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• W4231785819 abstract "Most dysplasia detected at surveillance colonoscopy is visible1Rutter M.D. Saunders B.P. Wilkinson K.H. et al.Most dysplasia in ulcerative colitis is visible at colonoscopy.Gastrointest Endosc. 2004; 60: 334-339Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar; they are predominantly flat, nonpolypoid in shape, and have indistinct borders from the surrounding tissue.2Soetikno R. Sanduleanu S. Kaltenbach T. An atlas of the nonpolypoid colorectal neoplasms in inflammatory bowel disease.Gastrointest Endosc Clin N Am. 2014; 24: 483-520Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar On this basis, the SCENIC panel unanimously agreed that patients with endoscopically invisible dysplasia (confirmed by a GI pathologist) be referred to an endoscopist with experience in inflammatory bowel disease (IBD) surveillance using chromoendoscopy with high-definition colonoscopy.3Laine L. Kaltenbach T. Barkun A. et al.SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease.Gastrointest Endosc. 2015; 81: 489-501.e26Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar We congratulate Rubin et al4Rubin D.T. Krugliak Cleveland N. Rodriguez D.M. Outcomes of colitis-associated dysplasia after referral from the community to a tertiary center.Gastrointest Endosc. 2016; 84: 1078-1079Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar for their recent letter. They highlight the value of referring such patients with endoscopically invisible dysplasia. The authors reviewed the findings in 37 patients (62 dysplasias) who were referred over a 7-year period for evaluation of colitis-associated dysplasia that was detected on white light colonoscopy. Repeated colonoscopy procedures at the tertiary center with the use of chromoendoscopy with high definition identified the referred dysplastic lesions in 26 of the 62 cases. They also found an additional 12 dysplastic lesions beyond the index dysplasia, 2 of which were cancer. The letter shows the variability of dysplasia detection in practice. The endoscopists identified only some of the referred dysplasia, yet found synchronous dysplasia and cancer that was not reported in the index examination. It is unclear from the letter by Rubin and colleagues4Rubin D.T. Krugliak Cleveland N. Rodriguez D.M. Outcomes of colitis-associated dysplasia after referral from the community to a tertiary center.Gastrointest Endosc. 2016; 84: 1078-1079Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar how the referred dysplasia cases were detected on the index examination—were they detected by targeted biopsy of a visualized discrete dysplastic lesion, or were they picked up by random biopsy? The authors note that they may not have been able to relocate the dysplasia in some cases because it was no longer there (removed by the referring physician) or simply because it was not seen. This discrepancy in detection likely reflects the subtle appearance of colitis-associated dysplasia. Description of the dysplastic lesion using standardized nomenclature, documentation of the lesion using high-quality photo documentation, and marking of the site (tattoo 5 cm distal to the lesion) for future inspection and possible resection are key aspects of information supplied by referring providers to improve relocating the dysplasia. Image-based teaching and video-based teaching to facilitate the understanding of the endoscopic patterns of dysplasia by use of image enhancement are key tools to improve its recognition. The overall findings by Rubin and coauthors4Rubin D.T. Krugliak Cleveland N. Rodriguez D.M. Outcomes of colitis-associated dysplasia after referral from the community to a tertiary center.Gastrointest Endosc. 2016; 84: 1078-1079Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar add support to the concept that detailed examination with high definition and chromoendoscopy improves the diagnostic yield of detecting dysplasia. In another recent study, Deepak and colleagues5Deepak P. Hanson G.J. Fletcher J.G. et al.Incremental diagnostic yield of chromoendoscopy and outcomes in inflammatory bowel disease patients with a history of colorectal dysplasia on white-light endoscopy.Gastrointest Endosc. 2016; 83: 1005-1012Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar similarly showed the significance of repeated examination, using chromoendoscopy in a referral cohort of 95 IBD patients who had dysplasia identified by random biopsy on white light surveillance colonoscopy. The use of high definition and image enhancement methods such as chromoendoscopy, coupled with the knowledge of the endoscopic appearances of colitic dysplasia, seems likely to explain the increased proportion of visible dysplastic lesions identified at repeated colonoscopy in the studies. Persistent efforts to standardize training and endoscopic surveillance practices, and the terminology and reporting used to characterize the endoscopic features of dysplasia, are another step toward improving the quality of colonoscopy surveillance in patients with IBD. All authors disclosed no financial relationships relevant to this publication. Outcomes of colitis-associated dysplasia after referral from the community to a tertiary centerGastrointestinal EndoscopyVol. 84Issue 6PreviewThe recent SCENIC consensus statement favors chromoendoscopy for surveillance of dysplasia when standard definition colonoscopes are used.1 It suggests that patients with invisible dysplasia found by white-light colonoscopy should be referred to an expert endoscopist for chromoendoscopy, but notes that there is “very low quality” evidence for this recommendation. Full-Text PDF" @default.
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