Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas, USA.
Gastroenterology and Hepatology, University of Texas Medical Branch Galveston, Galveston, Texas, USA.
Gastrointest Endosc. 2019 Mar;89(3):453-459.e3. doi: 10.1016/j.gie.2018.09.006. Epub 2018 Sep 14.
Right-sided lesions are often missed during standard colonoscopy (SC). A second forward-view examination or retroflexion in the right side of the colon have both been proposed as techniques to improve adenoma detection rate (ADR) in the right side of the colon. Comparative data on examining the right side of the colon with a second forward view or retroflexion is not known in a pooled analysis. We performed a systematic review of the literature to assess the yield of a second forward view compared with retroflexion examination for the detection of right-sided adenomas.
A systematic literature search was performed using the following databases: PubMed, Embase, Web of Science, and Cochrane. Only full-length published articles that provided information on adenoma detection and miss rates during either a second forward view or retroflexed view of the right side of the colon after the initial standard forward withdrawal (SC) were included. The following outcomes were assessed: comparison of adenoma miss rate (AMR) for second forward view versus retroflexion after SC, AMR of SC compared with second forward view, AMR of SC compared with retroflexion, and right-sided adenoma detection with second forward view and retroflexion. Pooled rates were reported as risk difference or odds ratios (OR) with 95% confidence intervals (CI) with a P value <.05 indicating statistical significance. Statistical analysis was performed with Review Manager v5.3.
We identified 4 studies with 1882 patients who underwent a second forward view of the right side of the colon after an initial SC. The average age of the patients was 58.3 years. Data on right-sided ADR were available from all 4 studies for the second forward view; however, only 2 of the studies provided information on right-sided ADR with retroflexion. The pooled estimate of AMR of a single SC was 13.3% (95% CI, 6.6%-20%) compared with a second forward-view examination (n = 4), whereas it was 8.1% (3.7%-12.5%) compared with a retroflexion examination (n = 3). However, when the second forward view was compared with retroflexion in terms of AMR from an analysis of 3 eligible studies, there was no statistically significant difference (7.3% vs 6.3%; pooled OR, 1.2; 95% CI, 0.9-1.61; P = .21). Second forward view of the right side of the colon increased the right-sided ADR by 10% (n = 4; second forward view vs SC, 33.6% vs 26.7%) with a pooled risk difference of 0.09 (95% CI, 0.03-0.15; P < .01). Retroflexion increased the right-sided ADR by 6% (n = 3; retroflexion vs SC, 28.4% vs 22.7%) with a pooled risk difference of 0.06 (95% CI, 0.03-0.09; P < 01).
After SC withdrawal, a second forward view and retroflexed view of the right side of the colon are both associated with improvement in ADR. One of these techniques should be considered during SC to increase ADR and to improve the quality of colonoscopy.
标准结肠镜检查（SC）常漏诊右侧病变。有人提出在 SC 后进行第二次正向检查或结肠右侧反转，以提高右侧结肠腺瘤检出率（ADR）。但在荟萃分析中，尚无关于使用第二次正向检查与结肠右侧反转检查右侧结肠的比较数据。我们对文献进行了系统评价，以评估第二次正向检查与结肠右侧反转检查相比，在检测右侧腺瘤方面的效果。
我们使用以下数据库进行了系统文献检索：PubMed、Embase、Web of Science 和 Cochrane。仅纳入提供有关在初始标准正向撤回（SC）后进行第二次正向检查或结肠右侧反转时检测到的腺瘤和漏诊率信息的全文发表文章。评估的结果包括：第二次正向检查与 SC 后结肠右侧反转的腺瘤漏诊率（AMR）比较，SC 与第二次正向检查的 AMR 比较，SC 与结肠右侧反转的 AMR 比较，以及使用第二次正向检查和结肠右侧反转检测右侧腺瘤。汇总率以风险差异或比值比（OR）报告，并附有 95%置信区间（CI），P 值<.05 表示具有统计学意义。使用 Review Manager v5.3 进行统计学分析。
我们确定了 4 项研究，共纳入了 1882 名接受初始 SC 后进行右侧结肠第二次正向检查的患者。患者的平均年龄为 58.3 岁。4 项研究均提供了有关右侧 ADR 的数据，但只有 2 项研究提供了有关结肠右侧反转的右侧 ADR 数据。与单独的 SC 相比，第二次正向检查的单 SC AMR 汇总估计值为 13.3%（95% CI，6.6%-20%）（n=4），而与结肠右侧反转相比，其 AMR 为 8.1%（3.7%-12.5%）（n=3）。然而，当从 3 项合格研究的分析中比较第二次正向检查和结肠右侧反转的 AMR 时，差异无统计学意义（7.3% vs 6.3%；汇总 OR，1.2；95% CI，0.9-1.61；P=0.21）。右侧结肠的第二次正向检查使右侧 ADR 提高了 10%（n=4；第二次正向检查与 SC 相比，33.6% vs 26.7%），汇总风险差异为 0.09（95% CI，0.03-0.15；P<.01）。结肠右侧反转使右侧 ADR 提高了 6%（n=3；结肠右侧反转与 SC 相比，28.4% vs 22.7%），汇总风险差异为 0.06（95% CI，0.03-0.09；P<.01）。
在 SC 撤回后，第二次正向检查和结肠右侧反转均与 ADR 提高相关。在 SC 期间，应考虑使用其中一种技术以提高 ADR 并提高结肠镜检查的质量。
