Outcomes of endoscopic treatment of second recurrences of large nonpedunculated colorectal adenomas.

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Piecemeal endoscopic mucosal resection (EMR) of large nonpedunculated colorectal adenomas is associated with significant recurrence rates. After salvage endoscopic treatment of recurrences, there is a significant rate of second recurrences. There is a paucity of data on the efficacy and safety of continued endoscopic treatment after a second recurrence. Consecutive patients with recurrent adenomas after initial piecemeal EMR of nonpedunculated colorectal adenomas >2cm were reviewed. We assessed the feasibility, safety and efficacy of continued endoscopic treatment in these patients. Sixty-four patients with 70 recurrent lesions were identified. All were retreated endoscopically. Follow-up colonoscopy (mean interval 6.4months) was performed on 62/70 lesions (89%), and a second recurrence was found in 21/62 (34%). One patient underwent surgery for a circumferential adenoma of the ileocecal valve. The other 20 lesions were treated endoscopically. Follow-up colonoscopy was performed on 15/20 (75%) and demonstrated a third recurrence in 3/15 (20%). One was a deep T1 cancer; curative surgery was performed. The other two patients each had one additional endoscopic treatment and both had no recurrence on subsequent colonoscopy. There were two complications: Both were delayed bleeds after treatment of the first recurrence. A mean of 1.3 endoscopic procedures was required to achieve a cure (range 1-3) for recurrent adenomas after piecemeal EMR. Endoscopic treatment of patients with second recurrences is safe and effective, but is associated with a significant rate of additional recurrences. Continued endoscopic treatment of patients with multiple recurrences is associated with high cure rates, low complication rates and a low risk of progression to malignancy.