Systematic Review With Network Meta-Analysis

Endoscopic Techniques for Dysplasia Surveillance in Inflammatory Bowel Disease

Andrea Iannone; Marinella Ruospo; Suetonia C. Palmer; Mariabeatrice Principi; Michele Barone; Alfredo Di Leo; Giovanni F. M. Strippoli

Disclosures

Aliment Pharmacol Ther. 2019;50(8):858-871. 

In This Article

Abstract and Introduction

Abstract

Background: International guidelines recommend dysplasia surveillance in IBD.

Aim: To compare endoscopic techniques for dysplasia surveillance

Methods: We searched MEDLINE, Embase, CENTRAL for randomised trials through May 2019. We estimated odds ratios (ORs) for binary and mean differences (MDs) for continuous outcomes, using frequentist random-effects network meta-analysis. We assessed study risk of bias and appraised evidence certainty using GRADE.

Results: Eighteen trials (2638 participants) were included. Standard definition white-light endoscopy (OR 0.44, 95% CI 0.26–0.73; high certainty) and i-SCAN (OR 0.47, 95% CI 0.25–0.90; moderate certainty) had lower odds of detecting neoplasia than chromoendoscopy. Fujinon intelligent colour enhancement (FICE), standard definition white-light endoscopy and i-SCAN had lower odds for this outcome than full spectrum high definition white-light endoscopy (ORs 0.02 to 0.15; low certainty). Standard definition white-light endoscopy had lower odds of detecting nonpolypoid neoplasia than full spectrum high definition white-light endoscopy, narrow band imaging, chromoendoscopy and high definition white-light endoscopy (ORs 0.01–0.14; moderate certainty). Full spectrum high definition white-light endoscopy ranked as the best technique for both outcomes (moderate certainty). Standard definition white-light endoscopy had lower odds of detecting neoplasia by target biopsy (OR 0.27, 95% CI 0.08–0.91) and had shorter procedure time (MD –14.81 minutes, 95% CI –25.03, −4.06) than chromoendoscopy (moderate certainty).

Conclusions: Chromoendoscopy, high definition white-light endoscopy, narrow band imaging, autofluorescence, FICE and full spectrum high definition white-light endoscopy may be comparable for dysplasia surveillance. Standard definition white-light endoscopy and i-SCAN probably provide lower yields for neoplasia identification. Full spectrum high definition white-light endoscopy may represent the first-line approach.

Introduction

People with ulcerative colitis and Crohn's disease experience a two-fold higher risk of colorectal cancer compared to the general population.[1,2] The risk of death associated with this malignancy is around 1.5 times greater in people with IBD than in the general population.[3]

Colorectal cancer develops through a multistep process, where low- and high-grade dysplasia represent an intermediary stage that progresses to cancer.[4–6] International guidelines recommend endoscopic surveillance in people with IBD to identify and eradicate colonic lesions at an early non-invasive stage, with the aim of reducing colorectal cancer incidence and mortality.[7–14] The target population for surveillance programs includes patients with left-sided or extensive ulcerative colitis,[7–11] and those with Crohn's disease involving at least one third or more than one segment of colon.[7–9,12] The first screening colonoscopy is recommended to occur at 8–10 years after disease onset.[7–10] Several endoscopic techniques for dysplasia surveillance have been evaluated for IBD in randomised trials, including standard definition and high definition white-light endoscopy, chromoendoscopy, narrow band imaging (Olympus, Tokyo, Japan), i-SCAN (Pentax, Tokyo, Japan) and autofluorescence (Olympus, Tokyo, Japan). Clinical guidelines recommend chromoendoscopy with target biopsies for surveillance programs in this population.[8–11,13,14] White-light endoscopy with random biopsies is considered only appropriate if chromoendoscopy is not available, whereas other endoscopic techniques have not been considered superior to chromoendoscopy.[7,9,11,13]

Guideline recommendations supporting the use of chromoendoscopy are based on evidence from observational studies and randomised trials that have methodological limitations due to selection, performance, detection, attrition or reporting bias. In a recent systematic review of randomised trials, we found that chromoendoscopy identifies more patients with dysplasia only when compared to standard definition white-light endoscopy, with no evidence of a difference in the comparison with high definition white-light endoscopy, narrow band imaging and i-SCAN.[15]

Standard pairwise meta-analysis only allows the direct comparison of two endoscopic techniques that have been evaluated head-to-head in randomised trials. In a setting in which there are severall options for endoscopic dysplasia surveillance, a network meta-analysis can facilitate comparisons of all endoscopic procedures simultaneously within a single framework and rank available techniques according to efficacy and safety. We aimed to provide evidence regarding the comparative efficacy of all endoscopic approaches for dysplasia surveillance in IBD using network meta-analysis of randomised trials.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....