Okay, next session is on colorectal neoplasia. So it's my pleasure to invite Dr. Marietta Aiucci, who is going to talk initially on the role of virtual chromatoscopy for the surveillance of colorectal neoplasia. Marietta is a close colleague of us, a friend from Europe, and is probably extensive in this area. It's really a pleasure to have you, Marietta. She's actually a professor of medicine at University of Birmingham in London, and she has published it really extensively. So I really look forward to hearing from her about this role of virtual chromatoscopy. Thank you very much for inviting me, and thank you for the SGE to give me this opportunity, and of course my friend Bo and Uday. So let's see what are the, these are my disclosures, and what are the open issues and the debate is still ongoing in the virtual chromatoscopy or dichromatoscopy in performing surveillance in IBD. So we know dichromatoscopy is the best endoscopic technique to be adopted in real practice, but it's still true in 2022. In advanced endoscopic techniques to detect and characterize dysplasia is the future, or even we can use only the new bright eye definition white light endoscopy and don't use no blue, no virtual, and how do we need to characterize this colonic lesion? Does it really help to use advanced technology and important to guide the therapy, and what is the horizon? So we know very well, so then how do we do? So we color in blue and we use the dichromatoscopy, or we color me in virtual, and or even don't color me at all and use high definition white light endoscopy. So in 2015, we had the CINIC guidelines and also the ECHO, then they have recommended to use dichromatoscopy with target biopsies as standard of care because there is an increased detection rate of dysplasia in IBD, but since then, what has happened? So we know then, unfortunately, despite that the dichromatoscopy is the best technique, it's not widely adopted in clinical practice, and you can see here from, you know, in 2017, there was this survey where indeed there is, there was concern about barrier, about the time, and especially about the training to adopt the technique. But also recently, this recent survey, you can see clearly then still there is some barrier to adopt dichromatoscopy in the daily practice, but why? Because it's too time consuming and people, they don't, and then also another barrier is also the training, but there is also still variability in practice. So as increase, you see the 75% of cases, they are using chromatoscopy, but whether there is still, you know, barrier in adopting. But since then, we had new, several studies, several randomized trials, then have clearly showed then that there is no difference between dichromatoscopy and virtual chromatoscopy to detect lesion in IBD. So you can see here, there is this study from Bishop, who has used the narrow-bounding imaging, and then you have our study that we have done in Canada, where we have used the iSCAN, and we didn't show any inferiority between the two technologies to detect lesion in IBD. Moving forward, the new meta-analysis, for example, this meta-analysis didn't show any differences between all the technologies, but interesting, and this is the open of the eye definition, the full spectrum eye definition white light may represent, they conclude, the first-line approach for detecting for surveillance in patients with inflammatory bowel disease. And to confirm this, in other meta-analyses where have been considered comparing the random, only the randomized trial, you see that the chromatoscopy is better than standard definition white light. The chromatoscopy is no better than eye definition white light, and indeed, if we go back on the meta-analysis of the CINIC, most of the study, they've been done with dichromatoscopy and standard definition. But also, this another randomized trial, which is our virtuoso trial, where it has been published recently in that, where we have done a randomized trial between virtual chromatoscopy and eye definition, and there was no clear difference between detection rate of this lesion. And interesting, also, we confirm that the target biopsies with high definition endoscopy system can be adequate in detecting neoplasia. So, based on this, recently, all the guidelines, and I will show, have changed. So, you see, then, the European Society where I've been involved, endoscopy has recommended the routine use of dye-based chromatoscopy or virtual chromatoscopy with target biopsies. In the same, also, the AGA clinical practice updated the update recently, where they consider dye-spray chromatoscopy or virtual chromatoscopy. And moving beyond the CINIC route, you can see the update, you can see then clearly, also here, the recommendation is use high definition scopes, ideally, dye chromatoscopy with target biopsies, if you don't have, if you are using the standard colonoscopy. Otherwise, you can use whatever. You can use dye chromatoscopy, NBI, or other VC, or other virtual chromatoscopy with target biopsies. Of course, remember, then, random biopsies still should be taken in patients with high risk of dysplasia. So, in patients with previous history of dysplasia, colorectal cancer, families of colorectal cancer, P primers, sclerosic cholangitis, and tuberculosis. And to confirm, and that's the moving, because moving versus the high definition, you can see this recent meta-analysis, then confirm again that VC was good as high definition white light endoscopy in VC in identifying dysplasia per patient's analysis. But interesting, when they look at dysplasia analysis, VC was inferior compared with high definition white light, and there was no difference about with VC. Definitely, probably, we need a more randomized trial, and to compare and see, but I think then we are moving, then perhaps in patients with low risk, we can doing high definition with target biopsies, especially with the new scopes, then they are more bright than I will show soon. So, what is the scenario? The scenario is we can use PAMGET, and we can use virtual chromatoscopy, or, you know, PAMGET or the catheter spray, or even you can use just the high definition, high definition scope with target biopsies. Of course, you need to consider now the new scopes, they have also bright diagram virtual chromatoscopy. So, like the LCI or non-clinical enhancement, and now I will show you the new red neurogrammatic. But I still believe that it's important to use, you know, the optical enhancement and optical diagnosis to characterize the lesion. Back with the CINIC guidelines, we have considered the descriptors, so they modify Paris classification, but we have introduced the descriptors of border, which are, you know, they are very easy to detect and to characterize with the dichromatoscopy. We know that the CUDOPID pattern is still debate, despite the fact I think we should, you know, why we don't need to, we can use, because we can have more details. We know that we need to use the magnification, but now there are the new near focus, the new digital magnification is very good. And we know that other limitation in IBD is related to the fact that you can have regenerative pattern or some mild inflammation. They can mimic, you know, a CUDOPID pattern malignant to this plastic. But let me give you an example. It's easy. All of us, we have the scope most, so why don't switch in a real time the button and piece of the scope? We can have more details, details about the margins of the lesion, details about which is important, the surrounding lesion, and then also the CUDOPID pattern. But let me give you an example. Just that this is, was the new classification and we have developed because to overcome the problem of the CUDOPID pattern. So we didn't want to, because you know, not all has near focus on magnification. So we have just considered morphology, surface architecture, vessel architecture, inflammation. Of course, this now needs to be validated in real life. And let me give you an example just to see the different scenario. So you have a lesion, of course, you can use diagram endoscopy and this can give you more details about the margins. And of course, you need to characterize the parties. I still use the CUDO and margins is important and also the presence or absence of restoration and this helps you to guide your therapy. And it's important then, of course, when you use a virtual endoscopy, you can have more details about the vascular pattern than with the diagram endoscopy, you can't see very well. Let me give you an example better. So you have the lesion. This is an AB lesion. This is eye definition. And then you have a diagram endoscopy. Definitely, the diagram endoscopy helps because it gives you, you know, details about, you know, enhance. But look at what's happened when you use the near focus NBI. You have more details about your vascularity. But the interesting, you can see this is the area where it was high grade dysplasia. Then it was a biopsies. We target biopsies before dissecting. Then you can see with the diagram endoscopy. So I think both it's important to use. And recently with ECHO, we have done this topical review because we wanted to standardize terminology between endoscopy, surgery, and histopathology. And you can see we have introduced the 5S to classify, to characterize the lesion in IBD. We've considered the S like a shape, S like a site, site, so in the associated colitis associated area or non-colitis associated area. The surface is a cutopic pattern and the surrounding is a mucosal activity or other lesion. Let me give you an example in this video. You can see this is a tracheal lesion beside there is a, you know, a pseudopolyp. But this was a dysplastic lesion. So you can see here, you can start, so the shape is non-polypoid. The size is 5-15 millimeters. The site is in the colitis area. The surface is 3S4 and the surrounding is quiescent. So we have decided about this 5S so the physician can easily remember and, of course, characterize the lesion. And you can see here I'm using the OCI and BL-Lite, which definitely give me more details about the lesion. The most important about, you know, the margins and also in this case there was this pseudodepression can help me with the pattern of muscular mucosa to understand if there is deep invasion or not. And also, you know, don't forget also in the pouch, it's important to use all this technology because they really help. In the pouch is most of patients that can have some inflammation and the inflammation can be dysplasia. It's quite a little bit, you know, the phenotype, let's say the lesion, they can be tricky in the pouch. And here we have a mastoid, you know, and so it's important to use all the technology available. So it's important to use first to assess your pouch, then use an NBI or whatever, virtual chromatoscopy, BL-Lite, OCI, optical enhancement, whatever. And then you can, of course, you see with the near focus, you can really see in details if there is some, you know, this plastic area, your target biopsies. And then also at the end, I will use the dye chromatoscopy just to enhance, of course, with very low concentration of the dye. And this is important because this, of course, the virtual chromatoscopy can help to guide the resection of the lesion. And not just this, but it's important after you resect, then the virtual chromatoscopy helps to assess the defect in the margins, the defect of the lesion, the rim, and make sure, you know, you don't have any residual polyps. And of course, also in the ESD. But what is the future of the horizon? Do we really need all this thing? So first of all, you can see here, this is the new red dye chromatic scope, then it's now available, which gives you more definition. So this was a very subtle lesion in the regenerative pattern of mucosa. You can see the new generation of the scope, they can tell you that this was not regenerative. It was a subtle lesion, you can define very well the pattern, look at it, and then you, of course, the margins, and this helps you for diagnosis and detection, but also to guide therapy. And the future is the artificial intelligence. So I don't really know, probably in my, you know, in one of my slides, I should have, you know, considered color me in blue, color me in virtual. Don't color me at all, but use artificial intelligence. And you can see here clearly, then, you know, the lesion, the artificial intelligence can detect the lesion also in the context of inflammation. We always thought it was very difficult to develop an artificial intelligence algorithm for IBD due for regenerative inflammatory changes. But you can see here clearly, then, you know, you can see the lesion and the AI has pointed out and has detected. And the future is more bright with the artificial intelligence, because now with the endocytoscope, with the new scope, they can see in the real time histology, you can see, then the artificial intelligence can tell you also when you need to biopsies. So where you need to take the biopsies that you look, you know, it's like a guide and tell if there is invasive cancer or not. So this perhaps will help to plan better the therapeutic reception. And so just to almost conclude, what do we need to do? So color me in blue, color me in virtual, don't color me at all. Or, you know, use the artificial intelligence. Definitely, I will say then, I always say I will differentiate between the experience and non-experience. We need to consider also the curriculum that have been developed by the European Society of Gastrointestinal Endoscopy. I think for the beginners, probably dichromendoscopy is good to start, get familiar, get familiar to detect deletion, to characterize deletion, and then gradually moving to the virtual chromendoscopy. And definitely, I think, and probably the future is the eye definition. And on top of this, the artificial intelligence. And the eye definition based also on the stratification of risk of patients. I will say perhaps in the patients, still myself, then I use everyday virtual chromendoscopy, or even eye definition. I, you know, in the patients with higher risk, I still like to use some blue. So to conclude, dichromendoscopy or virtual chromendoscopy with target biopsies are considered the standard of care. Eye definition colonoscopy with target biopsies can be considered is the future of the horizon. It's important to use standard terminology, especially when you characterize deletion. Optical enhancement really helps for detection, but most important for characterization, and to guide the personalized, real-time therapeutic therapy and organ sparing for these patients. And in the future, artificial intelligence will become an integral part for detection, characterization, and guiding therapy in patients with high IBD. Thank you very much.

virtual chromoendoscopy

colorectal neoplasia

inflammatory bowel disease

dichrochromoendoscopy

high-definition white light endoscopy