结肠镜检查中腺瘤漏诊率的大小、危险因素及相关因素：系统评价和荟萃分析。
Magnitude, Risk Factors, and Factors Associated With Adenoma Miss Rate of Tandem Colonoscopy: A Systematic Review and Meta-analysis.
机构信息
Department of Gastroenterology, Changhai Hospital, Second Military Medical University and Naval Medical University, Shanghai, China; Digestive Endoscopy Center, Changhai Hospital, Naval and Second Military Medical University, Shanghai, China; National Clinical Research Center for Digestive Diseases, Shanghai, China.
Department of Gastroenterology, Changhai Hospital, Second Military Medical University and Naval Medical University, Shanghai, China.
出版信息
Gastroenterology. 2019 May;156(6):1661-1674.e11. doi: 10.1053/j.gastro.2019.01.260. Epub 2019 Feb 6.
BACKGROUND & AIMS: We performed a systematic review and meta-analysis to comprehensively estimate adenoma miss rate (AMR) and advanced AMR (AAMR) and explore associated factors.
METHODS
We searched the PubMed, Web of Science, and Ovid EMBASE databases for studies published through April 2018 on tandem colonoscopies, with AMR and AAMR as the primary outcomes. We performed meta-regression analyses to identify risk factors and factors associated with outcome. Primary outcomes were AMR and AAMR and secondary outcomes were AMR and AAMR for different locations, sizes, pathologies, morphologies, and populations.
RESULTS
In a meta-analysis of 43 publications and more than 15,000 tandem colonoscopies, we calculated miss rates of 26% for adenomas (95% confidence interval [CI] 23%-30%), 9% for advanced adenomas (95% CI 4%-16%), and 27% for serrated polyps (95% CI 16%-40%). Miss rates were high for proximal advanced adenomas (14%; 95% CI 5%-26%), serrated polyps (27%; 95% CI 16%-40%), flat adenomas (34%; 95% CI 24%-45%), and in patients at high risk for colorectal cancer (33%; 95% CI 26%-41%). Miss rates could be decreased by adequate bowel preparation and auxiliary techniques (P = .06; P = .04, and P = .01, respectively). The adenoma detection rate (ADR), adenomas per index colonoscopy, and adenomas per positive index colonoscopy (APPC) were independently associated with AMR (P = .02, P = .01, and P = .008, respectively), whereas APPC was the only factor independently associated with AAMR (P = .006). An APPC value greater than 1.8 was more effective in monitoring AMR (31% vs 15% for AMR P < .0001) than an ADR value of at least 34% (27% vs 17% for AMR; P = .008). The AAMR of colonoscopies with an APPC value below 1.7 was 35%, vs 2% for colonoscopies with an APPC value of at least 1.7 (P = .0005).
CONCLUSIONS
In a systematic review and meta-analysis, we found that adenomas and advanced adenomas are missed (based on AMR and AAMR) more frequently than previously believed. In addition to ADR, APPC deserves consideration as a complementary indicator of colonoscopy quality, if it is validated in additional studies.
背景与目的
我们进行了一项系统评价和荟萃分析，以全面评估腺瘤遗漏率（AMR）和高级腺瘤遗漏率（AAMR），并探讨相关因素。
方法
我们检索了PubMed、Web of Science 和 Ovid EMBASE 数据库，以获取截至 2018 年 4 月发表的关于串联结肠镜检查的研究，主要结局为 AMR 和 AAMR。我们进行了荟萃回归分析，以确定风险因素和与结果相关的因素。主要结局为 AMR 和 AAMR，次要结局为不同部位、大小、病理、形态和人群的 AMR 和 AAMR。
结果
在对 43 篇文献和超过 15000 例串联结肠镜检查进行的荟萃分析中，我们计算出腺瘤的漏诊率为 26%（95%置信区间[CI]为 23%-30%），高级腺瘤的漏诊率为 9%（95%CI 为 4%-16%），锯齿状息肉的漏诊率为 27%（95%CI 为 16%-40%）。近端高级腺瘤（14%；95%CI 为 5%-26%）、锯齿状息肉（27%；95%CI 为 16%-40%）、扁平腺瘤（34%；95%CI 为 24%-45%）和结直肠癌高危患者（33%；95%CI 为 26%-41%）的漏诊率较高。充分的肠道准备和辅助技术可降低漏诊率（P=0.06；P=0.04，P=0.01，分别）。腺瘤检出率（ADR）、每例结肠镜检查的腺瘤数和每例阳性结肠镜检查的腺瘤数（APPC）与 AMR 独立相关（P=0.02，P=0.01，P=0.008，分别），而 APPC 是唯一与 AAMR 独立相关的因素（P=0.006）。APPC 值大于 1.8 比 ADR 值至少为 34%（AMR 的 P<0.0001）更能有效监测 AMR（31%对 15%），APPC 值至少为 1.7 的 AAMR 为 2%（AMR 的 P=0.008）。APPC 值低于 1.7 的结肠镜检查的 AAMR 为 35%，而 APPC 值至少为 1.7 的结肠镜检查的 AAMR 为 2%（P=0.0005）。
结论
在一项系统评价和荟萃分析中，我们发现腺瘤和高级腺瘤的漏诊（基于 AMR 和 AAMR）比以前认为的更频繁。除 ADR 外，如果在其他研究中得到验证，APPC 作为结肠镜质量的补充指标也值得考虑。
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