Colon to Rectum

Gut. 2024;73(5):741–50

Meulen LWT, Bogie RMM, Siersema PD, Winkens B, Vlug MS, Wolfhagen FHJ, Baven-Pronk M, van der Voorn M, Schwartz MP, Vogelaar L, de Vos tot Nederveen Cappel WH, Seerden TCJ, Hazen WL, Schrauwen RWM, Alvarez Herrero L, Schreuder RM, van Nunen AB, Stoop E, de Bruin GJ, Bos P, Marsman WA, Kuiper E, de Bièvre M, Alderlieste YA, Roomer R, Groen J, Bargeman M, van Leerdam ME, Roberts-Bos L, Boersma F, Thurnau K, de Vries RS, Ramaker JM, Vleggaar FP, de Ridder RJ, Pellisé M, Bourke MJ, Masclee AAM, Moons LMG

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.

DOI: 10.1136/gutjnl-2023-330020