Tu1527 Low Inter-Observer Agreement Among Endoscopists in Differentiating Dysplastic From...
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Tu1527 Low Inter-Observer Agreement Among Endoscopists in Differentiating Dysplastic From Non-Dysplastic Lesions Encountered During Colitis Surveillance Linda K. Wanders* 1 , Erik Mooiweer 2 , Peter D. Siersema 2 , Raf Bisschops 3 , Geert R. D’Haens 1 , Bas Oldenburg 2 , Evelien Dekker 1 1 Gastroenterology, Academic Medical Center, Amsterdam, Netherlands; 2 Gastroenterology, University Medical Center Utrecht, Utrecht, Netherlands; 3 Gastroenterology, University Hospital Leuven, Leuven, Belgium Introduction: During endoscopic surveillance in patients with longstanding colitis a variety of lesions can be encountered. Differentiation between dysplastic, especially low grade dysplasia, and non-dysplastic lesions can be challenging, but the accuracy of endoscopic differentiation has never been objectified. Methods: We assessed the inter-observer agreement among gastroenterologists in differentiating low grade dysplastic from non-dysplastic lesions. An online questionnaire was constructed containing 30 cases. For each case, a short medical history was given and an endoscopic image of a lesion found during surveillance employing chromoendo- scopy was shown. Ten cases contained low-grade dysplasia and 20 cases contained non-dysplastic lesions. The participants were asked to classify each lesion as dysplastic, with the subcategories sporadic adenoma, adenoma-like DALM or non- adenoma-like DALM, or as non-dysplastic with the subcategories normal mucosa, inflammation, post-inflammatory polyp or hyperplastic polyp. Referral center gas- troenterologists who performed at least 100 surveillance colonoscopies were clas- sified as experts, the remaining endoscopists were classified as non-experts, including non-academic gastroenterologists and fellows in training. The inter- observer agreement for the differentiation between dysplastic lesions from non- dysplastic lesions and the subtypes was calculated using Fleis Kappa. The sensitivity and specificity was assessed, using histopathology as reference standard. Results: In total, 17 endoscopists, 8 experts and 9 non-experts, assessed all 30 cases. The overall inter-observer agreement in differentiating between dysplastic and non-dysplastic lesions was fair 0.24 (95% CI 0.21-0.27); for experts 0.28 (95% CI 0.21-0.35) and for non-experts 0.22 (95% CI 0.17-0.28). The overall inter-observer agreement for differentiating between subtypes was fair 0.21 (95% CI 0.20 - 0.22); for experts poor 0.19 (95% CI 0.17 - 0.22) and non-expert fair 0.23 (95% CI 0.21 - 0.25). The overall sensitivity and specificity for identifying neoplasia were 76% (95% CI 70-82) and 51% (95% CI 46-56), respectively. Experts showed a sensitivity of 79% (95% CI 69-86) versus 74% (95% CI 65-82, pZ0.44) for non-experts whereas the specificity was 57% (95% CI 49-64) for experts versus 46% (95% CI 38-53, pZ0.04) for non-experts. Conclusion: Endoscopists, both experts and non-experts, cannot reliably differen- tiate between neoplastic and non-neoplastic lesions. This emphasizes the value of pathological assessment of all lesions encountered during chromoendoscopic colitis surveillance. Reference: Rutter MD, Riddel RH. Colorectal Dysplasia in Inflammatory Bowel Disease: A Clinicopathologic Perspective. CGH 2013 Tu1528 Adherence to ASGE Guidelines for Crohn’s Colitis Dysplasia Surveillance Among Gastroenterologists At an IBD Center vs Non- IBD Specialized Academic Faculty Yecheskel Schneider* 1 , Michelle Cohen 2 , Shirley Cohen-Mekelburg 1 , Monica Saumoy 1 , Stephanie Guo 1 , David Veal 1 , Peter Barish 1 , Ellen J. Scherl 2 , Brian P. Bosworth 2 1 Internal Medicine, New York Presbyterian - Weill Cornell Medical Center, New York, NY; 2 Division of Gastroenterology and Hepatology, New York Presbyterian - Weill Cornell Medical Center, New York, NY Background: Patients with inflammatory bowel disease (IBD) are at increased risk for colorectal neoplasia. A recent study of the CESAME cohort suggests that adherence to surveillance guidelines varies among clinicians. Our study examines adherence to ASGE guidelines for surveillance of Crohn’s colitis among faculty at an IBD center versus gastroenterologists at the same institution who do not specialize in treating IBD. Methods: We conducted a retrospective analysis of patients at our institution from January 2010 to July 2013. Using our endoscopy database, we identified patients who had a colonoscopy and ICD 9 code 555.x (regional enteritis). Patients with L1 ileal disease were excluded. Data collected included duration of disease, interval between repeat surveillance colonoscopies, and distance between biopsies. Adherence to ASGE guidelines was defined as surveillance colonoscopies every 12-24 months, and biopsies obtained every 10 cm, for patients with eight or more years of disease. For each component of the guidelines, the physician was noted to be either adherent or non-adherent. We compared adherence to guidelines for IBD-specialized (Group A) versus non-IBD specialized (Group B) gastroenter- ologists. Outcomes: We identified 196 patients with Crohn’s colitis who underwent at least one colonoscopy during the study period. There were 134 patients (120 in Group A and 14 in Group B) who had O8 years of disease and required surveillance colonoscopies. For these patients, mean age at exam was 42.9 17.0 years in Group A and 49.9 13.3 years in Group B (pZ0.17). Duration of disease was 18.6 11.0 and 25.5 10.1 years in Groups A and B respectively (pZ0.04). There was a sig- nificant difference in adherence to biopsy protocol between the two groups (82.4% in Group A vs 50% in Group B, pZ0.01). Additionally, 95 patients required repeat surveillance colonoscopies during the study period (85 in Group A and 10 in Group B). When evaluating both adherence to the interval between repeat colonoscopies and proper surveillance biopsy technique, there was a significant difference between Group A and Group B (63.5% and 20% respectively, pZ0.01). Additionally, there was a trend towards significance between the groups in evaluating surveillance in- terval alone (70.6% in Group A vs 40% in Group B, pZ0.07). Conclusion: When comparing gastroenterologists who specialize in treating patients with IBD as compared to non-IBD academic faculty, adherence to guidelines for dysplasia sur- veillance was significantly different between the groups. However, adherence was less than ideal in both groups, suggesting a need for continued education among all gastroenterologists to ensure that dysplasia detection guidelines are followed to improve quality care. Tu1529 Endoscopic Resection of Raised Dysplastic Lesions in Ulcerative Colitis: Long-Term Outcome Chang Ho R. Choi* 1,2 , ANA Ignjatovic Wilson 1 , Jonathan Landy 1 , Janindra Warusavitarne 1 , Siwan Thomas-Gibson 1 , Noriko Suzuki 1 , Brian P. Saunders 1 , Ailsa Hart 1 1 St. Mark’s Hospital, London, United Kingdom; 2 Tumour Biology, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom Introduction: Until recently a finding of dysplasia arising within segment of bowel affected by ulcerative colitis (UC) was an indication for colectomy. However, some dysplastic lesions are discrete and endoscopically resectable. Long-term follow-up data for these selected patients is currently limited. Objectives: To evaluate the long-term outcomes of patients with UC who have had an endoscopic resection of dysplasia within segment of bowel affected by colitis. Methods: Patients who had a surveillance colonoscopy for UC at St Mark’s Hospital between 1998 and 2008 and had an endoscopic resection of dysplastic lesions were identified from the endoscopy and histology databases. Data were obtained from clinical notes, endoscopy and histopathology reports. Results: One hundred patients met the inclusion criteria (male: female Z 66: 34). Eighty-seven had extensive and 13 left-sided colitis, with median disease duration of 24 years (IQR 13-33). The median age at disease onset and time of dysplasia diagnosis was 34 (IQR 27-48) and 61 (IQR 54-69) years, respectively. There were 121 discrete lesions in 100 patients (Ip (60), Is (36), IIa (3), IIb (4), IIa/c (1), LST (1), and 16 were described as "appearance suspicious for DALM (Paris classification not recorded)" but which were also resected endoscopically. The median lesion size was 8 mm (IQR 4-15). Lesions were removed using snare polypectomy (54), EMR (28), hot biopsy (15) or ESD (3) techniques. Histology showed LGD in 111 lesions and HGD in 10 lesions: 36 (30%) favored UC-associated dysplasia, 56(46%) favored adenoma, and 29 (24%) lesions were inconclusive between dysplasia and adenoma. Median duration of follow up was 70 months (IQR 53-89). Overall, two cancers were detected during that time: one in the same and one in a distant segment to the previous dysplasia. The rate of recurrence to dysplasia was 24% with median time to recurrence of 41 months (IQR 16-55). Nineteen patients (19%) had recurrence to the same grade of dysplasia that was initially treated: three patients had colectomy (two LGDs and one with no dysplasia), two patients died from unrelated cause, and 14 patients were still on endoscopic follow-up as of January 1st, 2013. Four patients (4%) have progressed from LGD to HGD, which were all detected during surveillance: three patients had colectomy (Duke’s A CRC, LGD, and indeterminate dysplasia, respectively), and one patient refused surgery whose latest colonoscopy showed LGD. Interestingly, all of these four patients had their initial dysplasia in distal colon. Finally, one patient was lost in follow up for five years and subsequent colonoscopy detected Duke’s C cancer. Conclusion: Patients with endoscopically resectable, well-circumscribed dysplastic lesions within the segment of colitis have a good outcome with endoscopic treat- ment with close surveillance. Tu1530 The Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Stricture in Patients With Inflammatory Bowel Disease Hye Won Lee*, Soo Jung Park, Sung Pil Hong, Jae Hee Cheon, Tae IL Kim, Won Ho Kim Department of internal medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea Background and Aim: Benign strictures are common complications in patients with inflammatory bowel disease (IBD). In IBD patients, endoscopic treatment has been tried as a way to relieve obstruction symptoms. This study assessed the long-term prognosis of endoscopic balloon dilation (EBD) for benign strictures in IBD. Methods: Patients from three tertiary referral medical centers with IBD strictures who underwent EBD between January 2000 and April 2013 were reviewed AB466 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 www.giejournal.org Abstracts
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Tu1527Low Inter-Observer Agreement Among Endoscopists inDifferentiating Dysplastic From Non-Dysplastic LesionsEncountered During Colitis SurveillanceLinda K. Wanders*1, Erik Mooiweer2, Peter D. Siersema2, Raf Bisschops3,Geert R. D’Haens1, Bas Oldenburg2, Evelien Dekker11Gastroenterology, Academic Medical Center, Amsterdam, Netherlands;2Gastroenterology, University Medical Center Utrecht, Utrecht,Netherlands; 3Gastroenterology, University Hospital Leuven, Leuven,BelgiumIntroduction: During endoscopic surveillance in patients with longstanding colitis avariety of lesions can be encountered. Differentiation between dysplastic, especiallylow grade dysplasia, and non-dysplastic lesions can be challenging, but the accuracyof endoscopic differentiation has never been objectified. Methods: We assessed theinter-observer agreement among gastroenterologists in differentiating low gradedysplastic from non-dysplastic lesions. An online questionnaire was constructedcontaining 30 cases. For each case, a short medical history was given and anendoscopic image of a lesion found during surveillance employing chromoendo-scopy was shown. Ten cases contained low-grade dysplasia and 20 cases containednon-dysplastic lesions. The participants were asked to classify each lesion asdysplastic, with the subcategories sporadic adenoma, adenoma-like DALM or non-adenoma-like DALM, or as non-dysplastic with the subcategories normal mucosa,inflammation, post-inflammatory polyp or hyperplastic polyp. Referral center gas-troenterologists who performed at least 100 surveillance colonoscopies were clas-sified as experts, the remaining endoscopists were classified as non-experts,including non-academic gastroenterologists and fellows in training. The inter-observer agreement for the differentiation between dysplastic lesions from non-dysplastic lesions and the subtypes was calculated using Fleis Kappa. The sensitivityand specificity was assessed, using histopathology as reference standard. Results: Intotal, 17 endoscopists, 8 experts and 9 non-experts, assessed all 30 cases. The overallinter-observer agreement in differentiating between dysplastic and non-dysplasticlesions was fair 0.24 (95% CI 0.21-0.27); for experts 0.28 (95% CI 0.21-0.35) and fornon-experts 0.22 (95% CI 0.17-0.28). The overall inter-observer agreement fordifferentiating between subtypes was fair 0.21 (95% CI 0.20 - 0.22); for experts poor0.19 (95% CI 0.17 - 0.22) and non-expert fair 0.23 (95% CI 0.21 - 0.25). The overallsensitivity and specificity for identifying neoplasia were 76% (95% CI 70-82) and 51%(95% CI 46-56), respectively. Experts showed a sensitivity of 79% (95% CI 69-86)versus 74% (95% CI 65-82, pZ0.44) for non-experts whereas the specificity was 57%(95% CI 49-64) for experts versus 46% (95% CI 38-53, pZ0.04) for non-experts.Conclusion: Endoscopists, both experts and non-experts, cannot reliably differen-tiate between neoplastic and non-neoplastic lesions. This emphasizes the value ofpathological assessment of all lesions encountered during chromoendoscopic colitissurveillance. Reference: Rutter MD, Riddel RH. Colorectal Dysplasia in InflammatoryBowel Disease: A Clinicopathologic Perspective. CGH 2013
Tu1528Adherence to ASGE Guidelines for Crohn’s Colitis DysplasiaSurveillance Among Gastroenterologists At an IBD Center vs Non-IBD Specialized Academic FacultyYecheskel Schneider*1, Michelle Cohen2, Shirley Cohen-Mekelburg1,Monica Saumoy1, Stephanie Guo1, David Veal1, Peter Barish1,Ellen J. Scherl2, Brian P. Bosworth21Internal Medicine, New York Presbyterian - Weill Cornell MedicalCenter, New York, NY; 2Division of Gastroenterology and Hepatology,New York Presbyterian - Weill Cornell Medical Center, New York, NYBackground: Patients with inflammatory bowel disease (IBD) are at increased riskfor colorectal neoplasia. A recent study of the CESAME cohort suggests thatadherence to surveillance guidelines varies among clinicians. Our study examinesadherence to ASGE guidelines for surveillance of Crohn’s colitis among faculty at anIBD center versus gastroenterologists at the same institution who do not specializein treating IBD. Methods: We conducted a retrospective analysis of patients at ourinstitution from January 2010 to July 2013. Using our endoscopy database, weidentified patients who had a colonoscopy and ICD 9 code 555.x (regional enteritis).Patients with L1 ileal disease were excluded. Data collected included duration ofdisease, interval between repeat surveillance colonoscopies, and distance betweenbiopsies. Adherence to ASGE guidelines was defined as surveillance colonoscopiesevery 12-24 months, and biopsies obtained every 10 cm, for patients with eight ormore years of disease. For each component of the guidelines, the physician wasnoted to be either adherent or non-adherent. We compared adherence to guidelinesfor IBD-specialized (Group A) versus non-IBD specialized (Group B) gastroenter-ologists. Outcomes: We identified 196 patients with Crohn’s colitis who underwentat least one colonoscopy during the study period. There were 134 patients (120 inGroup A and 14 in Group B) who had O8 years of disease and required surveillancecolonoscopies. For these patients, mean age at exam was 42.9 � 17.0 years in GroupA and 49.9 � 13.3 years in Group B (pZ0.17). Duration of disease was 18.6 � 11.0and 25.5 � 10.1 years in Groups A and B respectively (pZ0.04). There was a sig-
AB466 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
nificant difference in adherence to biopsy protocol between the two groups (82.4%in Group A vs 50% in Group B, pZ0.01). Additionally, 95 patients required repeatsurveillance colonoscopies during the study period (85 in Group A and 10 in GroupB). When evaluating both adherence to the interval between repeat colonoscopiesand proper surveillance biopsy technique, there was a significant difference betweenGroup A and Group B (63.5% and 20% respectively, pZ0.01). Additionally, therewas a trend towards significance between the groups in evaluating surveillance in-terval alone (70.6% in Group A vs 40% in Group B, pZ0.07). Conclusion: Whencomparing gastroenterologists who specialize in treating patients with IBD ascompared to non-IBD academic faculty, adherence to guidelines for dysplasia sur-veillance was significantly different between the groups. However, adherence wasless than ideal in both groups, suggesting a need for continued education among allgastroenterologists to ensure that dysplasia detection guidelines are followed toimprove quality care.
Tu1529Endoscopic Resection of Raised Dysplastic Lesions in UlcerativeColitis: Long-Term OutcomeChang Ho R. Choi*1,2, ANA Ignjatovic Wilson1, Jonathan Landy1,Janindra Warusavitarne1, Siwan Thomas-Gibson1, Noriko Suzuki1,Brian P. Saunders1, Ailsa Hart11St. Mark’s Hospital, London, United Kingdom; 2Tumour Biology, BartsCancer Institute, Queen Mary University of London, London, UnitedKingdomIntroduction: Until recently a finding of dysplasia arising within segment of bowelaffected by ulcerative colitis (UC) was an indication for colectomy. However,some dysplastic lesions are discrete and endoscopically resectable. Long-termfollow-up data for these selected patients is currently limited. Objectives: Toevaluate the long-term outcomes of patients with UC who have had anendoscopic resection of dysplasia within segment of bowel affected by colitis.Methods: Patients who had a surveillance colonoscopy for UC at St Mark’sHospital between 1998 and 2008 and had an endoscopic resection of dysplasticlesions were identified from the endoscopy and histology databases. Data wereobtained from clinical notes, endoscopy and histopathology reports. Results: Onehundred patients met the inclusion criteria (male: female Z 66: 34). Eighty-sevenhad extensive and 13 left-sided colitis, with median disease duration of 24 years(IQR 13-33). The median age at disease onset and time of dysplasia diagnosis was34 (IQR 27-48) and 61 (IQR 54-69) years, respectively. There were 121 discretelesions in 100 patients (Ip (60), Is (36), IIa (3), IIb (4), IIa/c (1), LST (1), and 16were described as "appearance suspicious for DALM (Paris classification notrecorded)" but which were also resected endoscopically. The median lesion sizewas 8 mm (IQR 4-15). Lesions were removed using snare polypectomy (54), EMR(28), hot biopsy (15) or ESD (3) techniques. Histology showed LGD in 111lesions and HGD in 10 lesions: 36 (30%) favored UC-associated dysplasia,56(46%) favored adenoma, and 29 (24%) lesions were inconclusive betweendysplasia and adenoma. Median duration of follow up was 70 months (IQR53-89). Overall, two cancers were detected during that time: one in the sameand one in a distant segment to the previous dysplasia. The rate of recurrence todysplasia was 24% with median time to recurrence of 41 months (IQR 16-55).Nineteen patients (19%) had recurrence to the same grade of dysplasia that wasinitially treated: three patients had colectomy (two LGDs and one with no dysplasia),two patients died from unrelated cause, and 14 patients were still on endoscopicfollow-up as of January 1st, 2013. Four patients (4%) have progressed from LGD toHGD, which were all detected during surveillance: three patients had colectomy(Duke’s A CRC, LGD, and indeterminate dysplasia, respectively), and one patientrefused surgery whose latest colonoscopy showed LGD. Interestingly, all of thesefour patients had their initial dysplasia in distal colon. Finally, one patient was lost infollow up for five years and subsequent colonoscopy detected Duke’s C cancer.Conclusion: Patients with endoscopically resectable, well-circumscribed dysplasticlesions within the segment of colitis have a good outcome with endoscopic treat-ment with close surveillance.
Tu1530The Long-Term Outcomes of Endoscopic Balloon Dilation forBenign Stricture in Patients With Inflammatory Bowel DiseaseHye Won Lee*, Soo Jung Park, Sung Pil Hong, Jae Hee Cheon, Tae IL Kim,Won Ho KimDepartment of internal medicine, Institute of Gastroenterology, YonseiUniversity College of Medicine, Seoul, Republic of KoreaBackground and Aim: Benign strictures are common complications in patients withinflammatory bowel disease (IBD). In IBD patients, endoscopic treatment has beentried as a way to relieve obstruction symptoms. This study assessed the long-termprognosis of endoscopic balloon dilation (EBD) for benign strictures in IBD.Methods: Patients from three tertiary referral medical centers with IBD strictureswho underwent EBD between January 2000 and April 2013 were reviewed
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