BSG IBD Surveillance Guidelines - part two

[Music] Welcome to BSG Top to Bottom Podcast series. We have been doing podcasts related to various gastro topics. My name is Prithi Bandari. I am one of the vice presidents of BSG and Chair of the Endoscopy section. So, would like to welcome you. We already had a series on the recent IBD guidelines on endoscopic surveillance led by my colleague Dr. Shaheed Adin and James East. This is the part 2. We will be discussing now the endoscopic aspect of IBD surveillance. I am delighted that I am joined by Professor James East to lead these guidelines. So, welcome James. Thank you. It is a great pleasure to be back on the BSG podcast. So, first, remind us James. How long did it take to develop these guidelines? I think we are about three years in all. It is a slow process, but maybe only 18 months with the full guideline group together. But the processes with the committees and things at the end always add a little bit extra until the final thing is done. But we came out roughly at the same time as the main guidance, which was the kind of strategic plan. That's brilliant. It just highlights the amount of time and effort goes into developing guidelines by so many people. So, well done. I think the BSG guidelines on IBD have been fantastic. I was looking at the downloads and the number of reads is phenomenal. So, well done for doing that. I gather that you covered a lot of aspects of IBD and surveillance and why we do surveillance in the cancer risk and stratification in the part 1. So, in this part, let's focus on the endoscopic aspects. And let's start with basics of IBD andoscopy, James, because I think we can come to advanced aspects and techniques and technology and skills. But there are certain things which are essentials like bowel prep, like the type of scope, like the sedation. So, what's your thought process on bowel prep for these patients? Is there anything specific, anything you would like to share on that? I think that the guideline actually had its own metronalysis, an updated metronalysis, that followed on from the ESG guidance in 2019. And for ESG at that time they suggested either four or two-liter peg-based preps. But there was some new data came out, subsequent to that looking at oral sulfate based and picosulfate-based preps. These tend to be much lower volume preps. And many IBD patients favor low volume preps. It is, preps is in fact one of the biggest aspects about patients being willing to come for surveillance, and willing to be concordant with the intervals of their surveillance. So, I think this is actually quite exciting. In terms of what that metronalysis showed, so it showed that in terms of cleaning, two-liter preps were as good as four-liter preps, but they were much more acceptable to patients, which is I think what we know in clinical practice. So that's peg-based preps, so two-liter or less. But also that the oral sulfate and picosulfate-based preps had equivalent cleansing to the two-liter or less peg-based preps, and were at least as acceptable and tolerable, and possibly even a little bit better, than those two-liter peg-based preps. And so what I think we should take away from this is actually that there's lots of choice now for preps in IBD, and that I would suggest that the key thing is find a prep that your patient is willing to take and give them an acceptable experience. Because I think the cleansing for oral sulfate, picosulfate, and two-liter or less-based peg is basically all the same. And so this actually comes quite strongly now down to patient preference to help with concordance. That's very good. So does that include these modern ultra-low volume preps as well, James? So I think that there's certainly some data for the sort of one-liter peg-based preps, and so it's not just two-liter, it's less than or equal to two-liter-based preps. So I think in the UK that the main preps that offers that is plenview, and so we should be able to use those preps with confidence, but that there is more data coming out, not all of it in randomized trials, showing acceptability for low-volume peg-based preps, and that it's effective in cleansing and that they are safe. Excellent. That gives a lot of choices now. And depending on patients, bowel habits, depending on the preference for fluid, but the bottom line is the colon has to be clean, and this has to be emphasized. And I find that during pre-assessment, if the nurse is, or whoever is doing the pre-assessment of these patients, if we spend five minutes talking about that, we can improve the compliance and the quality of the preps. So it's very, very important. So moving on from that, James, what about the comfort side during colonoscopy? When we're doing these surveillance, how important it is, you know, we, in the past, we used to give heavy doses of sedation, then we moved more and more towards less and less and less sedation. These patients keep coming again and again. So what's your thought process about the quality of sedation or underwater colonoscopy? Is there any thought process around that? So I think what needs to do with a technically good intubation to be as comfortable as possible, and that's an appropriate scope that might be a pediatric colonoscope, the use of position changes, use of underwater, use of CO2. All of those things, I think, can improve comfort. But we know that IBD patients get more pain during colonoscopy for a given level of sedation compared to other patients. That almost certainly represents visceral hyposensitivity related to inflammation, but also potentially having had psychological issues about having a bad experience in the past. And one thing that really shocked me in the guidelines was just how much patients dislike coming colonoscopy. And you see this on the forums, in Facebook and other things. I did a great podcast with the rest of the Octopus team recently, and they said the patient forums are absolutely full of this about really bad experiences, and that we are not recognizing this. If you look at the data, you know, the endoscopist thinks the patient had a bad experience in 15% of the endoscopies that were done. This is in a large UK unit with appropriate amounts of sedation that we would consider normal levels. And for the patients, it was two thirds. So there's a radical mismatch. And Colin Reese has had a recent paper on this in endoscopy, not in IBD patients, but in a general population showing that the Glasgow comfort score substantially underestimates patient pain experience compared to proper patient reported experience measures. So what flows from this one gives sedation, give a lot more sedation. And if you're thinking, should I give a little bit more sedation? The correct answer is yes. And then have another look at the patient. And if their toes are still twitchy, or they're minor things that suggest that they may be uncomfortable, yet just keep giving give more. So I think that that's what one aspect. And I think that what you're led to about patients needing to come back again in the game, that this is another critical bit that we must we must try and give people a good experience. So I think the pendulum has swung, particularly for IBD patients far too far, even with, you know, modern underwater pediatric technically nice go loskeby patients are having bad experiences. And our current tools like the the the Gloucester comfort score. I don't think are capturing this. So we are deluding ourselves. That actually the patient experience is acceptable when it's not good. So I think you highlight a very important aspect. And I think we should become a lot more conscious about this. So moving on from there to the actual technical aspect of colonoscopy. Of course, we need to use the best endoscopist, the best kit. But our new BSG guidelines are little bit against the trend which was developing for the last 10 years with ESG with a GA with ASG with echo. Everybody shifting their stance from dice break Roman doscape to virtual chroma and doscape giving a choice or recommending that it is as good. Whereas in these guidelines, we've come out saying that virtual chroma and doscape is recommended and not sorry, that dice break from in doscape is recommended. And we cannot recommend virtual chroma. So explain your thought process around it and how you came up to that conclusion because there are practical challenges and we can address those challenges later. But let's talk about how you came up with this recommendation. Sure. So again, this is a, we were able to create a new network metronalysis that had the maximum number of studies. We only included high definition because there's a lot of argument about, you know, now we're in high definition, maybe we don't need die. And we were able to include perhaps a wider range of virtual chroma and doscape studies. In some previous network metronalysis, they grouped together some things that maybe are not appropriately grouped together. For instance, auto fluorescence imaging and narrowed spectrum technologies. And so for us, we tried to avoid that. We have grouped together NBI, FICE and ICSCAN because we, you know, that they are all blue light technologies and BLI, in fact, I think was included as well. And we were very rigorous. We, you know, we really went and chased down the available studies. We contacted the authors for extra information. And so we think our search represents the most comprehensive view of the data at the time that that was done. And the results were a little bit surprising. So only randomized studies in. So no, you can't have, you know, large observational studies where enthusiastic virtual and chroma and doscape all used to virtual and people who don't really care about doing IBD and doscape just use white light and amazingly the virtual look better. And you know, those are usual sensitivity analysis multi-ndoscopists, so not just studies that were based on single endoscopists and multi-center studies. And what came out was that chroma and doscape helped a bit. So in the new grade analysis, you have to decide what you think is a small effect, what you think is a medium effect and what you think is a large effect. And you decide that before you've seen the data. And so here that the guideline development group decided what was a small effect, medium effect. And the risk ratio for chroma and doscape with all these studies combined in the network came out at 1.42. So almost a 50% increase in displaced detection. And that was considered a small effect. It didn't meet the criteria. It wasn't a big enough change to be classed as a medium effect. And the effect range, I think, went from a trivial effect, so it was just statistically significant to a moderate effect. So chroma and doscape, you know, it helped. It was statistically significantly better than high definition white light. But the effect was not massive. And so there was a conditional recommendation. So you know, you know, it's kind of, you know, you should consider not you must for chroma and doscape. None of the other techniques had sufficient quality of evidence for us to recommend them. However, when you look at the randomized data, the combined data for virtual techniques, by which I mean, blue light, narrow spectrum techniques, the risk ratio there compared to high definition white light was 0.99. And in fact, it was statistically, in a direct comparison, the die was just statistically better. But I think, you know, if the reference range is one and virtual, you know, a combination of all the virtual studies we've got in a network, matter analysis of 0.99, you know, you can use it if you want. But it probably, it on average, is not improving things. It's not making necessarily any worse either. So you can choose to do it. And we know individual adoscopists, you know, some people perform better with some techniques than others. But you know, thinking about your service as a whole, as an average, how are we going to improve? widespread implementation of virtual may not be helpful. And that, you know, there are some kind of first principle reasons, why that may be the case that with the inflammation in the background, the way that we think that virtual helps us is that highlight superficial microvessels. And actually, it makes the background quite busy. And so may not be as helpful as we think. So there is a conditional recommendation for die. And we had a low quality of evidence for a small effect. But that was robust for virtual surprise. So we weren't able to make a recommendation. And slightly surprisingly, the performance of virtual looked almost identical to high definition white light. Yeah. No, so I think the interesting aspect that take away from me is that die spray chroma and doscopy probably is more generalizable as compared to virtual chroma and doscopy because I think virtual chroma does require a lot more training and expertise and experience in evaluating vessel patterns, whereas die spray highlights the morphological changes a lot easier for most endoscopies to recognize, especially when there's a scarred horrible looking colon, I think virtual will confuse us more. But once you find a lesion assessing the lesion, I think virtual chroma plays a very good role. Once you found a lesion in understanding the lesion, the margins of the lesion, both die spray chroma. So still there is a space for those who do a lot of virtual chroma to use virtual. But what about random biopsies? Is there still a space for them or they're gone? So this is another pendulum swing thing, I think, that, you know, historically when Matt Rutter produced the 2010 guidance, or at least he led that component, that we were going to move, we were, we did move strongly away from non-targeted biopsies with no random biopsies, only biopsies for activity and extent, because we didn't think they were helpful as we moved into die spray and high definition. And I think that remains broadly true, but there do seem to be some groups, even when you do chroma andoscopy, where taking quadratic random biopsies from each segment, which I know everybody hates, still seems to offer benefit in terms of improving your displays detection rates, and that there are at least three reasonably large studies that support this. So the two groups that were taking random biopsies, you know, as well as chroma andoscopy, are potentially helpful, are in patients who've had previous dysplasia, and in patients with PSC, both groups we know are at high risk in the future. And while that seems a terrible burden to put onto the both the endoscopist and the pathologist, and potentially the patient, because they'll have a longer procedure, it does seem to improve yield, and that those two groups, for most services, will only represent about one in 10 of the IBD endoscopies that you do. So a bit like some people feel perhaps with chroma andoscopy that it's best targeted to higher risk cases, perhaps where the background is scarred and difficult, the random biopsies are again targeted to those groups, which are relatively infrequent, where improved detection has been demonstrated. Excellent. What about the idea of this invisible dysplasia? How invisible is invisible and how frequent is invisible? So I think the idea that we can definitely see all dysplasia, and the guidelines include a little bit of discussion about this new concept of non-conventional dysplasia, which may have potentially very subtle, you know, has very subtle pathological appearances, and if a pathologist is having trouble seeing it on a perfectly stained, still perfectly lit thing in their office, we shouldn't be too surprised that we might find it quite challenging on a moving, not perfectly stained, not perfectly prepped, colonic surface, while we're doing endoscopy. So I think invisible dysplasia exists, and I think we can all think of cases where we've been told where the dysplasia is, we go back, we look around, you know, it maybe looks quite busy, but there's no clear dysplastic lesion, but when you biopsy the pathologist says, "Yes, that's where it was," and you think, "Well, you know, I looked at it," and it wasn't right, but it wasn't, there wasn't a clear target. So I think that non-conventional dysplasia, particularly in PSC, you know, maybe half of this, the dysplasia is described as flatter and visible, but there's slightly unfortunate terminology that historically in IBD, flat and invisible have been conflated, whereas modern endoscopy flat means Paris 2. It doesn't mean that you can't see it. But I think invisible displays are probably, it exists and particularly when we think about non-commercial displays here, there is a place for biopsies in high-risk cases. - I agree. I think overall the message is that we do get referred a lot of these patients where random biopsies picked up. Nothing was visible. But in a lot of these patients, when we go back, knowing having that information in our unit, we can find that. So to me, I think if an endoscopy is fine, an invisible display there, which was not seen on index endoscopy, I think patients will need repeat colonoscopy and should best be done by an expert who does a lot of surveillance. Because some of them could be very flat lesion, which was not detected, maybe the bowel prep was not good. So patient needs repeat colonoscopy in optimal setting by the best endoscopies. But despite that, there will be a small number of patients where you will still have invisible. Let's, nobody, invisible. Let's move on to the next thing. But before we move on, who should be doing this surveillance? Because this is not an easy game to detect visible, invisible, flat, all these things? Indeed, as you suggest, the guideline suggests exactly that. If you find invisible, the answer is not to take the colon out that you come back and that you do with an expert andoscopist, which is not, has been very difficult to define. But essentially, someone who is appropriately trained has the appropriate skills and does plenty of it, which speaks to you that this little bit about who should be doing it and how people get trained and competent in IBD andoscopy. And I agree that you need to have the right setup. So you need good bowel prep, you need high definition scope, you need the team to be able to help you with colonoscopy, your nursing team, to be able to support that. But you need to be trained as well. Because as you suggest, the lesions can be very, very subtle. And some of that is experience and just doing things frequently. So it may be that, in fact, the guideline and Matt Rutter led on this section suggests that probably this isn't necessarily this diagnostic task, which is arguably one of the hardest diagnostic tasks we face in colonoscopy. And that if you miss, the consequences are very significant for the patient. So it's hard, it's boring, and it's high stakes. That's not a happy combination. So why anyone would want to be the person who has to do that? But we, you know, it's saying we need to offer, we need to do well. Patients want to be confident that we are technically competent. And so probably this should be something that a smaller group of endoscopists within a unit, assuming you're a larger unit and you have a few people that a smaller group of people may want to take this on. Again, this is thinking about comfort. They're going to give appropriate amounts of salvation. And they will have sufficient volume and experience with die. Again, doing die is actually, if you do it all the time, it becomes much quicker. But that group of people will acquire the knowledge and skills and competencies to deliver that service at a high level. And equally, that trainees can come and join those people on those lists. And we can have that mentorship and skill transfer that, you know, you can watch as many YouTube videos as you like. But I think, you know, there's nothing quite like being in the room and having to do it, you know, the hand skills, the sedation, the inter-procedural decision making the interaction with the nursing team, interaction with the patient, making sure you write an appropriate report so that if you find something, you know, dysplasia or something like that, that they can support MDT decision making. But it's hard. And it probably is a smaller group in most larger units that can deliver that. No. And on that note, I'd say that through BSG, we're starting another piece of work to develop some framework of standards around diabetes and doscopy service delivery. So hopefully we can address that in training and KPIs related to that. But I know that AI is coming, but it is still very early days for AI. But I'm sure many eyes there, a lot of these discussions will hopefully become redundant. The dysprey will probably disappear. And doscopy then will have an expert help. But I think we are far away from that. Let's not talk about it right now. I want to move on to talking about new place and the dysplasia management, because the reason why we're doing it is to detect the near place. So when we find the near place, or what we think is a near place, what is your thought process about taking biopsy of the near place, and then taking biopsy of the area around the near place? So it's interesting you choose the word near place, you're there, rather than dysplasia. Because one of the bits that has come out in the guidelines that serrated lesions don't seem to be part of the sort of IBD cancer inflammation cancer sequence, with quite strong data suggesting that they're not increasing risk in the same way that adenomital is non-conventional dysplasia is. So non-displastic serrated lesions just managed sporadically. But dysplasia, if you think you found serrated lesion, still please resect it. But it doesn't trigger the issues that finding adenomitous type dysplasia does. So for small dysplastic lesions, so I think the first thing says that the guideline is very strong on the idea that we should resect things on block. And if you start from that premise, then most people can resect lesions up to 10 millimeters on block when they find them. We often use cold techniques. Nowadays, so that it's safe. And we should just make sure we get that appropriate margin around the edge. And I think if only lesion that you find and you have suspicion that it's a dysplastic lesion to be resected usually on the spot. In terms of taking biopsies around the edge of these lesions, I think if you can see the edge clearly and with modern high-definition scopes, and either with virtual or die-based chroma and oscopy, you're clear about where the edge of the lesion stops. There is no indication with-- there's no real yield in terms of taking biopsies around the lesion. And I think that comes from an era where scopes and imaging was in the NICE POSWATE because we had a little bit blurry. And perhaps we were less familiar with what we were seeing. And I think now we're much more confident in that Conn-la-Heath's work when he was in Oxford. There's strongly supports that there is no real value in doing that. If you can't see the edge of it and you think it might be a kind of a field effect, then potentially that will be an appropriate time to take some biopsies. Yeah, I agree. That's a very good way to describe the role of biopsies. But safe when the lesions are larger than 10 millimeter, I mean, in a caulatic bowel, resecting those lesions are going to be challenging. I'm really pleased to say that the guidelines are pushing not just the DHG but ESG guidelines, all the other new delphies and all the other publication that coming along, all proposing that in colitis, we should aim for an block resection. So how do we manage larger flat lesions? Say, if we find a 15 to 20 millimeter lesion, we obviously should ask and ask if it's to take very good quality pictures, whether they should take biopsy or not, whether they should go to an MDT. What do you think? So I think biopsies, it is slightly difficult. I think extensive biopsies are almost certainly very unhelpful. Sometimes it can be difficult to be clear about, but just, you know, sometimes it's unclear whether it's truly near plastic or not. And if you're really stuck on that, there may be a single targeted biopsy to the most high risk-looking area, might be a reasonable thing to do, although, you know, it can make resection more difficult although it's already going to be scarred in a caulatic patient. But I think that, I think perhaps a key takeaway is that for these bigger lesions, you don't need to do them on the spot. What you do need to do is think about them in the wider context of the patient's lifetime of their disease and probably to have that discussion at a multidisciplinary team meeting to see how are we going to resect this lesion if that's the right thing to do. Because if you find one lesion that's circumscribed and you can resect it on block, actually that the long-term outcomes look very good. But if that patient has multifocal dysplasia, then actually, you know, endoscopic resection may not be the right thing. If you feel they've got actually feel cancerization and it may be that surgical options should be considered. So there's this kind of thing that, you know, see a polyp, I've got to chop it off. Actually, you know, that's a good thing. Am I the right person to take this polyp off? Do I have the skills and techniques? Have I got enough time on the list? How bad is the background scarring? So I think that there are lots of things to think about. And it may be, in fact, frequently for these larger lesions, particularly when we get up to say 20 millimetres or bigger, where to take them off on block with EMR is very challenging with the poor lifting that you often see. And it may be that to go to an MDT, talk about surgical options, talk about endoscopic options. And it may be that, for instance, to go for ESD, either hybrid or kind of conventional. And that may not be in your endoscopy unit. That may be somewhere nearby. But these are really important lesions to get out comprehensively. And so the MDT is a great place to have that discussion, talk about what are the local options, what are the regional options, and see how that is in the context. All the patients' biopsies that they've had in the past, what's the course of their disease? Are you getting control? What are we thinking about in terms of other medical therapies? So there's lots and lots of thinking to go into this. And a SNAP decision in the middle of your busy endoscopy list probably isn't the right way to do this. So the key thing is, and in fact, we only ask for three things in terms of audit for services. And one of them is if you find dysplasia, you must take it to an IBD equivalent MDT so that you can have this kind of big holistic patient lifetime discussion. It's 95% of patients need that with an aspirational target of 100. So we really thought that was important in both the clinicians on the guideline development group, but also the patients. The patient representatives. So it's very important just to emphasize again, so removing large treating large lesions in IBD colon, we need to look at the patient, their disease profile, the inflammation in the colon, other lesions, what patient wants, and what are the available options. And as you said, some of those options might not be locally available. And it's very, very important because at least from the endoscopic perspective, we only have one opportunity and we have to get it right. If we don't get it right endoscopically, first time round, as it is even first time round, it's very challenging. Next time round, scarred, residual lesion will be extremely challenging. And surgical option then become very difficult as well. So it's very important to think carefully about that. Also, I've just reflecting we have a five year follow-up date of 100 plus patients who had a reception in IBD colon. And I was very surprised to see almost 40% of these patients either get recurrent metacronous lesion, progressed to cancer and end up 20% of them having surgery and 15 to 18% of them died of other causes. So we need to really take a step back, think very carefully what we're doing and is it really in patients interest. And so if you reflect on it, the prevalence of these large lesions in IBD colon is not that high. You don't often see that. So I think the experience of the endoscopic in dealing with this, if you're going to do endoscopic resection, if everybody starts doing the experience and the skill set will not be there. So I think going forward, I think we should think about a framework where large complex IBD lesions can be dealt in selected centers. And that again, as we said earlier, it could also become very good list for training. And that's why I think how we can improve the outcome. But I wanted to ask you opinion on the concept of surgery because I'm at echo and I had a session with the surgeons here of our managing and was very interesting to hear from surgeons about the role of selective collectum. The convention is if it's IBD colon, there is nothing like segmental collectum and you need to take the whole colon out and either go for a ilioenol and astroverinase or a permanent stoma. So what's your thought process? So I think it's not a dirty secret, but I think it has been a secret that has come out from larger administrative data sets. And our phases has been quite a leader in getting this out of the has data sets. And when you look at what what resections IBD patients get, in fact, you know, more than half of them, maybe as many as two thirds, get a segmental resection, despite the guidelines saying very clearly, you should have either a pouch or an iliosdomy. And I think this represents what patients want. Patients are often very diverse to these kind of operations. And it probably reflects what we know that not all IBD related cancer is field cancerization. Our patients are getting older and some of them just get sporadic cancer and they've got perfectly well controlled disease, are minimal therapy and they get a cancer. But they don't need that whole colon out that, you know, they just need an appropriate cancer operation. And clearly, you know, that is being done. So I think it has become rather more nuanced that just the, you know, in part, we've gone much more towards endoscopic management of dysplasia. If we can't manage it endoscopically because it's multifocal and visible or technically very difficult position or maybe they've got associated bad inflammation or if it's a cancer. And we do need surgical resection. The idea that, you know, if this doesn't look to be a field cancerization process, then we might consider segmental resection. And in fact, the outcome, the longer term outcomes actually look to be very, you know, very similar to more extensive resections. So probably we already doing that process. But I would say that if you're going for a segmental resection, you need to be really sure about that field cancerization bit. So you're going to do dysprey, you're going to do random biopsies, you're going to have it done by an expert in dysquist because you're about to make a really big call. And at the moment, we don't have good, good decision making tools to help us decide whether dysplasia represents field cancer or dysl-ac cancer represents field cancerization or whether it represents sporadic disease. I think there are, there's very exciting work coming out of Trevor Graham's lab, looking at copy number alterations, which do seem to give really quite a strong differentiation between lesions that are likely to progress to high grade dysplasia cancer or those that won't. So it may be that, you know, this decision making process is going to be made more simple but by new molecular techniques in the future. And I think that those could come to clinical practice, you know, in the next five years before we write the next set of guidelines. So I think segmental is possible, but it needs to, you know, again, you need an MDT, you need to think really carefully, you need to make sure you go back and be as sure as you can be the segmental approach is appropriate, but clearly that there's lots of it being done. It's not just the UK, Canada, Europe, you know, it's obvious that surgeons with patients are making these decisions already and we should help them make them as safely as possible. Excellent, because I think in the future, hopefully the molecular markers and AI will help improve, identify the lesion and managing these lesions, which will be very good. I would also like to extend the same kind of caution about complex endoscopic resection before we do that. We should be assessing the whole colon very carefully, making sure there is no other lesion left, making understanding the residual or ongoing inflammation in the colon before we take them for endoscopic resection. But whether we do segmental resection or whether we do complex endoscopic resection, the other challenge that we should not underestimate both from patient perspective, service perspective and endoscopic perspective is we are now entering into a contract with a patient for intensive surveillance, because once a patient has developed a large dysplastic lesion, the risk of developing metachronous lesions or even a cancer during the follow-up period as our data shows is quite high. So that is another aspect that should be very carefully looked at. Indeed, now I think people, you know, if you've got fuel cancerization, you know, the development of those second of, you know, additional lesions is very fast. It's probably within three years looking at the data. And so yes, you need very intensive surveillance, maybe within three to six months of the first resection. And then at a year and then annually beyond that for the next five years. So every time we find dysplasia, we pull the trigger on both a a huge amount of work for the service, but a huge amount of work and inconvenience and discomfort and things for the patient. So it's gonna be a very intense period and that needs to be part of the discussion that you have when you say we found dysplasia, we think it's endoscopically resectable, but the quid pro quo is that you will need six colonoscopies in the next five years. Many patients may not be too pleased to hear that. That said, historically, once you had dysplasia, you're on annual surveillance forever and it's a game part of the guideline that we've said once you get to five years and in fact the Dutch group may even go for three years, once you've had that period, if nothing bad has happened, then it may be that your surveillance can be deescalated because your original dysplasia was probably just a sporadic lesion and that potentially you could be deescalated down to three years or other options. So again, that's a change in the guideline, this bit, this kind of a subtle bit that's just hidden away in the text, but I think will be important for patients. If they have a small dysplastic lesion, they've well controlled disease, they get intense surveillance for a period and it may be a game, molecular markers help us make that decision, but then potentially there is the opportunity to deescalate in the future. - Excellent, I think we covered a lot about detecting, about resecting, about managing. I think we should bring this to a close. I think this is very exciting time. I'm sure these guidelines will definitely help improve the quality of care we've offered to our patients with IBD. So thanks for all that, great guideline, great discussion and a lot more to come. Is there any other last point you wanna make? - I think that a little bit like we had in the last discussion, just it's a very, very simple point about concordance. Patient concordance is not very good and it's a job for all of us to help patients come at the right time for their surveillance, consultants, IBD nurses, medical secretaries and dosage booking team, and for us to educate our patients for why this is important. There is no cancer prevention if the patient doesn't attend. It's as simple as that. - Very good point to end our podcast. Thank you very much. - Thanks very much for the. (upbeat music)