SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2023 | VOLUME 21 | ISSUE 1 | 7 The management of dysplastic lesions in IBD is complex and in ideal settings should be discussed in a multi- disciplinary forum; Table 2 summarizes the current ECCO recommendations 19 . Management options include endoscopic removal, surgery, or surveillance. Depending on morphology and other characteristics, the lesion can be removed by simple polypectomy or more advanced techniques such as endoscopic mucosal resection (EMR), endoscopic submucosal resection (ESD) or hybrid techniques (ECCO). Lesions that are ideal for endoscopic removal are visible dysplasia, with a clearly demarcated border, and no invasive cancer or submucosal fibrosis. These procedures should ideally be performed by skilled endoscopists in high-volume centers. Surgery is indicated mainly for HGD in patients with PSC, or dysplasia that is non resectable. The options for surgery are total or subtotal colectomy, or ileo-anal pouch anastomosis (IPAA) surgery. Table 1: Identification and classification of dysplasia A. Modified Paris classification of polyps B. Classification of dysplasia in IBD Protruding (2.5 mm tall) Endoscopic character of visible dysplasia (the “Five S” features and histology) 1p (pedunculated) 1s (sessile) Site Size Shape Modified Paris classification Describe distinct and indistinct borders Surface Kudo pit pattern FACILE (Frankfurt advanced chromoendoscopic IBD lesions) Surrounding mucosa Mucosal inflammatory activity Submucosol fibrosis Other findings Histology High grade dysplasia (HGD) Low grade dysplasia (LGD) Indefinite dysplasia/unclassified atypia Non-protruding /Flat(<2.5 mm tall) 11a (slightly elevated) 11b (flat) 11c (depressed) 111 (excavated/ulcer) *Adapted from Murthy, S.K., et al 24 and Laine, L., et al 25 Current concerns around these guidelines are that they are based on non-personalized approaches and old data. As a result, it is possible that some patients are screened too late or others over screened; thus patient-specific factors should always be considered in the application of these guidelines. The guidelines recommend high-definition white light endoscopy (HDWLE), or chromoendoscopy with either dye-based chromoendoscopy (DCE), or virtual electronic chromoendoscopy (VCE) and targeted biopsies of any suspicious lesions. DCE and VCE have comparable dysplasia detection rates 21 . The question of whether random biopsies should be obtained is unresolved; however, since there may be invisible dysplasia (only discovered by histology on random biopsies), which in IBD is associated with advanced neoplasia and aneuploidy 22 , this practice is largely supported. Furthermore, in high- risk patients with a history of dysplasia and PSC random biopsies are encouraged 23 . In addition to the technical aspects of colonoscopy, it is important to have very good bowel preparation, record established quality metrics, and to allocate sufficient time on the list to perform this to a high standard. Endoscopic diagnosis and management of dysplasia in IBD The main aims of endoscopic treatment are to correctly identify the lesion, assess resectability, and if resectable to ensure complete endoscopic resection with negative margins. Morphologically, dysplastic lesions can be characterized as invisible or visible (polypoid or non- polypoid). Visible lesions can be described using the ‘Five S’ features and histology (adapted from the Paris classification) (Table 1) 24, 25 . Only visible dysplasia can be removed; however, the management of invisible dysplasia largely depends on patient factors, whether the dysplasia is low grade or high grade, and the presence of background inflammation. In the latter case, it is generally recommended that a repeat examination with chromoendoscopy should be done.