Introduction
Inflammatory bowel disease (IBD) is a chronic, relapsing and remitting disorder that is becoming increasingly prevalent worldwide.1 Despite major advances in this area, many patients with moderate to severe IBD do not achieve disease remission with immunosuppressive therapy.2 Dysplasia and fibrostenosis are two common consequences of uncontrolled chronic inflammation and these structural complications are often the primary reasons for surgical interventions.3 While there is certainly a time and a place for surgery in IBD, this approach is invasive and postoperative recrudescence of disease is common.4 Moreover patients with complex surgical or medical histories may not make optimal surgical candidates.
Dr. Michael Rubeiz
Thanks to advancements in a variety of endoscopic technologies, Over the last several years, applications of endoscopic therapies in IBD have been gaining traction and the need for these therapies is expected to continue to rise over time. As such, understanding the domains of available endoscopic options in IBD is important for the modern-day gastroenterologist. In this article, we will discuss some of the recent advancements in endoscopic therapies for IBD and how we may position these in clinical practice.
Protecting against colitis dysplasia and colon cancer
IBD is a risk factor for colorectal cancer because of the dysplasia-carcinoma sequence arising from chronic colitis. Endoscopic resection is the first-line treatment for conventional colitis-associated dysplasia (CAD).5,6 However, larger or complex lesions may not have been previously amenable to this organ-preserving approach. The application of newer techniques has extended the indication for endoscopic resection to include most CAD lesions, as an alternative to proctocolectomy. Endoscopic mucosal resection (EMR) is the most commonly used technique and its outcomes for CAD greater than 2 cm have been excellent (Figure 1).7 However, employing EMR for lesions greater than 2 cm in size may require piecemeal resection and this has been associated with a small risk of local recurrence.8 Endoscopic submucosal dissection (ESD) is an alternate method of endoscopic tissue resection that can reliably achieve en bloc (single specimen) resections even in larger lesions.9
Courtesy Dr. Genere and colleagues
Figure 1 - Endoscopic mucosal resection of colitis-associated dysplasia with low grade dysplasia. Well-demarcated, Paris classification Is lesion examined under high definition white light and digital chromoendoscopy (top panels). Piecemeal endoscopic mucosal resection and clip closure (bottom panels).
These technical advantages, however, have not been proven to result in broad clinical superiority of ESD over EMR for advanced lesions.10 The other consideration is that ESD is associated with greater risk of perforation and is more technically complex to perform.10 Yet, recent data supporting ESD in larger lesions is amounting and it may be more suitable for situations where conventional techniques fall short.11 To that end, dense submucosal fibrosis is a common characteristic of CAD and may prohibit successful EMR or ESD as a single modality. Different therapeutic methods can be incorporated in these circumstances, including combined ESD and EMR technique, tissue thermal ablation, or even full-thickness resection has been described.11-13
Dr. Kemmian Johnson
Taken together, we have many effective options for how we can effectively deal with CAD endoscopically and maintain our patients free of colorectal cancer. The method in which this is done may not matter as much at this juncture and may be more dependent on available local clinical expertise. Moreover, we can’t forget that metachronous lesions and neoplastic recurrence after endoscopic resection are not uncommon and a structured, vigilant endoscopic surveillance program for all patients undergoing endoscopic management of CAD is mandated.7,10
