Recurrence after piecemeal hot-snare endoscopic mucosal resection of 10–20-mm nonpedunculated colorectal polyps: a multicenter cohort study

Abstract

Background

Guidelines are equivocal on the need for early surveillance colonoscopy (ESC) after piecemeal endoscopic mucosal resection (pEMR) of 10–20-mm nonpedunculated colorectal polyps (NPCPs). This study assessed recurrence rates and associated factors at ESC following hot-snare pEMR of 10–20-mm NPCPs.

Methods

A retrospective, multicenter cohort study was performed at five hospitals in the Netherlands. Patients undergoing pEMR of 10–20-mm NPCPs (2014–2021) and referred for ESC (range 3–9 months) were included. The primary outcome was recurrence rate at ESC. Secondary outcomes included scar identification rates, both overall and at tattooed sites. A mixed-effects model was used to identify factors associated with recurrence.

Results

389 patients undergoing pEMR of 426 NPCPs 10–20 mm (median 15 mm, interquartile range 12.8–20.0 mm) were included. Overall, 262 scars (61.5%; 95%CI 56.8–66.0) and 81.6% of tattooed sites were identified at ESC. The recurrence rate was 35/426 (8.2%; 95%CI 6.0–11.2) overall and 35/262 (13.4%; 95%CI 9.8–18.0) when the scar was identified. Median recurrence size was 5 mm, without high grade dysplasia. No NPCP characteristics were associated with recurrence.

Conclusions

This real-world study found a substantial recurrence rate after hot-snare pEMR of NPCPs sized 10–20mm at ESC. ESC scar identification was moderate but improved with tattoo placement. Although early surveillance could be considered to avoid missing recurrence, the small recurrence size and absence of high grade dysplasia suggest that modestly extending the interval beyond that of our study may still allow timely detection of recurrences and metachronous lesions.

Publication History

Received: 27 June 2024

Accepted after revision: 14 February 2025

Accepted Manuscript online:
20 March 2025

Article published online:
19 May 2025

• References

• 1 Zauber AG, Winawer SJ, O’Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
• 2 Ferlitsch M, Hassan C, Bisschops R. et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – update 2024. Endoscopy 2024; 56: 516-545
• 3 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions: recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115: 435-464
• 4 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy – results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80.e71
• 5 Rao AK, Soetikno R, Raju GS. et al. Large sessile serrated polyps can be safely and effectively removed by endoscopic mucosal resection. Clin Gastroenterol Hepatol 2016; 14: 568-574
• 6 Djinbachian R, Iratni R, Durand M. et al. Rates of incomplete resection of 1- to 20-mm colorectal polyps: a systematic review and meta-analysis. Gastroenterology 2020; 159: 904-914.e912
• 7 Belderbos TD, Leenders M, Moons LM. et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014; 46: 388-402
• 8 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
• 9 Facciorusso A, Di Maso M, Serviddio G. et al. Factors associated with recurrence of advanced colorectal adenoma after endoscopic resection. Clin Gastroenterol Hepatol 2016; 14: 1148-1154.e1144
• 10 Tate DJ, Desomer L, Klein A. et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 2017; 85: 647-656.e646
• 11 Abu Arisha M, Scapa E, Wishahi E. et al. Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice. Gastrointest Endosc 2023; 97: 559-567
• 12 Door de Nederlandse Vereniging van Maag-, Darm- en Leverartsen in samenwerking met Nederlandse Vereniging van Pathologie. Nederlandse Richtlijn Coloscopie Surveillance. 2013. Accessed May 24, 2024 at: https://www.mdl.nl/files/richlijnen/Richtlijn_Coloscopie_Surveillance_definitief_2013.pdf
• 13 Hassan C, Quintero E, Dumonceau JM. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013; 45: 842-851
• 14 Plumb AA, Nickerson C, Wooldrage K. et al. Terminal digit preference biases polyp size measurements at endoscopy, computed tomographic colonography, and histopathology. Endoscopy 2016; 48: 899-908
• 15 Schlemper RJ, Riddell RH, Kato Y. et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
• 16 Lima Capela T, Ferreira AI, Macedo Silva V. et al. Recurrence rate after piecemeal endoscopic mucosal resection of <20 mm non-pedunculated colorectal lesions: should we worry about the risk?. Scand J Gastroenterol 2024; 59: 361-368
• 17 Klein A, Tate DJ, Jayasekeran V. et al. Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology 2019; 156: 604-613.e603
• 18 Sidhu M, Shahidi N, Gupta S. et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology 2021; 161: 163-170.e163
• 19 Radadiya D, Desai M, Patel H. et al. Analyzing methods for reducing recurrence rates after EMR of large nonpedunculated colorectal polyps: an indirect pairwise comparison. Gastrointest Endosc 2024; 99: 326-336.e326
• 20 Joao M, Areia M, Pinto-Pais T. et al. Can white-light endoscopy or narrow-band imaging avoid biopsy of colorectal endoscopic mucosal resection scars? A multicenter randomized single-blind crossover trial. Endoscopy 2023; 55: 601-607
• 21 Kandel P, Brand EC, Pelt J. et al. Endoscopic scar assessment after colorectal endoscopic mucosal resection scars: when is biopsy necessary (EMR Scar Assessment Project for Endoscope [ESCAPE] trial). Gut 2019; 68: 1633-1641
• 22 Ortiz O, Daca-Alvarez M, Rivero-Sanchez L. et al. Linked-color imaging versus high definition white-light endoscopy for evaluation of post-polypectomy scars of nonpedunculated lesions: LCI-Scar study. Endoscopy 2024; 56: 283-290
• 23 Shahidi N, Gupta S, Whitfield A. et al. Simple optical evaluation criteria reliably identify the post-endoscopic mucosal resection scar for benign large non-pedunculated colorectal polyps without tattoo placement. Endoscopy 2022; 54: 173-177
• 24 Baile-Maxia S, Mangas-Sanjuan C, Sala-Miquel N. et al. Incidence, characteristics, and predictive factors of post-colonoscopy colorectal cancer. United European Gastroenterol J 2024; 12: 309-318
• 25 Wisse PHA, de Boer SY, Oudkerk Pool M. et al. Post-colonoscopy colorectal cancers in a national fecal immunochemical test-based colorectal cancer screening program. Endoscopy 2024; 56: 364-372
• 26 Tate DJ, Desomer L, Argenziano ME. et al. Treatment of adenoma recurrence after endoscopic mucosal resection. Gut 2023; 72: 1875-1886
• 27 Cunha Neves JA, Rodriguez de Santiago E, Pohl H. et al. Perspectives and awareness of endoscopy healthcare professionals on sustainable practices in gastrointestinal endoscopy: results of the LEAFGREEN survey. Endoscopy 2024; 56: 355-363
• 28 Hassan C, Antonelli G, Dumonceau JM. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – update 2020. Endoscopy 2020; 52: 687-700
• 29 Gupta S, Lieberman D, Anderson JC. et al. Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91: 463-485.e465