Gastrointestinal Endoscopy
Volume 66, Issue 3 , Pages 530-532, September 2007

Recognition and appropriate management of dysplasia-associated lesions or masses in inflammatory bowel disease—experience does matter

Department of Medicine, Division of Gastroenterology and Hepatology, Virchow Hospital, Charité Medical School, Humboldt University, Berlin, Germany

Article Outline

Abbreviations: DALM, dysplasia-associated lesions or masses, IBD, inflammatory bowel disease

 

Every consensus statement or expert group guideline is only as good as the clinician applying it correctly in daily clinical practice.

Patients with longstanding inflammatory bowel disease (IBD) are at risk for development of a variety of complications.1 Among those, malignant complications include colon cancer in patients with ulcerative or Crohn's colitis, particularly in the presence of extensive colitis or primary sclerosing cholangitis, and atypical small bowel adenocarcinoma in patients with Crohn's enteritis.2, 3, 4, 5 These epidemiologic data and the fact that cancers diagnosed at an earlier stage generally have a better prognosis have led to the implementation of screening and surveillance colonoscopy in patients with IBD as a standard of care in most Western countries, endorsed by major professional societies and expert groups in consensus conferences.6, 7 Surprisingly, a recent meta-analysis did not find evidence that screening for colonic dysplasia and cancer with surveillance colonoscopy prolongs survival in patients with extensive colitis.8

In this issue of Gastrointestinal Endoscopy, Farraye et al9 point out a critical caveat that may account for some of the discrepancy between the desired outcome of the widely accepted screening and surveillance recommendations and the poor performance of colonoscopy in this special patient population—experience of the clinician performing the endoscopy.

In their study the authors compared the ability of 21 gastroenterologists in private practice, 26 academic gastroenterologists, and 18 inflammatory bowel disease experts to distinguish adenoma-like from non-adenoma-like dysplasia-associated lesions or masses (DALMs) in patients with ulcerative colitis and initiate appropriate management. Although there was no significant difference among the overall correct diagnosis rates of 3 different DALMs, IBD experts showed a significantly higher correct diagnosis rate and intraobserver agreement compared with the 2 groups of non-IBD experts. Furthermore, IBD experts chose significantly more often the correct management plan (ie, in line with guidelines) for the respective mucosal lesion compared with non-IBD experts in academic and private practice alike, even if such lesions were correctly recognized by the latter.

Although there are important limitations to this study, such as small sample size, selection bias, weak or absent criteria for the respective physician categories, and data extrapolation from interpreting a single static image from a dynamic study instead of a video clip, this article unmasks a sobering truth: every consensus statement or expert group guideline is only as good as the clinician applying it correctly in daily clinical practice.

In the study presented by Farraye et al, IBD experts, on average, performed about 3 times as many endoscopic surveillance procedures than their colleagues did. Certainly, the number of studies performed is an important variable but does not automatically translate into quality because there was no statistical correlation noted between the number of procedures performed and the correct diagnosis rate among non-IBD experts.

IBD experts generally practice at large tertiary referral centers, see more patients with advanced or complicated disease, and are therefore more likely to encounter the difficult-to-recognize mucosal lesions more frequently. Moreover, because of their highly specialized practice, they are usually more abreast of the current medical literature and thereby eventually acquire the experience that results in the more appropriate judgment on the lesions detected in their patients at endoscopy.

Poor judgment from lack of experience can kill. When New York Yankees baseball star and 95-hour private pilot Cory Lidle underestimated the turn radius of his single engine plane over Manhattan's East River he could not complete the intended U-turn and crashed into a high-rise, killing himself and his flight instructor.10 A seasoned 5000 plus hour airline transport pilot would have probably taken the side wind on the river into consideration, recognized the resulting lack of turn space, and initiated a different maneuver to complete the 180-degree turn successfully.

Good judgment based on experience can save lifes, patients' lives, that is. There is evidence that non-IBD patients with a negative colonoscopy have a reduced incidence of colorectal cancer over a 10-year period.11 This favorable outcome largely depends on the quality of the endoscopy performed. The quality of colonoscopy as a screening tool for colorectal cancer has recently come under scrutiny.12 Some important factors affecting the quality of a colonoscopy include proper bowel preparation, complete and careful inspection of the entire colon, which requires a minimum withdrawal time, and adherence to recommended management guidelines of various professional societies.13, 14, 15 As with pilots, endoscopists' performance is not merely measured by the number of hours (spent on the scope), but results from a solid theoretical knowledge base combined with extensive practical exposure to complex situations that ultimately add up to (clinical) experience.

How can we then improve screening accuracy for colonic dysplasia and cancer with surveillance colonoscopy and in turn improve survival in patients with extensive colitis?

Manufacturers of new endoscopic technologies and some investigators will try to make us believe that narrow band imaging, confocal endoscopy, endocytoscopy, and others will solve the problem. These novel techniques will initially work best and may improve screening and surveillance performance of colonoscopy, if at all, in the hands of endoscopists who are most experienced with them, which brings us back to the beginning of our discussion. Technology cannot replace experience. New York Yankees pitcher Cory Lidle had to pay the ultimate price to learn this lesson because flying one of the most advanced single-engine planes equipped with cutting-edge avionic technology could not save his life.

Because there is no lack of guidelines, we need to improve their adoption and application in clinical practice. This process starts in medical school and extends throughout postgraduate medical training of residents and fellows, all the way to continuing medical education of board-certified physicians. The use of new media, on-line supplements to medical journals, podcasting, and handheld portable computers can help clinicians to improve and update their knowledge and make sound decisions.16

Moreover, IBD experts should be encouraged to share their experience and expertise beyond publications and presentations at national and international meetings. At Charité, where we operate one of the largest and most comprehensive IBD centers in Germany, our patients are followed by their private gastroenterologists and us together. General gastroenterologists in private practice and colleagues at local or regional in community hospitals usually refer their patients when the diagnosis is suspected, the management becomes complex, or the patient so desires. Our task is to assist them in establishing the diagnosis or the management but not to replace their role. Many patients receive their screening and surveillance endoscopies at our center. Every patient sees us at least once or twice per year, or more frequently if desired or necessary. In addition, we have implemented a clinical hands-on rounds program where clinicians have the opportunity to receive advanced endoscopy instruction on specifically selected and scheduled cases, join us in clinic to update their knowledge on current management of IBD, or participate in regular conferences to discuss cases from their own practice with academic IBD experts.

This model has been adopted by the German government that recently started funding a major program to promote the integrated care of patients by physicians in private practice and large academic referral centers together in an effort to improve quality of care and cut costs by reducing unnecessary or duplicate diagnostic studies, including substandard screening and surveillance colonoscopies. The integrated care program is supplemented with the new organ-specific center certification. In 2007 Charité will open the first certified national bowel center at our department, which extends the idea and the incentives of integrated care to other specialties and service providers such as pharmacies and health stores.

In summary, the science of medicine can only successfully be translated into the art of medicine if we as academicians and specialists ensure the wide distribution and adoption of the clinical implications of our research to enable quality care everywhere. Our patients and colleagues deserve it.

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Disclosure 

The author has nothing to disclose.

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References 

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PII: S0016-5107(07)00224-6

doi:10.1016/j.gie.2007.02.006

Gastrointestinal Endoscopy
Volume 66, Issue 3 , Pages 530-532, September 2007

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