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Meulen LWT, Haasnoot KJC, Vlug MS, Wolfhagen FHJ, Baven-Pronk MAMC, van der Voorn MPJA, 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, Roomer R, Groen J, Bigirwamungu-Bargeman M, Siersema PD, Elias SG, Masclee A, Moons LM. Training in optical diagnosis in community hospitals is associated with improved recognition and treatment of T1 CRC: a prospective multicenter intervention study (OPTICAL II). Endoscopy 2024. [PMID: 38657659 DOI: 10.1055/a-2313-4996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND STUDY AIMS Recognition of T1 colorectal cancer (CRC) is difficult, with sensitivities of 35-60% in Western countries. We evaluated the real-life effects of the implementation of the OPTICAL model, a recently developed structured and validated prediction model, in Dutch community hospitals. PATIENTS AND METHODS In this prospective multicenter study, 383 endoscopists from 40 hospitals were invited to follow an e-learning on the OPTICAL-model, to increase sensitivity for detecting T1CRC in non-pedunculated polyps. Next, real-life recognition of T1CRC was evaluated in 25 hospitals. Endoscopic and pathologic reports of T1CRCs detected during the next year were collected retrospectively while endoscopists were unaware of this evaluation. Sensitivity for recognition of T1CRC, R0 resection rate, and treatment modality were compared for trained vs. untrained endoscopists and for recognised vs. unrecognised T1CRCs. RESULTS Within 1 year after the e-learning 251 endoscopists detected 528 non-pedunculated T1CRCs, 118 (47%) of the endoscopist were trained. T1CRCs had a median size of 20mm and were mainly located in the distal colorectum (66%). Trained endoscopists recognised T1CRCs more frequently than untrained endoscopists (sensitivity 74% vs. 62%; mixed model analysis OR 2.90; 95%CI 1.54-5.45. A higher rate of R0 resection was seen for T1CRCs detected by trained endoscopists (69% vs. 56%, OR 1.73; 95%CI 1.03-2.91). CONCLUSION Training in optical recognition of T1CRCs in community hospitals was associated with an increase in sensitivity for T1CRCs. Recognition led to a higher rate of en bloc local excision, resulting in higher R0-resection rates. This may be an important step towards more organ-preserving strategies.
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Affiliation(s)
- Lonne W T Meulen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, Netherlands
- The Netherlands GROW, School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | | | - Marije S Vlug
- Department of Gastroenterology and Hepatology, Dijklander Hospital, Hoorn, Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | | | | | - M P Schwartz
- Gastroenterology, Meander Medical Centre, Amersfoort, Netherlands
| | - Lauran Vogelaar
- Department of Gastroenterology and Hepatology, Diakonessenhuis Utrecht Zeist Doorn, Utrecht, Netherlands
| | | | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - W L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Netherlands
| | - R W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven Hospital Location Uden, Uden, Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, Netherlands
| | | | - Annick B van Nunen
- Department of Gastroenterology and Hepatology, Zuyderland Medical Centre Heerlen, Heerlen, Netherlands
| | - Esther Stoop
- Department of Gastroenterology and Hepatology, Medical Centre Haaglanden, Den Haag, Netherlands
| | - Gijs J de Bruin
- Department of Gastroenterology and Hepatology, Tergooi Medical Centre, Hilversum, Netherlands
| | - Philip Bos
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, Netherlands
| | - Willem A Marsman
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, Netherlands
| | - Edith Kuiper
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Marc de Bièvre
- Department of Gastroenterology and Hepatology,, VieCuri Medical Centre, Venlo, Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, Netherlands
| | - John Groen
- Department of Gastroenterology and Hepatology, Ziekenhuis Sint Jansdal, Harderwijk, Netherlands
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Ad Masclee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Leon Mg Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Meulen LWT, van der Zander QEW, Bogie RMM, Keulen ETP, van Nunen AB, Winkens B, Straathof JWA, Hoge CV, de Ridder R, Moons LMG, Masclee AAM. Evaluation of polypectomy quality indicators of large nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort. Gastrointest Endosc 2021; 94:1085-1095.e2. [PMID: 34139253 DOI: 10.1016/j.gie.2021.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS With the introduction of the national bowel cancer screening program, the detection of sessile and flat colonic lesions ≥20 mm in size, defined as large nonpedunculated colorectal polyps (LNPCPs), has increased. The aim of this study was to examine the quality of endoscopic treatment of LNPCPs in the Dutch screening program. METHODS This investigation comprised 2 related, but separate, substudies (1 with a cross-sectional design and 1 with a longitudinal design). The first examined prevalence and characteristics of LNPCPs in data from the national Dutch screening cohort from February 2014 until January 2017. The second, with screening data from 5 endoscopy units in the Southern part of the Netherlands from February 2014 until August 2015, examined performance on important quality indicators (technical and clinical successes, recurrence rate, adverse event rate, and surgery referral rate). All patients were part of the national Dutch screening cohort. RESULTS In the national cohort, an LNPCP was detected in 8% of participants. Technical and clinical success decreased with increasing LNPCP size, from 93% and 96% in 20- to 29-mm lesions to 85% and 86% in 30- to 39-mm lesions and to 74% and 81% in ≥40-mm lesions (P < .001; P = .034). The cumulative recurrence rate at 12 months increased with LNPCP size, from 9% to 22% and 26% in the respective size groups (P = .095). The adverse event rate was 5%. The overall surgical referral rate for noninvasive LNPCPs was 7%. CONCLUSIONS In this performance of 2 substudies, it was shown that quality parameters for endoscopic resection of large polyps in the Dutch screening cohort are not reached, especially in ≥30-mm polyps. Endoscopic resection of large polyps could benefit from additional training, quality monitoring, and centralization either within or between centers.
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Affiliation(s)
- Lonne W T Meulen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Quirine E W van der Zander
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Roel M M Bogie
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands; GROW, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Eric T P Keulen
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Annick B van Nunen
- Department of Internal Medicine and Gastroenterology, Zuyderland Medical Center, Sittard-Geleen, 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
| | - Jan Willem A Straathof
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Gastroenterology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Chantal V Hoge
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rogier de Ridder
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ad A M Masclee
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands; NUTRIM, School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
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Meulen LWT, van de Wetering AJP, Debeuf MEPH, Mujagic Z, Masclee AAM. Optical diagnosis of T1 CRCs and treatment consequences in the Dutch CRC screening programme. Gut 2020; 69:2049-2051. [PMID: 31937551 DOI: 10.1136/gutjnl-2019-320403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 12/08/2022]
Affiliation(s)
- Lonne W T Meulen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands .,Division of Gastroenterology and Hepatology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Alouisa J P van de Wetering
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Division of Gastroenterology and Hepatology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marie-Eline P H Debeuf
- Division of Gastroenterology and Hepatology, GROW, School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Zlatan Mujagic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Division of Gastroenterology and Hepatology, NUTRIM, School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ad A M Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Division of Gastroenterology and Hepatology, NUTRIM, School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Maastricht, The Netherlands
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