Colon to Rectum
Gut. 2024;73(5):741–50
Standardised training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): A multicentre cluster randomised trial
Objective: Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥ 20 mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with an early recurrence rate of up to 30%. The authors evaluated whether standardised EMR training could reduce recurrence rates in Dutch community hospitals.
Design: In this multicentre cluster randomised trial, 59 endoscopists from 30 hospitals were randomly assigned to the intervention group (e-learning and 2-day training including hands-on session) or control group. From April 2019 to August 2021, all consecutive EMR-treated LNPCPs were included. Primary endpoint was recurrence rate after 6 months.
Results: A total of 1412 LNPCPs were included; 699 in the intervention group and 713 in the control group (median size 30 mm vs. 30 mm, 45% vs. 52% size, morphology, site and access [SMSA] score IV, 64% vs. 64% proximal location). Recurrence rates were lower in the intervention group compared with controls (13% vs. 25%, odds ratio [OR] = 0.43; 95% confidence interval [CI]: 0.23–0.78; p = 0.005) with similar complication rates (8% vs. 9%, OR = 0.93; 95% CI: 0.64–1.36; p = 0.720). Recurrences were more often unifocal in the intervention group (92% vs. 76%; p = 0.006). In sensitivity analysis, the benefit of the intervention on recurrence rate was only observed in the 20–40 mm LNPCPs (5% vs. 20% in 20–29 mm, p = 0.001; 10% vs. 21% in 30–39 mm, p = 0.013) but less evident in ≥ 40 mm LNPCPs (24% vs. 31%; p = 0.151). In a post hoc analysis, the training effect was maintained in the study group, while in the control group the recurrence rate remained high.
Conclusion: A compact standardised endoscopic mucosal resection (EMR) training for large non-pedunculated colorectal polyps (LNPCPs) significantly reduced recurrences in community hospitals. This strongly argues for a national dedicated training programme for endoscopists performing EMR of ≥ 20 mm LNPCPs. Interestingly, in sensitivity analysis, this benefit was limited for LNPCPs ≥ 40 mm.