Failing to optimise conditions for high-quality endoscopic surveillance
As colitis surveillance procedures are challenging and it is extremely difficult to discriminate between inflammatory/post-inflammatory changes and neoplastic changes, it is important that patient preparation is optimised, that a careful inspection technique is employed and that the highest definition endoscopic equipment is used for surveillance.
Wherever possible, surveillance should be performed when a patient’s colitis is quiescent, and it might sometimes be necessary to increase their disease-modifying medication to achieve this. However, that being said, it is important to remember that, as described above, patients who have chronic active disease have a particularly increased risk of CRC, hence these procedures should not be unduly delayed to achieve quiescence.
The use of high-definition endoscopes with digital enhancement is recommended.13 Of course, there is no point using high-definition equipment if bowel preparation is poor, so particular attention should be given to using an effective bowel preparation regimen (previous reports should always be read to identify patients who might require enhanced bowel preparation). Furthermore, during the endoscopic procedure, additional water irrigation can help optimise bowel cleansing. I also use intravenous hyoscine on a regular basis, unless contraindicated, as this can suppress muscular tone, which reduces blind spots and peristalsis and therefore aides lesion detection. As with any diagnostic colonoscopy, a methodical, careful inspection technique is important.
Dye-spray colonoscopy adds another dimension to the complexity of the procedure for the endoscopist. In reality, learning how to apply the dye is not technically difficult; the real challenge is learning how to discriminate normal from abnormal findings. Although the application of dye sprays is cumbersome, there is consistent evidence that it increases the neoplasia yield.13 Recent studies have shown that digital enhancement has closed the gap with dye spray detection, but, at present, I feel that dye spraying remains the gold standard, a view supported by a recent network meta-analysis.14 That being said, if I had to choose between an expert endoscopist confident in digital image enhancement or an average endoscopist using dye spray, I would definitely choose the former — although I would, of course, prefer a combination of both!
Application of the dye requires additional time and it is important that this is accounted for when booking the patient. Dye-spray catheters help with circumferential application of the dye, but I now find that applying the dye using an irrigator pump is more time-efficient because it is simple to obtain circumferential coverage if the dye is applied to the anti-gravity wall. Excess dye should be suctioned prior to inspection, otherwise pools of dye may obscure pathology.
In the context of pancolonic dye-based chromoendoscopy or virtual chromoendoscopy, the ESGE (European Society of Gastrointestinal Endoscopy) recommends taking targeted biopsies of any visible lesions; additional random background biopsies (four-quadrant non-targeted biopsies every 10cm) are only required in certain high-risk scenarios, including patients with previous colonic neoplasia, a tubular-appearing colon, strictures, ongoing therapy-refractory inflammation, or PSC.
Please log in with your myUEG account to post comments.