Optimal surveillance interval after piecemeal endoscopic mucosal resection for large colorectal neoplasia: a multicenter randomized controlled trial


Background and aims

Colorectal neoplastic lesions (≥ 20 mm) are commonly treated via piecemeal endoscopic mucosal resection (p-EMR) but have a high rate of local recurrence. We aimed to clarify the optimal surveillance interval after p-EMR for these neoplasias.


In this multicenter (15 participating institutions) prospective, randomized trial, 180 patients recruited over a 4-year period and were classified based on tumor location, tumor diameter, histological diagnosis, institution, and number of resected specimens. The patients underwent curative p-EMR followed by scheduled surveillance colonoscopy at 3, 6, 12, and 24 months after p-EMR (group A; n = 90) or at 6, 12, and 24 months after p-EMR (group B; n = 90). The primary endpoint was cumulative local recurrence at 6 months after p-EMR. Secondary endpoints included local recurrence and the cumulative surgical resection rate of recurrent tumors during the 24-month follow-up period.


The median tumor diameter was 25 mm (IQR 20–30). Six months after p-EMR, 12 and 6 local recurrences were noted in groups A and B, which corresponded to 13 and 8 recurrences, respectively, during the 24-month surveillance period. The primary and secondary endpoints of recurrence were not significantly different between the groups on either intention-to-treat or per-protocol analysis; no surgery case was observed in group B when a strict surveillance protocol of 6-, 12-, and 24-month follow-up post-EMR was followed.


For patients who underwent p-EMR for neoplastic lesions, additional postprocedural 3-month surveillance did not show superior results in detecting recurrence compared with a 6-month surveillance interval.

Clinical trial registration: UMIN000015740.

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Argon plasma coagulation




Endoscopic mucosal resection


Endoscopic submucosal dissection




Piecemeal endoscopic mucosal resection




High-grade dysplasia/intramucosal carcinoma


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We are deeply grateful to Dr. Yasuhiro Ohno (National Cancer Center East Hospital), Dr. Tomoaki Shinohara (Saku Central Hospital), Dr. Hisashi Doyama (Ishikawa Prefectural Central Hospital), and Dr. Yuichiro Yamaguchi (Shizuoka Cancer Center) for their immense support with enrolling the patients and explaining the study design to them, as well as for insightful comments on the manuscript and the overall study.


This work was supported by The National Cancer Center Research and Development Fund (21-25, 29-A-13). The funder had no role in designing the study, handling the data, or in the preparation and publication of the manuscript.

Author information




YS and TN involved in study concept and design and drafted the manuscript. TN, SH, SY, HI, KH, H-MC, SK, TM, KH, NS, TA, AC, MF, NK, KF, TS, TM, and YS participated in acquisition of data. HI, TN, TS, and YS performed the analysis and interpretation of data. YS and TS contributed to the critical revision of the manuscript for important intellectual content. YM did statistical analysis. YS involved in funding acquisition.

Corresponding author

Correspondence to Yutaka Saito.

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Takeshi Nakajima, Taku Sakamoto, Shinichiro Hori, Shinya Yamada, Hiroaki Ikematsu, Keita Harada, Han-Mo Chiu, Shinsuke Kiriyama, Tomoki Michida, Kinichi Hotta, Naoto Sakamoto, Takashi Abe, Akiko Chino, Masakatsu Fukuzawa, Nozomu Kobayashi, Kazutoshi Fukase, Takahisa Matsuda, Yoshitaka Murakami, Hideki Ishikawa, and Yutaka Saito have no conflicts of interest or financial ties to disclose.

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Nakajima, T., Sakamoto, T., Hori, S. et al. Optimal surveillance interval after piecemeal endoscopic mucosal resection for large colorectal neoplasia: a multicenter randomized controlled trial. Surg Endosc (2021). https://doi.org/10.1007/s00464-021-08311-6

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  • Piecemeal endoscopic mucosal resection (p-EMR)
  • Colorectal neoplasia
  • Surveillance colonoscopy
  • Surveillance interval
  • Local recurrence