic esophageal cancer were treated with primary CRT between May 1993 and April 1999 with curative intent and subsequent surveillance with endoscopy and CT scans. Patients with residual disease on endoscopy and/or CT 6 weeks after CRT were considered for immediate esophagectomy. The remaining patients continued endoscopic surveillance and were considered for esophagectomy only when local relapse was detected. Five-year survival was estimated using the Kaplan-Meier method, and univariate and multivariate analyses were performed to identify significant factors associated with disease-specific survival. Results With a median follow-up of 62 months, the 5-year overall and disease-specific survival was 30% (95% confidence interval [CI]: 17%–43%) and 37% (95% CI: 22%–50%), respectively. Fourteen of 24 (58%) patients who survived more than 2 years did not require an esophagectomy. On univariate analysis, favorable prognostic factors for disease-specific survival were female gender ( p = 0.026), CT-defined N 0 status ( p = 0.027), and negative endoscopy at 6 weeks after CRT ( p < 0.0001). On multivariate analysis, N 0 status and negative endoscopy after CRT remained significant ( p = 0.03 and p < 0.0001, respectively) for disease-specific survival. On multivariate analysis for overall survival, female gender and negative endoscopy were significant ( p = 0.35 and p < 0.001, respectively). The hazard ratios for disease-specific survival with positive nodal status and positive endoscopy were 2.44 (95% CI: 1.14–5.3) and 5.18 (95% CI: 2.3–11.6), respectively. Conclusion Endoscopic response after primary CRT for esophageal cancer was the most significant predictive factor for overall and disease-specific survival. Regular endoscopic surveillance after CRT achieved survival rates comparable to other strategies and successfully preserved the esophagus in the majority of patients who survived more than 2 years.

Yield of endoscopy in dyspepsia and concurrent treatment with proton pump inhibitors: The blind leading the blind?

Yield of endoscopy in dyspepsia and concurrent treatment with proton pump inhibitors: The blind leading the blind?

Surveillance after positive and negative colonoscopy examinations: issues, yields, and use.

As colorectal cancer screening gains acceptance by the public, the use of colonoscopy will increase. The frequency of surveillance examinations after detection of an adenoma is one of the largest contributors to the cost of colorectal cancer screening. Ten years after the publication of the landmark National Polyp Study, the issue of when to perform surveillance examinations and how often to expect advanced findings remains acute. Current guidelines for surveillance vary across specialty organizations. Individuals with advanced adenomas are at increased risk for recurrent advanced adenomas. The impact of multiple nonadvanced adenomas or a single nonadvanced adenoma on subsequent risk of an advanced adenoma or cancer is less clear. Still less is known about findings on repeat examinations after an initial negative examination, whether after colonoscopy or sigmoidoscopy. The yield after a negative examination is an important consideration in determining the recommended interval for screening colonoscopy. For example, the data supporting a 10-yr interval for screening colonoscopy is only indirect. What little we do know about the yield after negative examinations comes from selected, nonrepresentative populations. Of concern, evidence from several polyp prevention trials demonstrates higher yields for subsequent cancer than would be expected, despite a relatively high use of surveillance procedures in follow-up. Further population-based research on the frequency of use and yield of surveillance examinations is needed. Studies that examine the need and the needed timing of subsequent surveillance are essential to containing costs for screening as well as to informing the public better about what endoscopic screening can and cannot accomplish.

The color of dysplasia in ulcerative colitis

The color of dysplasia in ulcerative colitis

Screening and surveillance for Barrett esophagus in high-risk groups: a cost-utility analysis.

Once-in-a-lifetime screening for Barrett esophagus has been proposed for patients with gastroesophageal reflux disease (GERD), but there is little evidence of its cost-effectiveness. 1) To determine the cost-effectiveness of screening high-risk groups for Barrett esophagus and providing surveillance to patients with Barrett esophagus and dysplasia or to all patients with Barrett esophagus and 2) to compare the results with the cost-effectiveness of no screening or surveillance. A decision analytic model was developed to examine no screening or surveillance and screening and surveillance for Barrett esophagus with dysplasia only or Barrett esophagus without dysplasia every 2 to 5 years. Low- or high-grade dysplasia received surveillance every 6 or 3 months, respectively. Published literature and the Health Care Financing Administration. 50-year-old white men with symptoms of GERD. 50 years of age until 80 years of age or death. Third-party payer. Incremental cost-effectiveness ratio. Screening with surveillance limited to patients with Barrett esophagus with dysplasia required $10 440 per quality-adjusted life-year (QALY) saved compared to no screening or surveillance. The incremental cost-effectiveness ratio of surveillance every 5 years in patients with Barrett esophagus without dysplasia compared to surveillance of patients with Barrett esophagus with dysplasia was $596 000 per QALY saved. The annual incidence of adenocarcinoma must exceed 1 case per 54 patient-years of follow-up (1.9%) for surveillance of Barrett esophagus without dysplasia every 5 years to yield an incremental cost-effectiveness ratio less than $50 000 per QALY saved. Screening 50-year-old men with symptoms of GERD to detect adenocarcinoma associated with Barrett esophagus is probably cost-effective. However, subsequent surveillance of patients with Barrett esophagus but no dysplasia, even at 5-year intervals, is an expensive practice.

Increasing antimalarial drug resistance in Uganda and revision of the national drug policy.

Chloroquine (CQ) resistance was first documented in Uganda in 1988. Subsequent surveillance of antimalarial drug resistance, conducted by the Ugandan Ministry of Health and several research organizations, suggests that resistance to CQ is now widespread, reaching critical levels in many areas of the country. In June 2000, the Ministry of Health held a National Consensus Meeting to evaluate the available drug efficacy data and review the national antimalarial drug policy. After extensive debate, the combination of CQ + sulfadoxine-pyrimethamine (SP) was chosen to replace CQ as the first-line treatment of uncomplicated malaria as an interim policy. This review evaluates the in vivo drug efficacy studies conducted in Uganda since 1988 and issues confronted in revision of the drug policy. The Ugandan experience illustrates the challenges faced by sub-Saharan African countries confronted with rising CQ resistance but limited data on potential alternative options. The choice of CQ + SP as a provisional policy in the absence of prerequisite efficacy, safety and cost-effectiveness data reflects the urgency of the malaria treatment problem, and growing pressure to adopt combination therapies. Surveillance of CQ + SP treatment efficacy, collection of additional data on alternative regimens and active consensus building among key partners in the malaria community will be necessary to develop a rational long-term antimalarial treatment policy in Uganda.

Detection of West Nile virus-infected mosquitoes and seropositive juvenile birds in the vicinity of virus-positive dead birds.

Mosquitoes and wild birds were collected from three sites near locations in the New York City metropolitan area where single, West Nile (WN) virus-positive dead birds were found early in the 2000 transmission season. The mosquitoes were tested for the presence of infectious virus with a Vero cell culture assay and for WN viral RNA by using reverse transcriptase-polymerase chain reaction (RT-PCR) protocols. Serum samples from wild birds were tested for the presence of neutralizing antibodies against WN virus. Infectious WN virus and WN viral RNA were found in Culex species adult mosquitoes from each of the three sites, and a seropositive hatch-year house sparrow (Passer domesticus) was found in one of the three sites. Molecular techniques used to identify the species in the positive mosquito pools found that most of the pools contained a combination of Culex pipiens and Cx. restuans. The minimum infection rate in Culex species mosquitoes from the sites ranged from 0.2 to 6.0 per 1,000 specimens tested. The results demonstrated that, at least early in the transmission season, detection of a WN virus-positive dead bird indicates a local WN virus transmission cycle. This information is valuable in focusing subsequent surveillance and vector management programs. In addition, the RT-PCR procedure for detecting WN viral RNA in mosquito pools detected more positive pools than did the Vero cell plaque assay.

Women With a History of Placental Abruption: When in a Subsequent Pregnancy Should Special Surveillance for a Recurrent Placental Abruption be Initiated?

Placental abruption tends to recur in later pregnancies, but its time of onset is unpredictable. Women with a past history of abruption frequently are admitted, or else begin intensive ambulatory antenatal care, using thegestational age of the previous episode as a starting point. The goal of this cohort study was to determine the best time during a subsequent pregnancy to begin intensive surveillance to prevent recurrent abruption. More than 1.8 million births in Norway from 1967 through 1998, representing 928,779 women, were included in the study if the pregnancy lasted at least 16 completed weeks. A total of 492,861 women were followed through their first two deliveries. Four cohorts were assessed: 1) women with a complicated placental abruption, 2) uncomplicated abruption, 3) complicated birth without placental abruption, and 4) uncomplicated birth without abruption. A complicated birth with or without placental abruption was defined as a case with preterm delivery, fetal growth restriction, or perinatal death. Placental abruption complicated 6.4 per 1000 deliveries in birth order 1 and 6.2 per 1000 in birth order 2. The 104 recurrent abruptions represented 38 per 1000 deliveries. The recurrence rate in cohort 4 was 4.6 per 1000, and that in cohort 3 was 8.8 per 1000 deliveries. Analysis of cohort 1 disclosed recurrent placental abruption in 41 per 1000 deliveries. In this group it was estimated that 27 complicated abruptions would have occurred outside the hospital or before starting special observation at the gestational age of the initial episode, compared with only 3 if observation began 12 weeks before. Cohort 2 had recurrences at a rate of 30 per 1000. Starting surveillance 12 weeks earlier would reduce the expected number of complicated abruptions from 14 to 3. When there is a past history of placental abruption complicated by preterm delivery, a small-for-gestationalage infant, or perinatal death, observation starting 6 weeks before the gestational age of the initial event may reduce the risk of recurrence to one approaching the initial risk. An even longer surveillance time may be appropriate after an uncomplicated term placental abruption.

Six of the Best, Colorectal 22

Aims: To audit the effectiveness of a Rectal Bleeding Clinic (RBC) in detecting premalignant colonic lesions and early colorectal cancers. Methods: All 1175 consecutive patients referred to the RBC from November 1997 to September 2001 were assessed by detailed history, clinical examination and flexible sigmoidoscopy. Those with neoplastic lesions diagnosed on flexible sigmoidoscopy underwent subsequent colonoscopy. The final definitive histology of each patient was confirmed from the histology department database which was also used to identify a control group of consecutive patients with colorectal cancer diagnosed in conventional outpatients' clinics. Results: One hundred and thirty eight patients (11.7 per cent) had significant neoplastic lesions. Of these, 88 had adenomatous polyps and 50 patients had invasive cancer. Of the invasive cancers, 18 (36 per cent) patients had Duke's A lesions, as compared to 16 per cent of the control group of patients coming through conventional clinics during this period. Sixteen patients (8.1 per cent) aged 40–49 years were diagnosed as having neoplastic lesions (10 with low-grade dysplasia, one with high-grade dysplasia and five with invasive cancer). Conclusions: A rapid-access RBC enables detection of a higher proportion of potentially curable early colorectal cancers than conventional clinics in addition to a large number of premalignant lesions which can be treated endoscopically with subsequent colonoscopic surveillance. Our findings in the 40–49 years age group lead us to question the wisdom of a minimum age for these clinics of 50 years as practiced in some centres.

The development of a sub-surface monitoring system for organic contamination in soils and groundwater.

A major problem when dealing with environmental contamination is the early detection and subsequent surveillance of the contamination. This paper describes the potential of sub-surface sensor technology for the early detection of organic contaminants in contaminated soils, sediments, and landfill sites. Rugged, low-power hydrocarbon sensors have been developed, along with a data-logging system, for the early detection of phase hydrocarbons in soil. Through laboratory-based evaluation, the ability of this system to monitor organic contamination in water-based systems is being evaluated. When used in conjunction with specific immunoassays, this can provide a sensitive and low-cost solution for long-term monitoring and analysis, applicable to a wide range of field applications.

In vivo proton (H1) magnetic resonance spectroscopy for cervical carcinoma.

Proton magnetic resonance spectroscopy (MRS) may be a useful tool in both the initial diagnosis of cervical carcinoma and the subsequent surveillance after radiation therapy, particularly when other standard diagnostic methods are inconclusive. Single voxel magnetic resonance (MR) spectral data were acquired from 8 normal volunteers, 16 patients with cervical cancer before radiation therapy, and 18 patients with cervical cancer after radiation therapy using an external pelvic coil at a 1.5-T on a Signa system. The presence or absence of various resonances within each spectrum was evaluated for similarities within each patient group and for spectral differences between groups. Resonances corresponding to lipid and creatine dominated the spectrum for the eight normal volunteers without detection of a choline resonance. Spectra from 16 pretreatment patients with biopsy-proven cervical cancer revealed strong resonances at a chemical shift of 3.25 ppm corresponding to choline. Data acquired from the 18 posttreatment setting studies was variable, but often correlated well with the clinical findings. Biopsy confirmation was obtained in seven patients. H1 MRS of the cervix using a noninvasive pelvic coil consistently demonstrates reproducible spectral differences between normal and neoplastic cervical tissue in vivo. However, signal is still poor for minimal disease recurrence. Further study is needed at intervals before, during, and after definitive irradiation with biopsy confirmation to validate the accuracy of MRS in distinguishing persistence or recurrence of disease from necrosis and fibrosis.

Enoxaparin treatment in high-risk trauma patients limits the utility of surveillance venous duplex scanning

Objective: The value of surveillance venous duplex scanning for detecting unsuspected deep venous thrombosis (DVT) in trauma patients who are receiving enoxaparin prophylaxis is open to question. This study was undertaken to determine whether enoxaparin reduced the clinical utility of surveillance scanning and whether management of these patients was altered by findings of the scans. Methods: The medical records of trauma patients who met defined criteria for high DVT risk, admitted during 30 consecutive months, were reviewed. These patients received enoxaparin 30 mg every 12 hours for the duration of their admissions. Per protocol, surveillance lower extremity venous duplex scans were performed within 72 hours of enoxaparin administration and then weekly until patients were discharged from the hospital. The records were reviewed for thromboembolic events (DVT or pulmonary embolism [PE]), patient location and ambulatory status, therapeutic interventions (systemic anticoagulation, vena cava filter), and complications of enoxaparin therapy. Results: A total 241 patients underwent 513 venous duplex examinations (1-13 per patient). Eight patients had DVT on the initial scan; seven of these patients were asymptomatic. Five were treated with anticoagulation and/or vena cava filter placement. Of the 233 patients with initially negative duplex scan results, five patients (2%) developed clinically unsuspected lower extremity DVT while hospitalized. All of these five patients were in an intensive care unit. Three of the five patients had no change in treatment. Two of the five underwent anticoagulation, and one vena cava filter was placed. PE occurred in two hospitalized patients, one of whom was ambulatory, with negative duplex scan results. After hospital discharge, six other patients had symptomatic DVT or PE despite in-hospital scans with negative results. Complications associated with enoxaparin included hemorrhage (2) and thrombocytopenia (8). Conclusions: After initial negative scan results, repeat surveillance duplex scanning during hospitalization detected a low incidence (2%) of DVT in high-risk patients. Furthermore, the detection of unsuspected DVT altered the clinical management of less than 1% of the patients tested. Thus, after a venous duplex scan with negative results and initiation of enoxaparin prophylaxis, subsequent surveillance duplex examinations are not warranted in asymptomatic trauma patients. (J Vasc Surg 2001;34:447-52.)

Women with a history of placental abruption: when in a subsequent pregnancy should special surveillance for a recurrent placental abruption be initiated?

It is common to admit to hospital or start intensive ambulatory antenatal care of pregnant women with a previous placental abruption using the gestational age of the previous placental abruption as a starting point. In some instances, close surveillance may be commenced much earlier. There is no consensus when in a subsequent pregnancy such measures should be initiated. The analyses aimed at the prevention of complicated (preterm, small for gestational age, or perinatal death) recurrent placental abruptions, assessing at which time in a subsequent pregnancy special surveillance should start in order to anticipate and prevent a recurrence. A cohort study based on the Medical Birth Registry of Norway. Calculation of gestational age specific risks of placental abruption in a second pregnancy and estimation of when to initiate surveillance in order to reduce an increased risk of recurrent placental abruption to the initial level of initial abruption in the second pregnancy. In women with a complicated (preterm, small for gestational age, or perinatal death) first delivery, the risks of an initial and recurrent complicated placental abruption in the second pregnancy were 7/1000 and 33/1000, respectively (relative risk 4.9). To reduce the recurrence risk in a second pregnancy to 7/1000, special surveillance six weeks prior to the gestational age of the initial abruption would be necessary. In women with an uncomplicated first delivery, the risks in the second pregnancy of an initial and recurrent complicated abruption were 3 and 19/1000, respectively (relative risk 7.1). To reduce the recurrence risk to 3/1000, surveillance at least 12 weeks prior would be necessary. The increased recurrence rate would necessitate increased awareness in terms of special surveillance in the second pregnancy. In pregnancies at risk of a recurrent placental abruption, monitoring up to three months before the gestational age of the initial abruption is necessary.

Do safety practices differ between responders and non-responders to a safety questionnaire?

Objective—To compare reported safety practices between responders and non-responders to a safety survey. Design—Cross sectional survey at baseline compared with safety practices reported at subsequent child health surveillance checks. Subjects—Parents...

Pancreatic transplantation and subsequent graft surveillance by pancreatic portal-enteric anastomosis and temporary venting jejunostomy.

To evaluate portal-enteric (PE) pancreas and kidney transplantation with venting jejunostomy (VJ) for its efficacy, safety, and reproducibility. Simultaneous pancreas and kidney transplantation for patients with long-standing insulin-dependent diabetes mellitus that progresses to renal failure has revolutionized their treatment and quality of life. A current clinical focus is to refine the technical aspects of this procedure. Simultaneous pancreas and kidney transplantation with PE anastomosis with VJ appears to offer several advantages over bladder drainage. VJ allows initial decompression of the enteric anastomosis, monitoring of pancreatic function by ostomy amylase, and simple access for endoscopic evaluation and biopsy of the allograft. Simultaneous pancreas and kidney transplantation with VJ was performed in 21 patients from December 1996 to October 2000 at Willis Knighton/LSU Regional Transplant Center. All patients had long-standing insulin-dependent diabetes mellitus and subsequent renal failure. They were evaluated at the time of surgery by a multidisciplinary transplant team and monitored for numerous factors, including length of hospital stay, immunosuppressive regimen, and ischemia times. All patients had intermittent visual and biochemical evaluation of pancreatic secretions monitored by means of the VJ. Of the 21 patients, 10 were women and 11 were men. Four patients were black and 17 were white. The mean age at transplantation was 38 years; average human leukocyte antigen (HLA) match was one; and average cold ischemia time was 12 hours. The median hospital stay was 16 days. Four episodes of postoperative bleeding requiring exploration occurred in four patients. Postoperative wound infections developed in four patients. There were 12 episodes of rejection in nine patients. All patients with suspected acute pancreatic rejection underwent endoscopy by means of the VJ and duodenal biopsy for evaluation. Two patients lost pancreatic function subsequent to kidney failure, one secondary to noncompliance and the other as a result of hemolytic-uremic syndrome. Patient, kidney, and pancreatic survival rates were 100%, 90%, and 90%, respectively. The mean follow-up period was 25 (range 2-48) months. The authors believe that PE pancreatic drainage with VJ is a more physiologic method to perform pancreatic transplantation than bladder drainage. PE drainage allows rapid diagnosis of acute rejection and anastomotic leak and provides a simple way to monitor ostomy amylase and transplant duodenal bleeding. This technique is safe and has minimal associated complications.

Poor durability of carotid angioplasty and stenting for treatment of recurrent artery stenosis after carotid endarterectomy: An institutional experience

Purpose: Recurrent stenosis after carotid endarterectomy (CEA) is often regarded as an optimal application of carotid artery angioplasty and stenting (CAS). The extended durability of CAS for recurrent carotid artery stenosis after CEA is unknown. We present the intermediate-term surveillance results for all eight CAS procedures performed over a 28-month period at a single tertiary referral center. Methods: Patients had recurrent carotid stenosis after CEA, whether symptomatic or asymptomatic, of 80% to 99% stenosis on preprocedural carotid duplex scan examination. Uncovered, self-expanding metal stents, in conjunction with angioplasty, were used in all patients. Baseline and scheduled interval follow-up duplex ultrasound scan was used to assess intrastent restenosis. Further angiography was reserved for those patients obtaining additional intervention. Results: One transient ischemic attack was observed 1 day after the procedure, and no cerebral infarcts occurred. All patients had angiographic resolution of the stenosis and postprocedural duplex scan studies without residual stenosis. Subsequent interval surveillance duplex scan examinations revealed significant (60%-79%) to critical (80%-99%) recurrent stenosis in six (75%) of eight patients, two of whom went on to further interventions. Of those with intrastent restenosis, four (75%) progressed to critical (80%-99%) stenosis. Mean follow-up was 20.2 months (range, 12-37 months). The two lesions that have not yet shown restenosis are those with the shortest follow-up interval, each at 12 months. Conclusions: In contrast to the optimistic claims in other series, this limited series suggests that angioplasty with stenting for recurrent carotid artery occlusive disease after CEA, although relatively safe in the short term, has significant limitations in terms of durability of results. (J Vasc Surg 2001;33:1008-14.)

Screening and surveillance colonoscopy in chronic Crohn's colitis.

Unlike ulcerative colitis, there are few reports on the efficacy of surveillance colonoscopy in patients with chronic Crohn's colitis and therefore little agreement as to whether routine surveillance is indicated. We report on 259 patients with chronic Crohn's colitis who underwent screening and subsequent surveillance colonoscopy and biopsy since 1980. Biopsies were performed at 10-cm intervals and from strictures and polypoid masses. Pathology was classified as normal, dysplasia (indefinite, low-grade, high-grade), or carcinoma. A total of 663 examinations were performed on 259 patients. The median interval between examinations was 24 months; examinations were performed more frequently (1-6 months) in patients with dysplasia on biopsy. A thinner-caliber colonoscope was required to complete 12% of screening examinations and 23% of surveillance examinations. The pediatric colonoscope helped increase our yield of neoplasia by 19%. The screening and surveillance program detected dysplasia or cancer in 16% (10 indefinite, 23 low-grade, and 4 high-grade dysplasias and 5 cancers). A finding of definite dysplasia or cancer was associated with age >45 years and increased symptoms. By life table analysis, the probability of detecting dysplasia or cancer after a negative screening colonoscopy was 22% by the fourth surveillance examination. Colonoscopic surveillance should be strongly considered in chronic extensive Crohn's colitis.