Background and Aims
Colorectal EMR for nonpolypoid neoplasia achieves better outcomes when performed by
expert endoscopists. The time point at which the endoscopist achieves expert level
remains to be defined. The objective of this study was to establish a learning curve
of colorectal EMR for nonpolypoid neoplasia based on residual tissue on surveillance
colonoscopy and adverse event rate.
Methods
Five hundred seventy-eight consecutive patients underwent EMR of colorectal neoplasia
by 1 of 3 primary endoscopists between December 2004 and September 2013 in a tertiary
academic center. Primary analyses focused on the largest lesion for patients with
more than 1 lesion (median age, 69 years; median polyp size, 30 mm; 51% en bloc resection).
Data on surveillance colonoscopy were available for 74%. Learning curves were calculated
for each of the 3 main outcome measurements: the presence of residual neoplasia on
surveillance colonoscopy, endoscopic assessment of incomplete EMR, and the occurrence
of an immediate bleeding adverse event.
Results
Residual neoplasia on surveillance colonoscopy was present for 23.2% of patients,
the rate of endoscopist-assessed incomplete EMR was 27.6%, and immediate bleeding
adverse events occurred in 6.9% of patients. Although there was between-endoscopist
variability, the overall rates of residual neoplasia and incomplete EMR decreased
to below 20% to 25% after 100 EMRs; initial decreases in both rates were observed
for earlier EMRs. Immediate bleeding adverse events occurred at a low frequency for
each endoscopist across all EMRs. Perforation requiring surgical intervention occurred
in 1 patient (0.2%).
Conclusions
This study demonstrated that an unexpectedly high number of 100 colorectal EMR procedures
for large nonpolypoid colorectal neoplasia are required to achieve a plateau phase
for crucial outcomes.
Abbreviations:
APC (argon plasma coagulation), ASA (American Society of Anesthesiologists), ESD (endoscopic submucosal dissection), NBI (narrow-band imaging), OR (odds ratio)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: April 21, 2016
Accepted:
April 12,
2016
Received:
January 12,
2016
Footnotes
DISCLOSURES: M. Raimondo has received research funding from Exact Sciences and ChiRhoClin, Inc. M. Wallace is the Editor-in-Chief of Gastrointestinal Endoscopy. He has received research funding from Takeda Pharmaceuticals, NinePoint Medical, Boston Scientific, and Cosmo Pharmaceuticals. He has acted as a consultant for Olympus. All other authors disclosed no financial relationships relevant to this publication.
Identification
Copyright
Copyright © 2016 by the American Society for Gastrointestinal Endoscopy
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Access this article on ScienceDirectLinked Article
- Learning curve for EMR of large nonpolypoid colorectal neoplasia: an alternative analysis method using longitudinal modelsGastrointestinal EndoscopyVol. 85Issue 6
- PreviewWe read with interest the article by Bhurwal et al1 describing the EMR learning curve. The study followed 3 endoscopists and recorded repeated outcome measures with increasing EMR procedure numbers. The authors used graphical evaluation and the test of linear trend to report their findings. We believe that conducting logistic regression and examining the test of trend in this setting is not optimal, given that the observations in the analyzed dataset were not independent but rather were interrelated because they were performed by the same 3 endoscopists over a period of time.
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