Hilde Willekens

Chromoendoscopy versus narrow band imaging in UC: a prospective randomised controlled trial

Background Patients with long-standing UC have an increased risk for the development of colonic neoplastic lesions. Chromoendoscopy (CE) has been proven to enhance neoplasia detection while the role of virtual chromoendoscopy (VC) is still to be defined. Objective To compare the performance of CE to VC for the detection of neoplastic lesions in patients with long-standing UC. Design A multicentre prospective randomised controlled trial. 131 patients with long-standing UC were randomised between CE with methylene blue 0.1% (n=66) or VC with narrow band imaging (NBI) (n=65). Biopsies were taken from visible lesions and surrounding mucosa. No random biopsies were performed. The primary outcome was the difference in total number of neoplastic lesions detected in each group. Results There was no significant difference between NBI and CE for neoplasia detection. Mean number of neoplastic lesions per colonoscopy was 0.47 for CE and 0.32 for NBI (p=0.992). The neoplasia detection rate was not different between CE (21.2%) and NBI (21.5%) (OR 1.02 (95% CI 0.44 to 2.35, p=0.964). Biopsies from the surrounding mucosa yielded no diagnosis or dysplasia. The per lesion neoplasia detection was 17.4% for CE and 16.3% for NBI (OR 1.09 (95% CI 0.59 to 1.99, p=0.793). The total procedural time was on average 7 min shorter in the NBI group. Conclusion CE and NBI do not differ significantly for detection of colitis-associated neoplasia. Given the longer withdrawal time for CE and easier applicability, NBI may possibly replace classical CE. Trial registration number NCT01882205; Results.

Virtual chromoendoscopy (I-SCAN) detects more polyps in patients with Lynch syndrome: a randomized controlled crossover trial

Background and study aims (Virtual) chromoendoscopy detects more polyps than standard white-light endoscopy in patients with Lynch syndrome. Previous back-to-back trials did not randomize for the examination order, creating a possible bias in favor of chromoendoscopy. We aimed to assess the difference in polyp detection between high definition white-light endoscopy (HD-WLE) and virtual chromoendoscopy with I-SCAN in patients with Lynch syndrome. Patients and methods In this prospective, controlled trial, patients were randomized to either HD-WLE followed by I-SCAN (Group 1; n = 31) or I-SCAN followed by HD-WLE (Group 2; n = 30). Polyps found during the first pass were removed. The primary end point of the study was the difference in adenoma detection between HD-WLE and I-SCAN, expressed as the miss rate for adenomas for each technique. Results In Group 1, I-SCAN detected four additional patients with at least one adenoma, whereas HD-WLE did not increase the adenoma detection rate in Group 2 (relative risk [RR] 0.4; P = 0.08). In Group 1, five adenomas were detected and removed with HD-WLE and a second pass with I-SCAN detected a further eight adenomas. In Group 2, I-SCAN detected 15 adenomas and subsequent HD-WLE detected 2 additional adenomas. The adenoma miss rate was significantly higher for HD-WLE (62 %) compared with I-SCAN (12 %; RR 0.44, 95 % confidence interval [CI] 0.21 to 0.87; P = 0.007). The miss rate for lesions was 57 % and 24 %, respectively, and was significantly different in favor of I-SCAN (RR 0.54, 95 %CI 0.3 to 0.85; P = 0.005). The mean inspection time in both groups was not significantly different during first (485 vs. 536 seconds; 95 %CI - 139.91 to 33.34) or second pass (421 vs. 387 seconds; 95 %CI - 32.24 to 104.89). Conclusion Our data suggest that virtual chromoendoscopy with I-SCAN reduces the adenoma and polyp miss rate in patients with Lynch syndrome, independently of inspection time. TRIAL REGISTRATION ClinicalTrials.gov (NCT01823471).

Oesophageal biopsies are insufficient to predict final histology after endoscopic resection in early Barrett’s neoplasia

Background Endoscopic resection (ER) with or without ablation is the first choice treatment for early Barrett’s neoplasia. Adequate staging is important to assure a good oncological outcome. Objective The purpose of this study was to investigate the diagnostic accuracy of pre-operative biopsies in patients who undergo ER for high-grade dysplasia (HGD) or early adenocarcinoma (EAC) in Barrett’s oesophagus (BE) and the cardia. Methods Between November 2005–May 2012, 142 ERs performed in 137 patients were obtained. Worst pre-ER and ER histology were compared. Upgrading/downgrading was defined as any more/less severe histological grading on the ER specimen. Results The accuracy of pre-ER biopsies in predicting final histology was 61%. ER changed the pre-treatment diagnosis in 55 of the 142 procedures (39%) with downgrading in 23 cases (16%) and upgrading from HGD to T1a or T1b in 32 cases (23%). In the majority of upgraded cases, a visible lesion according to the Paris classification could be detected (26/32, 81%). Conclusion The diagnostic accuracy of oesophageal biopsies alone in predicting final pathology in Barrett’s dysplasia is only 61%. The majority of upgraded lesions are detectable. When ablative therapy is considered in HGD Barretts dysplasia a meticulous inspection for and removal of all small visible lesions is mandatory.

Efficacy and safety of radiofrequency ablation of Barrett’s esophagus in the absence of reimbursement: a multicenter prospective Belgian registry

BACKGROUND  Radiofrequency ablation (RFA), combined with endoscopic resection, can be used as a primary treatment for low grade dysplasia, high grade dysplasia, and early esophageal adenocarcinoma (EAC) in Barretts esophagus (BE). The aim of the Belgian RFA registry is to capture the real-life outcome of endoscopic therapy for BE with RFA and to assess efficacy and safety outside study protocols, in the absence of reimbursement. PATIENTS AND METHODS  Between February 2008 and January 2017, data from 7 different expert centers were prospectively collected in the registry. Efficacy outcomes included complete remission of intestinal metaplasia (CR-IM), complete remission of dysplasia (CR-D), and durability of remission. Safety outcomes included immediate and late adverse events. RESULTS  684 RFA procedures in 342 different patients were registered. Of these, 295 patients were included in the efficacy analysis, with CR-IM achieved in 88 % and CR-D in 93 %, in per-protocol analysis; corresponding rates in intention-to-treat analysis were 82 % and 87 %, respectively. Sustained remission was seen in 65 % with a median (interquartile range) follow-up of 25 (12 - 47) months. No risk factors for recurrent disease were identified. Immediate complications occurred in 4 % of all procedures and 6 % of all patients, whereas late complications occurred in 9 % of all procedures and in 20 % of all patients. CONCLUSIONS  Data from the Belgian registry confirm that RFA in combination with endoscopic resection is an efficient treatment for BE with dysplasia or early EAC. In the absence of reimbursement, more rescue treatments are used, not compromising outcome. Since there is recurrent disease after CR-IM in 35 %, surveillance endoscopy remains necessary.