Successful management of large, recurrent colorectal polyps: experience from a UK tertiary referral centre

Aims Polyps that are recurrent, growing over and around scarred mucosa and submucosa pose a major challenge for the therapeutic endoscopist. A variety of resection techniques are available in this setting before resorting to resectional surgery. We reviewed outcomes and management trends over a 9 year period at our institution.

Methods A retrospective study of all patients between January 2015 and December 2023 who underwent ER of colorectal polyps>20mm was performed. A standard data set was collected and comparisons between treatment-naïve and recurrent polyps made.

Results Of 1103 attempted endoscopic resections of large polyps, 131 (11.9%) were recurrent after one or more previous attempts at ER prior to referral. Median polyp size was 30mm (range 20-160mm). Compared to treatment-naive polyps, recurrent polyps were more likely to be tertiary referrals (15.1% vs 6.9%), in the rectum (45.8% vs 32.1%), involve the dentate line (13.7% vs 6.1%), or be circumferential or near-circumferential (10.7% vs 5.2%). 31 (23.7%) were resected by endoscopic submucosal dissection (ESD), 45 (34.4%) by conventional endoscopic mucosal resection (EMR), 14 (10.7%) by a knife-assisted EMR, 32 (24.2%) by underwater EMR, 3 (2.3%) by cold EMR, and 6 (4.6%) by TASER (combined ESD+TAMIS) procedure. The use of underwater EMR has significantly increased for recurrent polyps (9.5% of resections 2015-2017 vs 50.0% 2021-2023; p<0.001). Recurrent polyps more commonly underwent the use of resection adjuncts, with 30/131 (22.9%) undergoing argon plasma coagulation and cold avulsion (ACA) vs 27/1174 (2.3%) in treatment-naive polyps. 1 polyp was considered for endoscopic full thickness resection, but would not pull into the proof cap due to fibrosis, and was instead successfully managed with underwater EMR and ACA. Both treatment-naive and recurrent polyps have similarly high rates of successful ER (96.8% vs 99.2%) and low rates of serious complications (delayed bleeding 1.4% vs 1.5%, and deep mural injury 2.9% vs 2.3%). Overall, there were 4 perforations (3 treatment-naïve polyps and 1 recurrent polyp). 3 of these were managed with endoscopic clips, antibiotics and overnight admission. 1 patient required emergency surgery. Recurrence rates were significantly higher for recurrent polyps (49.0% vs 12.6%; p<0.001). Successful eradication rates for recurrent polyps improved to 75.6% and 83.7% at second and third endoscopic follow-up, respectively. 9 recurrent polyps were ultimately referred for surgery: 2 for malignancy with high-risk features, and 7 for non-endoscopically manageable benign recurrence not considered suitable for endoscopic full thickness resection due to size or fibrosis.

Conclusions Successful endoscopic resolution with low complication rates can be achieved for recurrent polyps, but often over more than one endoscopic session. Multiple endoscopic resection techniques were deployed, with increasing use of underwater EMR. Endoscopic full thickness resection or surgery was rarely required as rescue therapy.

Publication History

Article published online:
27 March 2025