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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 RMM, 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. Gut 2024; 73:741-750. [PMID: 38216328 DOI: 10.1136/gutjnl-2023-330020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024]
Abstract
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%. We 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%, OR 0.43; 95% CI 0.23 to 0.78; p=0.005) with similar complication rates (8% vs 9%, OR 0.93; 95% CI 0.64 to 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 EMR training for 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. TRIAL REGISTRATION NUMBER NTR7477.
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Affiliation(s)
- Lonne W T Meulen
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Roel M M Bogie
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marije S Vlug
- Department of Gastroenterology and Hepatology, Dijklander Hospital, Hoorn, The Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Martine Baven-Pronk
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - Michael van der Voorn
- Department of Gastroenterology and Hepatology, Haga Hospital, Den Haag, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Lauran Vogelaar
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | | | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, The Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Annick B van Nunen
- Department of Gastroenterology and Hepatology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Esther Stoop
- Department of Gastroenterology and Hepatology, Haaglanden Medical Centre, Den Haag, The Netherlands
| | - Gijs J de Bruin
- Department of Gastroenterology and Hepatology, Tergooi Hospital, Hilversum, The Netherlands
| | - Philip Bos
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Willem A Marsman
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Edith Kuiper
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Marc de Bièvre
- Department of Gastroenterology and Hepatology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Yasser A Alderlieste
- Department of Gastroenterology and Hepatology, Rivas Zorggroep, Gorinchem, The Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - John Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | - Marloes Bargeman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Monique E van Leerdam
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Linda Roberts-Bos
- Department of Gastroenterology and Hepatology, Laurentius Hospital, Roermond, The Netherlands
| | - Femke Boersma
- Department of Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Karsten Thurnau
- Department of Gastroenterology and Hepatology, Hospital group Twente, Almelo, The Netherlands
| | - Roland S de Vries
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Jos M Ramaker
- Department of Gastroenterology and Hepatology, Elkerliek Hospital, Helmond, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Ad A M Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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