Treatment of adenoma recurrence after endoscopic mucosal resection

David J Tate; Lobke Desomer; Maria Eva Argenziano; Neha Mahajan; Mayenaaz Sidhu; Sergei Vosko; Neal Shahidi; Eric Lee; Stephen J Williams; Nicholas G Burgess; Michael J Bourke

doi:10.1136/gutjnl-2023-330300

Treatment of adenoma recurrence after endoscopic mucosal resection

Gut. 2023 Oct;72(10):1875-1886. doi: 10.1136/gutjnl-2023-330300. Epub 2023 Jul 6.

Authors

David J Tate^{1

2

3}, Lobke Desomer¹, Maria Eva Argenziano², Neha Mahajan¹, Mayenaaz Sidhu^{1

4}, Sergei Vosko¹, Neal Shahidi^{1

5}, Eric Lee¹, Stephen J Williams¹, Nicholas G Burgess^{1

4}, Michael J Bourke^{6

4}

Affiliations

¹ Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.
² Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium.
³ Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
⁴ Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
⁵ Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
⁶ Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia michael@citywestgastro.com.au.

PMID: 37414440
DOI: 10.1136/gutjnl-2023-330300

Abstract

Objective: Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort.

Design: Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two.

Results: 213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up.

Conclusions: RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases.

Trial registration numbers: NCT01368289 and NCT02000141.

Keywords: COLONIC ADENOMAS; COLONOSCOPY; COLORECTAL ADENOMAS; ENDOSCOPIC PROCEDURES.

Publication types

Clinical Study
Research Support, Non-U.S. Gov't

MeSH terms

Adenoma* / pathology
Colonic Polyps* / pathology
Colonoscopy / methods
Colorectal Neoplasms* / pathology
Endoscopic Mucosal Resection* / adverse effects
Endoscopic Mucosal Resection* / methods
Humans
Neoplasm Recurrence, Local / epidemiology
Prospective Studies

Associated data

ClinicalTrials.gov/NCT01368289
ClinicalTrials.gov/NCT02000141