Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
Am J Gastroenterol. 2019 Aug;114(8):1219-1230. doi: 10.14309/ajg.0000000000000156.
Accurate, real-time, endoscopic risk stratification of colorectal polyps would improve decision-making and optimize clinical efficiency. Technologies to manipulate endoscopic optical outputs can be used to predict polyp histology in vivo; however, it remains unclear how accuracy has progressed and whether it is sufficient for routine clinical implementation.
A meta-analysis was conducted by searching MEDLINE, Embase, and the Cochrane Library. Studies were included if they prospectively deployed an endoscopic optical technology for real-time in vivo prediction of adenomatous colorectal polyps. Polyposis and inflammatory bowel diseases were excluded. Bayesian bivariate meta-analysis was performed, presenting 95% confidence intervals (CI).
One hundred two studies using optical technologies on 33,123 colorectal polyps were included. Digital chromoendoscopy differentiated neoplasia (adenoma and adenocarcinoma) from benign polyps with sensitivity of 92.2% (90.6%-93.9% CI) and specificity of 84.0% (81.5%-86.3% CI), with no difference between constituent technologies (narrow-band imaging, Fuji intelligent Chromo Endoscopy, iSCAN) or with only diminutive polyps. Dye chromoendoscopy had sensitivity of 92.7% (90.1%-94.9% CI) and specificity of 86.6% (82.9%-89.9% CI), similarly unchanged for diminutive polyps. Spectral analysis of autofluorescence had sensitivity of 94.4% (84.0%-99.1% CI) and specificity of 50.9% (13.2%-88.8% CI). Endomicroscopy had sensitivity of 93.6% (85.3%-98.3% CI) and specificity of 92.5% (81.8%-98.1% CI). Computer-aided diagnosis had sensitivity of 88.9% (74.2%-96.7% CI) and specificity of 80.4% (52.6%-95.7% CI). Prediction confidence and endoscopist experience alone did not significantly improve any technology. The only subgroup to demonstrate a negative predictive value for adenoma above 90% was digital chromoendoscopy, making high confidence predictions of diminutive recto-sigmoid polyps. Chronologic meta-analyses show a falling negative predictive value over time. A significant publication bias exists.
This novel approach to meta-analysis demonstrates that existing optical technologies are increasingly unlikely to allow safe "resect and discard" strategies and that step-change innovation may be required. A "diagnose and leave" strategy may be supported for diminutive recto-sigmoid polyps diagnosed with high confidence; however, limitations exist in the evidence base for this cohort.
准确、实时的内镜结直肠息肉危险分层将改善决策并优化临床效率。用于操纵内镜光学输出的技术可用于预测体内息肉的组织病理学；然而，目前尚不清楚准确性的进展情况，以及它是否足以用于常规临床实施。
通过搜索 MEDLINE、Embase 和 Cochrane 图书馆进行荟萃分析。前瞻性地使用内镜光学技术实时预测腺瘤性结直肠息肉的研究被纳入。排除息肉病和炎症性肠病。进行贝叶斯双变量荟萃分析，呈现 95%置信区间 (CI)。
共纳入 102 项研究，涉及 33123 个结直肠息肉，使用光学技术。数字 chromoendoscopy 区分肿瘤（腺瘤和腺癌）和良性息肉的敏感性为 92.2%（90.6%-93.9%CI），特异性为 84.0%（81.5%-86.3%CI），不同技术（窄带成像、富士智能 chromo Endoscopy、iSCAN）之间没有差异，也与微小息肉无关。染料 chromoendoscopy 的敏感性为 92.7%（90.1%-94.9%CI），特异性为 86.6%（82.9%-89.9%CI），微小息肉的情况类似。自发荧光的光谱分析的敏感性为 94.4%（84.0%-99.1%CI），特异性为 50.9%（13.2%-88.8%CI）。内窥显微镜的敏感性为 93.6%（85.3%-98.3%CI），特异性为 92.5%（81.8%-98.1%CI）。计算机辅助诊断的敏感性为 88.9%（74.2%-96.7%CI），特异性为 80.4%（52.6%-95.7%CI）。预测信心和内镜医生的经验本身并不能显著提高任何技术的性能。唯一证明腺瘤阴性预测值超过 90%的亚组是数字 chromoendoscopy，这使得直肠乙状结肠微小息肉的高置信度预测成为可能。时间荟萃分析表明，阴性预测值随时间呈下降趋势。存在显著的发表偏倚。
这种新的荟萃分析方法表明，现有的光学技术不太可能允许安全的“切除和丢弃”策略，可能需要进行重大创新。对于用高置信度诊断的微小直肠乙状结肠息肉，可以支持“诊断和保留”策略；然而，该队列的证据基础存在局限性。
