So the next talk has a special distinction, this is the Gene and Lean Overhaul Endowed Lecture presented by the ESG Foundation through generous financial support from friends, presented by Dr. Frank Farrar from the Division of Gastroenterology and Hepatology, who is Director of IBD Center there and Professor of Medicine, the Mayo Clinic in Jacksonville, Florida, and he will present the inaugural lecture titled Endoscopic Surveillance and Management of Colorectal Dysplasia in IBD. Well, good afternoon, everyone. I'd like to thank Dr. Rex and the ASGE for asking me to speak. Dr. Overholt was a president of the ASGE, a master in the American College and made seminal observations in endoscopy early when endoscopy was released to gastroenterologists and we actually use today some of the observations that he's made. These are my disclosures. Just like Dr. Ruggiero, some images. Many of the endoscopic lesions that we see will be obvious, like these three on top, but then there are others in high-risk individuals, for example, those that have PSC, where you do need to take biopsies in the colon to identify dysplasia. So what do we now know in 2022? We know that the goal of surveillance colonoscopy is to detect and treat asymptomatic colorectal neoplasia and that's either dysplasia or early-stage cancer to reduce morbidity and mortality related to colorectal cancer. Most dysplasia in ulcerative colitis and Crohn's disease of the colon is visible using high-definition white light colonoscopy or image-enhanced endoscopy and is rarely invisible. In many cases, dysplasia in patients with IBD can be managed endoscopically, not by myself or Dr. Ruggiero, based on some of the previous cases you saw, but by one of your colleagues in advanced endoscopy. And the good news is that multiple recent studies have demonstrated a decreased risk of developing colorectal cancer in our patients with IBD. We need to use historical, clinical, and endoscopic variables to identify patients at high risk for developing colorectal neoplasia and we must stop the overuse of surveillance colonoscopy in low-risk individuals. Even though someone may have had ulcerative colitis for 20 years, if they've had serial colonoscopies that are normal endoscopically and histologically, they don't need yearly colonoscopy. This was a study that was published in Gash Neurology of protective factors like the use of thiopurines, 5-ASA, and most importantly, surveillance colonoscopy. And this goes over the high-risk individuals' PSC, previous dysplasia, and extensive disease. Control of inflammation is essential with medical therapy. Prior to doing endoscopy, inflammation can obscure subtle dysplastic lesions. Biopsies from inflamed mucosa may be difficult for your pathologist to diagnose. Optimal bowel preparation is crucial. We do washing on insertion of the colonoscope. We use high-definition endoscopes. You can either use chromoendoscopy or virtual chromoendoscopy, and we need to pay particular attention and take targeted sampling of areas of suspicious mucosal irregularity or elevated areas. We should not be using old terms like down or adenoma-like polyp. Again, we discontinue these, but what we need to do is describe lesions as either pedunculated or sessile, and there are a number of different flat lesions. And then if you take a biopsy from the colon in an area that you see no lesion, that would be called invisible dysplasia, no longer calling it flat dysplasia. You should use the five S's. These are ways you describe colonic lesions. You want to describe the size, the presence within an area, or of past or current colitis, the morphology, clarity of the borders, whether it was ulcerated, location in the colon, and then how you resected it. I was fortunate enough to be involved in the CENIC consensus recommendations from 2015. This is a paper that was published in GIE by Jim Marion from Mount Sinai. It wasn't a rigorous meta-analysis of all the literature, but it came with new recommendations that I think are quite appropriate. We want to use high-definition colonoscopy for dysplasia surveillance. If you're still using a non-high-definition colonoscope, then you should certainly be using dye-spray chromoendoscopy with targeted biopsy. Again, DCE, white light endoscopy, NBI, and virtual chromoendoscopy are all viable options during surveillance, and you should choose the option that you're most comfortable with. We still need to do random biopsies in addition to targeted biopsies in high-risk individuals. Those would be patients with PSC, a patient who's referred to you with previous dysplasia found on white light endoscopy. And then EMR and ESD may be used to resect dysplastic lesions, both polypoid and flat. And we do need a multidisciplinary approach, including the patient, the advanced endoscopist, your colorectal surgeon, and the IBD expert. All of them need to be involved in making the correct decision for the patient. For those that want to learn how to do chromoendoscopy, dye-based chromoendoscopy, this is a paper that was published in GIE in 2017 with nice videos. This comes from the AGA, basically what we want to—oop, go back. This comes from the AGA. We begin surveillance 8 to 10 years after disease onset, and these other points we've already gone over. Also from that same guideline, we stratify individuals that need one-year, three-year, or five-year endoscopy. Patients who need one-year colonoscopy would be those that have ongoing active inflammation, PSC, a family history of colorectal cancer, especially under the age of 50. Those with dense pseudopolyposis or a previous biopsy showing visible or invisible dysplasia. And then the other extreme—and I must be honest, I don't do very many patients five years. Typically, three years would be those individuals that have had serial negative colonoscopies. This is a small select group of individuals. Everyone else gets it at two to three years. So we now have to deal about the lesions that we're going to see. So these are the lesions that I would manage, something under two centimeters, clear borders. I would do endoscopic resection, and then these individuals need to come back. So this would be polyploid dysplasia endoscopically resectable. The other extreme would be a lesion that either myself or my advanced endoscopist can't resect. If I see something that's clearly dysplastic, I'm not even going to biopsy it. I'll tattoo it for my advanced endoscopist. These are the lesions that, again, I would tattoo but not try to attempt resection. I need to rebook that patient with an advanced endoscopist that has 90 minutes that can try to remove the lesion. And again, I think we'll be seeing some videos on these type of lesions. And then for those individuals where you take a random biopsy in an area that's either inflamed or not inflamed and you see no lesion, those are individuals with invisible dysplasia. And if a person has persistent high-grade invisible dysplasia, it is recommended that they undergo surgery. The good news, this was one review article in GIE from 2021. It was a large database study. The risk of colorectal cancer after dysplasia resection in patients with IBD is low, supporting the strategy of doing what we're doing, which is endoscopic resection. We've talked about AI multiple times. This is one example of an AI system where you basically are looking at this inflamed colon. The AI system identifies an area that's suspicious. And then basically, you then use your advanced endoscopic techniques to decide whether this is resectable. And again, this video basically shows two lesions that are low-grade dysplasia and endoscopically resectable. So my take-home points are the absolute risk of colorectal cancer in patients with IBD is low and is decreasing. Subgroups of patients with IBD with severe long-standing active disease and those patients with PSC are at greater risk for colorectal cancer. And those individuals should undergo yearly colonoscopy. Low-risk individuals, I said three to five years. I certainly would say two to three. But certainly, there might be a small subset of individuals, someone who's had proctitis their entire life with biopsies never showing a proximal extent would be someone you could consider for five-year intervals. We use dye-based or virtual chromoendoscopy with high-definition colonoscopes for subsets of patients at higher risk. In our group at Mayo, three of us use dye-based chromoendoscopy with Indigo Carmine, and one of our colleagues uses narrowband imaging as her adjunct. Public management of IBD-related neoplasia is an option with patient-advanced endoscopist and colorectal surgery and IBD expert input all necessary. Advances in artificial intelligence will certainly advance the field and hopefully make our lives easier. Thank you very much. Thank you.

Mayo Clinic

Gene and Lean Overhaul Endowed Lecture

Endoscopic Surveillance

Colorectal Dysplasia

IBD