Surveillance in inflammatory bowel disease: is chromoendoscopy the only way to go? A systematic review and meta-analysis of randomized clinical trials

Abstract

Background and study aims Ulcerative colitis (UC) and Crohn’s disease (CD) have higher risk of colorectal cancer (CRC). Guidelines recommend dysplasia surveillance with dye-spraying chromoendoscopy (DCE). The aim of this systematic review and meta-analysis was to review all randomized clinical trials (RCTs) available and compare the efficacy of different endoscopic methods of surveillance for dysplasia in patients with UC and CD. Methods Databases searched were Medline, EMBASE, Cochrane and SCIELO/LILACS. It was estimated the risk difference (RD) for dichotomous outcomes (number of patients diagnosed with one or more dysplastic lesions, total number of dysplastic lesions diagnosed and number of dysplastic lesions detected by targeted biopsies) and mean difference for continuous outcomes (procedure time). Results This study included 17 RCTs totaling 2,457 patients. There was superiority of DCE when compared to standard-definiton white light endoscopy (SD-WLE). When compared with high-definition (HD) WLE, no difference was observed in all outcomes (number of patients with dysplasia (RD 0.06; 95 % CI [–0.01, 0.13])). Comparing other techniques, no difference was observed between DCE and virtual chromoendoscopy (VCE – including narrow-band imaging [NBI], i-SCAN and flexible spectral imaging color enhancement), in all outcomes except procedure time (mean difference, 6.33 min; 95 % CI, 1.29, 11.33). DCE required a significantly longer procedure time compared with WLE (mean difference, 7.81 min; 95 % CI, 2.76, 12.86). Conclusions We found that dye-spraying chromoendoscopy detected more patients and dysplastic lesions than SD-WLE. Although no difference was observed between DCE and HD-WLE or narrow-band imaging, the main outcomes favored numerically dye-spraying chromoendoscopy, except procedure time. Regarding i-SCAN, FICE and auto-fluorescence imaging, there is still not enough evidence to support or not their recommendation.

AGA Clinical Practice Update on Endoscopic Surveillance and Management of Colorectal Dysplasia in Inflammatory Bowel Diseases: Expert Review

“…More recent network meta-analyses of RCTs have not shown any single technique to be statistically superior for detecting dysplasia (HD-WLE [with nontargeted biopsies], DCE, or NBI) although there is a trend favoring DCE. 72,73 Some studies have shown a very low incidence of advanced colorectal neoplasia in follow-up examinations when dysplasia is not identified with DCE or on consecutive negative examinations, [74][75][76] questioning the necessity to routinely perform frequent DCE after multiple negative high-quality examinations. Surveys in both Japan and the United States report that most gastroenterologists continue to use HD-WLE with targeted biopsies for surveillance, reserving DCE for higher-risk situations (eg, PSC and history of dysplasia).…”

Surveillance and management of colorectal dysplasia and cancer in inflammatory bowel disease: Current practice and future perspectives

“…Previous meta-analyses including only randomised controlled trials (RCT) reported similar dysplasia detection rates with and without chromoendoscopy in patients with IBD. [48][49][50] In contrast, superiority of surveillance using chromoendoscopy was reported in a recent well-conducted RCT from Sweden (Supplementary Table 1 provides summary data of these RCTs). [51] Nowadays, most guidelines still recommend chromoendoscopy, but also state that white light endoscopy using HD endoscopes is a good alternative.…”

Colorectal Dysplasia and Cancer Surveillance in Ulcerative Colitis

“…Although stool studies are an attractive option due to their convenience and safety, these are more suitable for predicting advanced lesions and may not be sensitive for early stages of dysplasia [ 38 ]. A comparison of various endoscopic modalities used for surveillance has been summarized in Table 2 [ 36 , 40 ].…”