Colon to Rectum
Gut. 2025;74(4):547-556
Surveillance in inflammatory bowel disease: White light endoscopy with segmental re-inspection versus dye-based chromoendoscopy – A multi-arm randomised controlled trial (HELIOS)
Background: It remains unclear if the increased colorectal neoplasia detection rate in inflammatory bowel disease (IBD) by high-definition (HD) dye-based chromoendoscopy compared with HD white-light endoscopy is due to enhanced contrast or increased inspection times. Longer withdrawal times may yield similar neoplasia detection rates as found by HD chromoendoscopy.
Objective: To compare colorectal neoplasia detection rates for HD white-light endoscopy with segmental re-inspection and HD chromoendoscopy, using single-pass HD white-light endoscopy as an additional control group.
Design: In a multicentre, randomised controlled trial, IBD patients aged ≥ 18 years without active disease and scheduled for endoscopic surveillance were included. Patients were 2:2:1 randomised to HD white-light endoscopy with segmental re-inspection of each colonic segment (double pass), HD chromoendoscopy or single-pass HD white-light endoscopy. The primary outcome was colorectal neoplasia detection rate. Assuming equal colorectal neoplasia rates (non-inferiority margin of 10%) between segmental re-inspection and chromoendoscopy and superiority of segmental re-inspection versus single-pass HD white-light endoscopy, a sample size of 566 patients was required.
Results: In total, 563 patients were analysed per-protocol. Colorectal neoplasia detection rates were 10.3% (n = 24/234) for HD white-light endoscopy with segmental re-inspection and 13.1% (n = 28/214) for HD chromoendoscopy. This confirmed non-inferiority to HD chromoendoscopy (Δ -2.8%, lower limit 95% confidence interval [CI]: -7.8, p < 0.01). In addition, the number of detected colorectal neoplasia per 10 min of withdrawal time was similar between HD white-light endoscopy with segmental re-inspection and HD chromoendoscopy (0.062 vs. 0.058, p = 0.83). Single-pass HD white-light endoscopy yielded a lower colorectal neoplasia rate (6.1%; n = 7/115) than segmental re-inspection but this was not statistically significant (Δ 4.1%, 95% CI: -2.2:9.6%, p = 0.19).
Conclusions: High-definition (HD) white-light endoscopy with segmental re-inspection was non-inferior to HD chromoendoscopy for colorectal neoplasia detection in IBD patients. It can therefore be assumed that the benefit of HD chromoendoscopy may be explained by the longer withdrawal time and not necessarily the enhanced contrast. However, re-inspection per se did not lead to a significantly higher colorectal neoplasia rate than single-pass HD white-light endoscopy alone.
DOI: 10.1136/gutjnl-2024-333446
Prof. Dr. Peter Hasselblatt
Deputy Director Department of Internal Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
Better look twice during screening colonoscopies for inflammatory bowel disease
Current guidelines recommend initiating colorectal cancer surveillance in patients with inflammatory bowel disease (IBD) after 8 years of disease duration or from the time of diagnosis in those with concomitant primary sclerosing cholangitis. Subsequent surveillance colonoscopies should be performed at risk-adapted intervals. Based on the results of numerous studies and meta-analyses, the preferred screening modality is dye-assisted chromoendoscopy with targeted biopsies of abnormal mucosal areas. If chromoendoscopy is not available, high-definition white-light endoscopy (HD-WLE) with targeted biopsies can be performed as an alternative. There are two possible explanations for the superiority of chromoendoscopy. On the one hand, the dye may be superior to white light for detecting dysplastic mucosal alterations. On the other hand, chromoendoscopy is technically more demanding and leads to increased examination times and thus a more meticulous inspection of the mucosa. The current HELIOS trial addressed these issues by randomizing 563 IBD patients to undergo screening colonoscopy using 1 of 3 approaches: chromoendoscopy, HD-WLE, or HD-WLE with repeated (“double-pass”) inspection of each intestinal segment and thus longer inspection times. Double-pass HD-WLE was not inferior to chromoendoscopy in detecting dysplastic lesions or in the number of lesions detected per time. These results suggest that longer inspection times may be more important compared to the use of dyes in order to detect colitis-associated dysplasia. The median withdrawal times were 19 minutes for HD-WLE and 26 minutes for chromoendoscopy, underscoring the importance of adequate inspection time and optimum equipment for screening colonoscopies in IBD patients. This statement is also endorsed by current guidelines: When using HD-WLE, it should be performed “with particular care and an appropriate withdrawal time.”