Meta-analysis of dye-based chromoendoscopy compared with standard- and high-definition white-light endoscopy in patients with inflammatory bowel disease at increased risk of colon cancer

Published:April 19, 2019DOI:https://doi.org/10.1016/j.gie.2019.04.219

      Background

      Patients with ulcerative colitis have an increased risk of colorectal cancer. We sought to assess the comparative efficacy of standard white-light endoscopy (SDWLE) or high-definition white-light endoscopy (HDWLE) versus dye-based chromoendoscopy through a meta-analysis and rate the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.

      Methods

      A systematic review of the literature in PubMed, EMBASE, and Web of Science was performed in April 2018. The primary outcome was the number of patients in whom dysplasia was identified using a per patient analysis in randomized controlled trials (RCT) and analyzed separately for non-RCTs. Analysis was performed using RevMan 5.3 reporting random-effects risk ratios.

      Results

      Of the 27,904 studies identified, 10 studies were included 6 of which were RCTs (3 SDWLE and 3 HDWLE). Seventeen percent (84/494) of patients were noted to have dysplasia using chromoendoscopy compared with 11% (55/496) with white-light endoscopy (relative risk [RR] 1.50; 95% confidence interval [CI], 1.08-2.10). When analyzed separately, chromoendoscopy (n = 249) was more effective at identifying dysplasia than SDWLE (n = 248) (RR, 2.12; 95% CI, 1.15-3.91), but chromoendoscopy (n = 245) was not more effective compared with HDWLE (n = 248) (RR, 1.36; 95% CI, 0.84-2.18). The quality of evidence was moderate. In non-RCTs, dysplasia was identified in 16% (114/698) of patients with chromoendoscopy compared with 6% (62/1069) with white-light endoscopy (RR, 3.41; 95% CI, 2.13-5.47). Chromoendoscopy (n = 58) was more effective than SDWLE (n = 141) for identification of dysplasia (RR, 3.52; 95% CI, 1.38-8.99), and chromoendoscopy (n = 113) was also more effective than HDWLE (n = 257) (RR, 3.15; 95% CI, 1.62-6.13). The quality of the evidence was very low.

      Conclusion

      Based on this meta-analysis, non-RCTs demonstrate a benefit of chromoendoscopy over SDWLE and HDWLE, whereas RCTs only show a small benefit of chromoendoscopy over SDWLE, but not over HDWLE.

      Graphical abstract

      Abbreviations:

      CI (confidence interval), CRC (colorectal cancer), GRADE (Grading of Recommendations Assessment, Development, and Evaluation), HDWLE (high-definition white-light endoscopy), IBD (inflammatory bowel disease), RCT (randomized controlled trial), RR (risk ratio), SCENIC (Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations), SDWLE (standard-definition white-light endoscopy)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Annese V.
        • Beaugerie L.
        • Egan L.
        • et al.
        European evidence-based consensus: inflammatory bowel disease and malignancies.
        J Crohns Colitis. 2015; 9: 945-965
        • Lichtenstein G.R.
        • Loftus E.V.
        • Isaacs K.L.
        • et al.
        ACG clinical guideline: management of Crohn’s disease in adults.
        Am J Gastroenterol. 2018; 113: 481
        • Farraye F.A.
        • Melmed G.Y.
        • Lichtenstein G.R.
        • et al.
        ACG clinical guideline: preventive care in inflammatory bowel disease.
        Am J Gastroenterol. 2017; 112: 241
        • Kornbluth A.
        • Sachar D.B.
        Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee.
        Am J Gastroenterol. 2010; 105: 501
        • Farraye F.A.
        • Odze R.D.
        • Eaden J.
        • et al.
        AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease.
        Gastroenterology. 2010; 138: 738-745
        • Xie J.
        • Itzkowitz S.H.
        Cancer in inflammatory bowel disease.
        World J Gastroenterol. 2008; 14: 378
        • Hlavaty T.
        • Huorka M.
        • Koller T.
        • et al.
        Colorectal cancer screening in patients with ulcerative and Crohn's colitis with use of colonoscopy, chromoendoscopy and confocal endomicroscopy.
        Eur J Gastroenterol Hepatol. 2011; 23: 680-689
        • Krugliak Cleveland N.
        • Colman R.J.
        • Rodriquez D.
        • et al.
        Surveillance of IBD using high definition colonoscopes does not miss adenocarcinoma in patients with low-grade dysplasia.
        Inflamm Bowel Dis. 2015; 22: 631-637
        • Shah S.C.
        • Torres J.
        • Itzkowitz S.H.
        Management of dysplasia in IBD.
        in: Schlachta C. Sylla P. Current common dilemmas in colorectal surgery. Springer, Cham2018: 43-53
        • Rubin D.T.
        • Rothe J.A.
        • Hetzel J.T.
        • et al.
        Are dysplasia and colorectal cancer endoscopically visible in patients with ulcerative colitis?.
        Gastrointest Endosc. 2007; 65: 998-1004
        • Laine 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.e26
        • Konijeti G.G.
        • Shrime M.G.
        • Ananthakrishnan A.N.
        • et al.
        Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis.
        Gastrointest Endosc. 2014; 79: 455-465
        • Higgins P.D.
        Miles to go on the SCENIC route: should chromoendoscopy become the standard of care in IBD surveillance?.
        Am J Gastroenterol. 2015; 110: 1035-1037
        • Abdalla M.
        • Herfarth H.
        Rethinking colorectal cancer screening in IBD, is it time to revisit the guidelines?.
        J Crohns Colitis. 2018; 1: 3
        • Mowat C.
        • Cole A.
        • Windsor A.
        • et al.
        Guidelines for the management of inflammatory bowel disease in adults.
        Gut. 2011; 60: 571-607
        • Marion J.F.
        • Waye J.D.
        • Present D.H.
        • et al.
        Chromoendoscopy-targeted biopsies are superior to standard colonoscopic surveillance for detecting dysplasia in inflammatory bowel disease patients: a prospective endoscopic trial.
        Am J Gastroenterol. 2008; 103: 2342
        • Mooiweer E.
        • Van der Meulen-de Jong A.
        • Ponsioen C.
        • et al.
        Chromoendoscopy for surveillance in inflammatory bowel disease does not increase neoplasia detection compared with conventional colonoscopy with random biopsies: results from a large retrospective study.
        Am J Gastroenterol. 2015; 110: 1014
        • Kiesslich R.
        • Goetz M.
        • Lammersdorf K.
        • et al.
        Chromoscopy-guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis.
        Gastroenterology. 2007; 132: 874-882
        • Marion J.F.
        • Waye J.D.
        • Israel Y.
        • et al.
        Chromoendoscopy is more effective than standard colonoscopy in detecting dysplasia during long-term surveillance of patients with colitis.
        Clin Gastroenterol Hepatol. 2016; 14: 713-719
        • Rutter M.D.
        • Saunders B.P.
        • Schofield G.
        • et al.
        Pancolonic indigo carmine dye spraying for the detection of dysplasia in ulcerative colitis.
        Gut. 2004; 53: 256-260
        • Restellini S.
        • Bessissow T.
        • Dulai P.S.
        • et al.
        Comparison of endoscopic dysplasia detection techniques in patients with ulcerative colitis: a systematic review and network meta-analysis.
        Inflamm Bowel Dis. 2018; 24: 2518-2526
        • Harbour R.
        • Miller J.
        A new system for grading recommendations in evidence based guidelines.
        BMJ. 2001; 323: 334-336
        • Kiesslich R.
        • Fritsch J.
        • Holtmann M.
        • et al.
        Methylene blue-aided chromoendoscopy for the detection of intraepithelial neoplasia and colon cancer in ulcerative colitis.
        Gastroenterology. 2003; 124: 880-888
        • Freire P.
        • Figueiredo P.
        • Cardoso R.
        • et al.
        Surveillance in ulcerative colitis: is chromoendoscopy-guided endomicroscopy always better than conventional colonoscopy? A randomized trial.
        Inflamm Bowel Dis. 2014; 20: 2038-2045
        • Mohammed N.
        • Kant P.
        • Abid F.
        • et al.
        High definition white light endoscopy (HDWLE) versus high definition with chromoendoscopy (HDCE) in the detection of dysplasia in long standing ulcerative colitis: a randomized controlled trial [abstract].
        Gastrointest Endosc. 2015; 81: AB148
        • Park S.J.
        • Kim H.-S.
        • Yang D.-H.
        • et al.
        Tu2086 high definition chromoendoscopy with water-jet versus high definition white light endoscopy in the detection of dysplasia in long standing ulcerative colitis: a multicenter prospective randomized controlled study.
        Gastroenterology. 2016; 150: S1270
        • Iacucci M.
        • Kaplan G.G.
        • Panaccione R.
        • et al.
        A randomized trial comparing high definition colonoscopy alone with high definition dye spraying and electronic virtual chromoendoscopy for detection of colonic neoplastic lesions during IBD surveillance colonoscopy.
        Am J Gastroenterol. 2018; 113: 225
        • Gasia M.F.
        • Ghosh S.
        • Panaccione R.
        • et al.
        Targeted biopsies identify larger proportions of patients with colonic neoplasia undergoing high-definition colonoscopy, dye chromoendoscopy, or electronic virtual chromoendoscopy.
        Clin Gastroenterol Hepatol. 2016; 14: 704-712.e4
        • Günther U.
        • Kusch D.
        • Heller F.
        • et al.
        Surveillance colonoscopy in patients with inflammatory bowel disease: comparison of random biopsy vs. targeted biopsy protocols.
        Int J Colorectal Dis. 2011; 26: 667-672
        • Iacucci M.
        • Hassan C.
        • Gasia M.F.
        • et al.
        Serrated adenoma prevalence in inflammatory bowel disease surveillance colonoscopy, and characteristics revealed by chromoendoscopy and virtual chromoendoscopy.
        Can J Gastroenterol Hepatol. 2014; 28: 589-594
        • Trindade A.J.
        • Lichtenstein D.R.
        • Aslanian H.R.
        • et al.
        Devices and methods to improve colonoscopy completion (with videos).
        Gastrointest Endosc. 2018; 87: 625-634
        • Subramanian V.
        • Ragunath K.
        advanced endoscopic imaging: a review of commercially available technologies.
        Clin Gastroenterol Hepatol. 2014; 12: 368-376.e1
        • Bhat Y.M.
        • Abu Dayyeh B.K.
        • Chauhan S.S.
        • et al.
        High-definition and high-magnification endoscopes.
        Gastrointest Endosc. 2014; 80: 919-927
        • Feagins L.A.
        • Souza R.F.
        • Spechler S.J.
        Carcinogenesis in IBD: potential targets for the prevention of colorectal cancer.
        Nat Rev Gastroenterol Hepatol. 2009; 6: 297
        • Kaltenbach T.
        • Sandborn W.J.
        Endoscopy in inflammatory bowel disease: advances in dysplasia detection and management.
        Gastrointest Endosc. 2017; 86: 962-971
        • Cohen-Mekelburg S.
        • Schneider Y.
        • Gold S.
        • et al.
        Advances in the diagnosis and management of colonic dysplasia in patients with inflammatory bowel disease.
        Gastroenterol Hepatol. 2017; 13: 357
        • Steers W.D.
        Falling short: causes and implications of drug shortages in the United States.
        Wolters Kluwer, Philadelphia, PA2014
        • Boland B.S.
        • Shergill A.
        • Kaltenbach T.
        Endoscopic surveillance in long-standing colitis.
        Curr Treat Options Gastroenterol. 2017; 15: 429-439
        • Shukla R.
        • Salem M.
        • Hou J.K.
        Use and barriers to chromoendoscopy for dysplasia surveillance in inflammatory bowel disease.
        World J Gastrointest Endosc. 2017; 9: 359
        • Barclay R.L.
        • Vicari J.J.
        • Doughty A.S.
        • et al.
        Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.
        N Engl J Med. 2006; 355: 2533-2541
        • Barclay R.L.
        • Vicari J.J.
        • Greenlaw R.L.
        Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy.
        Clin Gastroenterol Hepatol. 2008; 6: 1091-1098

      Linked Article

      • Chromoendoscopy meta-analysis: correcting subgroup analysis interpretation
        Gastrointestinal EndoscopyVol. 91Issue 3
        • Preview
          Feuerstein et al1 conclude that chromoendoscopy is superior to standard-definition white-light endoscopy (SDWLE) but not superior to high-definition white-light endoscopy (HDWLE) in patients with inflammatory bowel disease. They base this conclusion on an analysis of 2 subgroups (chromoendoscopy vs SDWLE and chromoendoscopy vs HDWLE) within their meta-analysis of randomized trials of chromoendoscopy versus white-light endoscopy. However, their interpretation of this subgroup analysis is incorrect.
        • Full-Text
        • PDF