Zhang M, Yin R, Ying J, Liu GQ, Wang P, Ge JX. Risk factors and clinical prediction models for short-term recurrence after endoscopic surgery in patients with colorectal polyps. World J Gastrointest Surg 2025; 17(8): 109057 [DOI: 10.4240/wjgs.v17.i8.109057]
Corresponding Author of This Article
Jian-Xin Ge, Chief Physician, Department of Gastroenterology, Nanjing Jiangbei Hospital, No. 552 Geguan Road, Jiangbei New District, Nanjing 210048, Jiangsu Province, China. doc_gejianxin@163.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Zhang M conceived and designed the study and wrote the manuscript; Ge JX conceived and designed the study and oversaw the data collection process; Yin R and Ying J contributed to the data analysis; and Liu GQ and Wang P collected the data and literature. Each author has read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All the authors made significant contributions to the research and preparation of this manuscript.
Institutional review board statement: This study was approved by the Ethics Committee of Nanjing Jiangbei Hospital (Approval No. 2024040).
Informed consent statement: The need for patient consent was waived by the Ethics Committee due to the retrospective nature of the study.
Conflict-of-interest statement: The authors declare no conflict of interest.
Data sharing statement: The data used in this study can be obtained from the corresponding author upon request.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jian-Xin Ge, Chief Physician, Department of Gastroenterology, Nanjing Jiangbei Hospital, No. 552 Geguan Road, Jiangbei New District, Nanjing 210048, Jiangsu Province, China. doc_gejianxin@163.com
Received: May 14, 2025 Revised: June 17, 2025 Accepted: July 8, 2025 Published online: August 27, 2025 Processing time: 103 Days and 4.2 Hours
Abstract
BACKGROUND
Colorectal polyps (CPs) are important precursor lesions of colorectal cancer, and endoscopic surgery remains the primary treatment option. However, the short-term recurrence rate post-surgery is high, and the risk factors for recurrence remain unknown.
AIM
To comprehensively explore risk factors for short-term recurrence of CPs after endoscopic surgery and develop a nomogram prediction model.
METHODS
Overall, 362 patients who underwent endoscopic polypectomy between January 2022 and January 2024 at Nanjing Jiangbei Hospital were included. We screened basic demographic data, clinical and polyp characteristics, surgery-related information, and independent risk factors for CPs recurrence using univariate and multivariate logistic regression analyses. The multivariate analysis results were used to construct a nomogram prediction model, internally validated using Bootstrapping, with performance evaluated using area under the curve (AUC), calibration curve, and decision curve analysis.
RESULTS
CP re-occurred in 166 (45.86%) of the 362 patients within 1 year post-surgery. Multivariate logistic regression analysis showed that age (OR = 1.04, P = 0.002), alcohol consumption (OR = 2.07, P = 0.012), Helicobacter pylori infection (OR = 2.34, P < 0.001), polyp number > 2 (OR = 1.98, P = 0.005), sessile polyps (OR = 2.10, P = 0.006), and adenomatous pathological type (OR = 3.02, P < 0.001) were independent risk factors for post-surgery recurrence. The nomogram prediction model showed good discriminatory (AUC = 0.73) and calibrating power, and decision curve analysis showed that the model had good clinical benefit at risk probabilities > 20%.
CONCLUSION
We identified multiple independent risk factors for short-term recurrence after endoscopic surgery. The nomogram prediction model showed a certain degree of differentiation, calibration, and potential clinical applicability.
Core Tip: This retrospective study explored risk factors for short-term recurrence of colorectal polyps after endoscopic surgery and developed a nomogram prediction model. We identified key risk factors such as age, alcohol consumption, Helicobacter pylori infection, number of polyps, sessile polyps, and adenomatous pathology. A nomogram prediction model developed based on these factors showed good discriminatory and calibration abilities, offering clinicians a practical tool for individualized recurrence risk assessment to optimize treatment and follow-up strategies.
Citation: Zhang M, Yin R, Ying J, Liu GQ, Wang P, Ge JX. Risk factors and clinical prediction models for short-term recurrence after endoscopic surgery in patients with colorectal polyps. World J Gastrointest Surg 2025; 17(8): 109057
Colorectal polyps (CPs) are abnormal tissue proliferations that protrude from the mucosal surface of the colon. They are considered important precursor lesions to colorectal cancer (CRC)[1]. The World Health Organization revealed that CRC is the third most prevalent malignant neoplasm worldwide, with over 1.9 million cases and approximately 930000 mortalities reported globally each year[2]. The incidence of CPs increases significantly with age, particularly prevalent in individuals aged > 50[3]. Epidemiological studies show that the prevalence of CPs varies significantly across regions, with a higher prevalence observed in developed countries. This difference may be associated with dietary structure, lifestyle, and screening prevalence[4,5]. Furthermore, genetic factors, obesity, smoking, and alcohol consumption have been recognized as significant risk factors for the development of CPs[6,7]. As the population ages and lifestyles continue to change, the incidence of CPs is expected to rise, further increasing the burden on healthcare systems. Despite advancements in endoscopic techniques that have improved the early detection and treatment of CPs, post-surgery recurrence remains a significant clinical concern.
At present, the primary treatment for CPs is endoscopic resection, which includes techniques such as high-frequency electrocoagulation resection, endoscopic submucosal dissection, and endoscopic mucosal resection[8]. The benefits of these endoscopic treatment techniques, including reduced trauma, expedited recovery, and a diminished incidence of complications, have led to their predominance in the management of CPs. Despite the continuous development and improvement in endoscopic therapeutic techniques, the recurrence of CPs after endoscopic surgery remains a significant clinical challenge. Reportedly, the short-term recurrence rate after colorectal polypectomy (usually defined as within 1-3 years) can be as high as 20%-50%, particularly in patients with multiple polyps, adenomatous polyps, or a family history of recurrence[9]. The recurrence of polyps significantly impacts the healthcare burden experienced by patients and potentially compromises adherence to treatment regimens. A major concern is that recurrent polyps may obscure the presence of new or incompletely resected precancerous lesions, increasing the risk of developing CRC[10]. Consequently, effective prevention and control of post-surgery recurrence of CP have become a crucial concern in contemporary clinical practice and research.
Despite findings from numerous studies addressing recurrence after endoscopic surgery for CPs, the risk factors for short-term recurrence have not been fully delineated, and uniform and validated clinical prediction models are lacking. In this study, we had two aims: First, to comprehensively and systematically investigate the risk factors for short-term recurrence after endoscopic surgery in patients with CPs using a retrospective analysis; and second, to construct a nomogram prediction model. The nomogram prediction model is an intuitive and practical risk assessment tool that integrates the results of multivariate analyses into a graphical scoring system[11]. We incorporated a wider range of clinicopathological indicators than those in previous studies. Comprehensive statistical methods were used for multivariate analysis, thereby enhancing the accuracy and comprehensiveness of the risk factor analysis. The constructed clinical prediction model will be more relevant for clinical applications, thus helping clinicians accurately assess patients’ recurrence risk pre-surgery. This finding will facilitate the formulation of a more personalized treatment and follow-up plan and improve the treatment effects and quality of life of patients, which is of great clinical significance.
MATERIALS AND METHODS
Study design and patients
In this retrospective study, we obtained data from patients with CPs treated at Nanjing Jiangbei Hospital between January 2022 and January 2024. We retrieved data from 378 patients and excluded 16 patients owing to incomplete clinical data. We analyzed data from the remaining 362 patients. They all met the following inclusion criteria: (1) Age ≥ 18 years; (2) CPs diagnosed by endoscopy and pathology; (3) Indication for surgery and having undergone endoscopic polypectomy; (4) Complete regular follow-up visits for at least 1 year post-surgery; and (5) Complete clinical data. The exclusion criteria were as follows: (1) Combined CRC or other malignant tumors; (2) Severe dysfunction of vital organs, including the heart, lungs, liver, and kidneys; (3) Previous history of colorectal surgery (other than the current endoscopic polypectomy); and (4) Inflammatory bowel disease or other chronic bowel diseases that may affect polyp recurrence. The Ethics Committee of the Nanjing Jiangbei Hospital (Approval No. 2024040) approved this study. The need for patient consent was waived by the Ethics Committee due to the retrospective nature of the study.
Data collection
We collected basic demographic data and detailed clinical information using the hospital's electronic medical record system. Basic demographic data included age, sex, height, weight, smoking history, and alcohol consumption history. Clinical information included presence of a family history of CPs, hypertension, diabetes, hyperlipidemia, Helicobacter pylori (H. pylori) infection, and presence of combined gastric polyps. Endoscopy and surgical intervention information included polyp diameter, number, location, color, morphology, resection method, and intraoperative bleeding. We also collected pathological results. During the data collection process, professionally trained data collectors were responsible for information extraction, and specialized personnel were responsible for conducting secondary checks to ensure data accuracy and completeness.
Relapse measurement
We followed up on all patients for at least 1 year and collected test results for regular review within one year. In the first year post-surgery, patients were advised to adhere to medical recommendations and undergo regular check-ups every 3 months. Relapse was defined as a new or recurrent polyp found in situ on colonoscopy within 1 year post-surgery. New polyps are found in the mucosa of the colon or rectum outside the site of the initial surgical resection. In contrast, recurrent polyps in situ are found at the site of the initial surgical resection. Recurrence was confirmed by pathological examination.
Statistical analysis
Continuous variables are expressed as mean ± SD, and categorical variables are expressed as frequency (percentage). Differences between relapse and non-relapse groups were analyzed using the χ2 test (categorical variables) and t-test (continuous variables). Risk factors were screened using univariate and multivariate logistic regression analyses, and OR and 95%CI for each variable were calculated. Statistically significant factors (P < 0.05) in the univariate analysis were included in the multivariate logistic regression model, and the variables were screened using backwards stepwise regression. A nomogram prediction model was constructed based on the multifactor logistic regression analysis results. The model’s discriminatory power was assessed using the receiver operating characteristic curve and area under the curve (AUC); the closer the AUC was to 1, the stronger was the model’s ability to discriminate between patients who experienced relapses and those who did not. We assessed the calibration of the model using a calibration curve and compared the consistency between the predicted probability of the model and the actual observed probability. The model was considered well-calibrated if the calibration curve was close to the ideal curve and the Hosmer-Lemeshow test yielded P > 0.05. The Bootstrapping method was used to sample the original cohort 1000 times for internal validation to evaluate the model’s stability and reliability. Decision curve analysis was conducted to evaluate the clinical utility of the model across different risk thresholds, with probability thresholds as the horizontal coordinates and net clinical benefit as the vertical coordinates, to determine the clinical application value of the model under different risk probabilities. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the nomogram prediction model were calculated using the optimal Jordon index. We conducted all statistical analyses using SPSS (version 26.0) and R software (version 4.0.3), and P < 0.05 (two-sided) was considered statistically significant.
RESULTS
General demographic characteristics
In this study, we included 362 patients, with 166 (45.86%) of them showing a recurrence of polyps within 1 year. The mean age of all patients was 53.32 ± 9.80 years (Table 1). The mean age was higher in the relapse group than in the non-relapse group (P = 0.002). The proportions of smokers and drinkers in the relapse group were higher than those in the non-relapse group (P < 0.05). No significant differences were observed in sex (P = 0.144), body mass index (P = 0.280), hypertension (P = 0.478), diabetes (P = 0.293), hyperlipidemia (P = 0.205), or family history of CPs (P = 0.725) between the two groups.
The proportion of H. pylori infections and polyp number > 2 was higher in the relapse group than in the non-relapse group (P < 0.05) (Table 2). Furthermore, the proportion of patients diagnosed with stemless and adenomatous polyps was significantly higher in the relapse group than in the non-relapse group (P < 0.05). No significant differences were noted in other clinical characteristics between the two groups.
Table 2 Differences in clinical characteristics between the two groups, n (%).
Variables
Total (n = 362)
Non-relapse group (n = 196)
Relapse group (n = 166)
Statistic
P value
H. pylori infection
χ2 = 11.15
< 0.001
No
252 (69.61)
151 (77.04)
101 (60.84)
Yes
110 (30.39)
45 (22.96)
65 (39.16)
Gastric polyp
χ2 = 0.19
0.663
No
317 (87.57)
173 (88.27)
144 (86.75)
Yes
45 (12.43)
23 (11.73)
22 (13.25)
Polyp diameter
χ2 = 2.86
0.091
≤ 2 cm
239 (66.02)
137 (69.90)
102 (61.45)
> 2 cm
123 (33.98)
59 (30.10)
64 (38.55)
Polyp number
χ2 = 5.75
0.016
≤ 2
231 (63.81)
136 (69.39)
95 (57.23)
> 2
131 (36.19)
60 (30.61)
71 (42.77)
Polyp location
χ2 = 1.76
0.184
Distal colon
186 (51.38)
107 (54.59)
79 (47.59)
Proximal colon
176 (48.62)
89 (45.41)
87 (52.41)
Polyp color
χ2 = 0.71
0.400
Rubedo
303 (83.70)
167 (85.20)
136 (81.93)
Non-redness
59 (16.30)
29 (14.80)
30 (18.07)
Polyp morphology
χ2 = 5.26
0.022
Pedunculated or subpedunculated
95 (26.24)
61 (31.12)
34 (20.48)
Sessile
267 (73.76)
135 (68.88)
132 (79.52)
Excision mode
χ2 = 0.22
0.638
EMR
281 (77.62)
154 (78.57)
127 (76.51)
Others
81 (22.38)
42 (21.43)
39 (23.49)
Intraoperative bleeding
χ2 = 1.11
0.292
No
327 (90.33)
180 (91.84)
147 (88.55)
Yes
35 (9.67)
16 (8.16)
19 (11.45)
Pathological type
χ2 = 17.29
< 0.001
Others
126 (34.81)
87 (44.39)
39 (23.49)
Adenomatous
236 (65.19)
109 (55.61)
127 (76.51)
Univariate logistic regression analysis
Relapse (yes, 1; no, 0) was used as the dependent variable in the logistic regression model. Univariate logistic regression analysis results showed that age (OR = 1.04, P = 0.002), smoking (OR = 2.07, P = 0.016), drinking (OR = 1.68, P = 0.049), H. pylori infection (OR = 2.16, P < 0.001), polyp number (OR = 1.69, P = 0.017), polyp morphology (OR = 1.75, P = 0.023), pathological type (OR = 2.60, P < 0.001) were significantly correlated with postoperative relapse in patients with CP (Table 3).
We screened the variables in the multivariate logistic regression models using the backwards stepwise regression method. The results showed that age, drinking (yes: 1, no: 0), H. pylori infection (yes: 1, no: 0), polyp number (> 2: 1, ≤ 2: 0), polyp morphology (sessile polyps: 1, pedunculated or subpedunculated polyps: 0) and pathological type (adenomatous polyps: 1, non-adenomatous polyps: 0) were independent influencing factors of relapse (P < 0.05) (Table 4).
A nomogram prediction model was created following the multivariate logistic regression results. The model formula was as follows: Logistic = -4.20 + 0.04 age + 0.73 drinking + 0.85 H. pylori infection + 0.68 polyp number + 0.74 polyp morphology + 1.10 pathological type. The prediction model is shown in Figure 1.
Figure 1 Nomogram prediction model. H. pylori: Helicobacter pylori.
Confusion matrix analysis of prediction models
The accuracy, sensitivity, specificity, PPV, and NPV of the nomogram prediction model were 0.69 (0.64-0.74), 0.80 (0.74-0.85), 0.56 (0.48-0.64), 0.68 (0.62-0.74) and 0.70 (0.62-0.78), respectively, with the best Jorden index as the cut-off value (Table 5).
Table 5 Confusion matrix analysis of prediction models.
Accuracy (95%CI)
Sensitivity (95%CI)
Specificity (95%CI)
PPV (95%CI)
NPV (95%CI)
Cut-off
0.69 (0.64-0.74)
0.80 (0.74-0.85)
0.56 (0.48-0.64)
0.68 (0.62-0.74)
0.70 (0.62-0.78)
0.535
Evaluation and validation of prediction models
The original cohort was sampled 1000 times using the Bootstrap method for internal verification. The AUC for the modeling and validation cohorts were 0.73 (0.68-0.78) and 0.76 (0.71-0.80), respectively (Figure 2). The AUC results showed that the model had a certain degree of differentiation. The calibration curve results demonstrated good agreement (i.e., degree of fit) between the observed and predicted values in the modeling and (Hoser-Lemeshow, P = 0.557) and validation cohorts (Hoser-Lemeshow, P = 0.170), indicating that the model was well-calibrated (Figure 3). The decision curve was drawn with different probability thresholds as horizontal coordinates and clinical net benefit as vertical coordinates. The decision curve results of the modeling and validation cohorts show that the prediction model can yield net clinical benefits when the risk probability is > 20% (Figure 4).
As an important precancerous lesion in CRC, post-surgery recurrence of CP has been a significant clinical concern[12]. Advancements in endoscopic technology has significantly improved early diagnosis and treatment of CPs; however, post-surgery recurrence is still relatively common, which seriously affects patient prognosis and increases the medical burden[13,14]. In this study, we systematically investigated the risk factors for recurrence within 1 year post-surgery by retrospectively analyzing data from 362 patients who underwent endoscopic polypectomy. We developed a nomogram prediction model. The independent risk factors for short-term recurrence following CP surgery included age, smoking, alcohol consumption, H. pylori infection, polyp number, polyp morphology (sessile polyps), and pathological type (adenomatous polyps). Predictive models constructed based on these factors were well discriminated and calibrated and can provide clinicians with individualized recurrence risk assessment tools.
First, age was a significant risk factor for postoperative recurrence, consistent with the results of previous studies. With increasing age, the capacity for mucosal repair diminishes, and genetic damage may accumulate, thereby increasing the likelihood of polyp recurrence[15,16]. Furthermore, older patients often have various underlying diseases, and these metabolic abnormalities may promote polyp formation and recurrence via chronic inflammation and oxidative stress[17]. In this study, the mean age of patients in the relapse group was significantly higher than that of patients in the non-relapse group, further supporting this view. Alcohol consumption is also observed to be linked to an increased risk of relapse. Alcohol (ethanol) is metabolized mainly by ethanol dehydrogenase (ADH) and CYP2E1 to acetaldehyde, which is further metabolized to acetic acid by acetaldehyde dehydrogenase[18]. Acetaldehyde is a highly reactive compound that binds to DNA, proteins, and lipids, causing cellular damage and abnormal function[19,20]. Accumulation of acetaldehyde can directly damage colonic mucosal epithelial cells, disrupt mucosal barrier function, and increase the sensitivity of the mucosa to carcinogens, thereby promoting polyp formation and recurrence[21]. Additionally, alcohol contributes to a chronic inflammatory state of the colonic mucosa by activating intestinal immune cells (macrophages and T-cells) and by releasing pro-inflammatory cytokines (TNF-α, IL-6, and IL-8)[22]. This chronic inflammation is an important driver of CPs and colorectal carcinogenesis, creating a suitable microenvironment for polyp formation and recurrence through sustained cell proliferation, angiogenesis, and immunosuppression[23,24]. Nevertheless, the specific mechanism of action requires further experimental verification.
Second, H. pylori infection was identified independent risk factor in this study. H. pylori has a unique biology and can colonize the gastric and duodenal mucosa[25]. H. pylori activates the host immune system via virulence factors (CagA and VacA), releasing pro-inflammatory cytokines[26]. These cytokines promote a chronic inflammatory state in the colonic mucosa, leading to an imbalance between the abnormal proliferation and apoptosis of mucosal cells. The effects of H. pylori infection on the immune system may indirectly promote CP recurrence. H. pylori infection also induces the immune system to produce Th1 and Th17 cell-mediated immune responses[27]. These cytokines are involved in the inflammatory response in the stomach and may also act on the colorectal mucosa through blood circulation to induce a local immune response. Moreover, H. pylori infection may induce a state of immune tolerance, making the immune system less capable of clearing precancerous lesions[28]. This state of immune tolerance may create favorable conditions for the recurrence of CPs. Future studies should further the interrelationships between these mechanisms and provide new strategies for preventing and treating CPs by reducing the risk of CP recurrence through clinical interventions (eradicating H. pylori infection and regulating intestinal flora).
In this study, we also observed an association between polyp characteristics and risk of recurrence. We discovered that the risk of recurrence significantly increased in patients with a polyp number of > 2. The presence of multiple polyps implies a broader base of lesions in the colorectal mucosa, and the overall pathological state of the intestinal mucosa is more complex than that of a single polyp. Even with thorough endoscopic resection, there is a greater chance of retaining microscopic polyp tissue or diseased cells owing to the wide distribution of multiple polyps. These residual tissues may grow post-surgery, potentially leading to polyps[8]. Polyp morphology is an important predictor of post-surgery recurrence. Sessile polyps, which lack a distinct tip structure or a broader base, are particularly difficult to completely remove during endoscopic resection[29]. Furthermore, they may grow more aggressively, have higher cell proliferation activity, and have more complex biological behavior, increasing their likelihood of recurring after removal[30]. Previous research has suggested that the tissue microenvironment around barren polyps may be more conducive to polyp cell survival and growth. For instance, localized angiogenesis is more abundant, providing adequate nutritional support for polyp recurrence[31]. Moreover, in this study, adenomatous polyps were an important risk factor for recurrence. Adenomatous polyps have high cell proliferative activity and malignant potential, and their biological behavior differs significantly from that of normal tissue cells[32]. At the molecular level, adenomatous polyps often have multiple genetic alterations, including mutations in Adenomatous Polyposis Coli and activation of Kirsten Rat Sarcoma Viral Oncogene Homolog[33,34]. These genetic alterations disrupt the regulatory mechanisms underlying cell proliferation, differentiation, and apoptosis, resulting in continuous cell proliferation and increased viability. However, the cellular behavior of nonadenomatous polyps is relatively similar to that of normal tissues, with lower proliferative activity and a lower risk of recurrence. Taken together, there is a strong relationship between polyp number, morphology, pathological type, and the risk of recurrence after endoscopic surgery for CPs. Future studies should investigate the molecular mechanisms associated with these polyp characteristics and identify potential therapeutic targets for more effective prevention and control of polyp recurrence.
Nevertheless, this study has some limitations. First, this was a single-center, retrospective study, which may have been subject to selection and information biases. Second, the sample size was relatively small, which may have affected the extrapolation of the results. Moreover, the long-term predictive performance of the model could not be assessed because of the limited period of this study, which did not allow the long-term monitoring of recurrence. Future multicenter, large-sample prospective studies are warranted to improve the representativeness and reliability of the results. Simultaneously, the follow-up time should be extended to track the long-term recurrence of polyps to improve our understanding of the recurrence pattern of polyps and provide a more solid basis for developing more accurate and effective clinical intervention strategies.
CONCLUSION
The study findings indicate that CPs are important precancerous lesions of CRC, and their postoperative recurrence has been a focus of clinical concern. In this study, we retrospectively analyzed the clinical data of 362 patients with CPs. We discovered that age, alcohol consumption, H. pylori infection, number of polyps, the morphology of sessile polyps, and adenomatous pathological type were independent risk factors for recurrence within 1 year post-surgery. We created a nomogram prediction model based on these factors. The model showed good discriminatory and calibration abilities and could provide clinicians with an individualized recurrence risk assessment tool. The study findings can help clinicians to accurately assess the patient’s recurrence risk pre-surgery to formulate a more personalized treatment and follow-up strategy, optimize the allocation of medical resources, reduce the recurrence rate, and ultimately improve the long-term prognosis of patients.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade C
Creativity or Innovation: Grade B
Scientific Significance: Grade C
P-Reviewer: Schizas D S-Editor: Qu XL L-Editor: A P-Editor: Wang CH
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