Standardizing training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): a multicenter, cluster randomized trial

Aims Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥20mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with a high recurrence rate of up to 30%. We evaluated whether standardized EMR training could reduce the post-EMR recurrence rate in Dutch community hospitals.

Methods In this multicenter, cluster randomized trial, 63 endoscopists of 30 hospitals were randomly assigned to the intervention (e-learning and 2-day training including hands-on session) or control group. From April 2019 until August 2021, all consecutive LNPCPs treated by EMR were included. Primary endpoint was the 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 30mm vs 30mm, 45% vs 52% SMSA IV, 64% vs 64% proximal location). Recurrence rate was lower in the intervention group compared to controls (13% vs. 25%, OR 0.43; p=0.006), with a similar complication rate (8% vs 8%). As for subgroup analysis, the intervention effect was present in 20-40mm LNPCPs (7% vs. 20%; p<0.001) but not for ≥40mm LNPCPs (24% vs. 31%; p=0.109). The intervention group more often used a colloid (87% vs 63%) and adrenaline (73% vs 41%) in the submucosal injection fluid, identified and adjunctively removed residual neoplastic tissue (24% vs 18%), and applied adjuvant treatment (92% vs 75%).

Conclusions Standardized EMR training for LNPCPs significantly reduced post-EMR recurrence in community hospitals. However, LNPCPs ≥40mm remained associated with high recurrence rates. For these lesions, centralization of treatment in referral centers should be considered.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
14 April 2023