Kamran Umair, King Dominic, Abbasi Abdullah, Coupland Ben, Umar Nosheen, Chapman Warren C, Hebbar Srisha, Trudgill Nigel J
Department of Gastroenterology, Sandwell and West Birmingham NHS Trust, West Bromwich, UK.
Department of Gastroenterology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK.
Endoscopy. 2023 Feb;55(2):109-118. doi: 10.1055/a-1917-0192. Epub 2022 Aug 31.
Missing upper gastrointestinal cancer (UGIC) at endoscopy may prevent curative treatment. We have developed a root cause analysis system for potentially missed UGICs at endoscopy (post-endoscopy UGIC [PEUGIC]) to establish the most plausible explanations. METHODS : The electronic records of patients with UGIC at two National Health Service providers were examined. PEUGICs were defined as UGICs diagnosed 6-36 months after an endoscopy that did not diagnose cancer. An algorithm based on the World Endoscopy Organization post-colonoscopy colorectal cancer algorithm was developed to categorize and identify potentially avoidable PEUGICs. RESULTS : Of 1327 UGICs studied, 89 (6.7 %) were PEUGICs (patient median [IQR] age at endoscopy 73.5 (63.5-81.0); 60.7 % men). Of the PEUGICs, 40 % were diagnosed in patients with Barrett's esophagus. PEUGICs were categorized as: A - lesion detected, adequate assessment and decision-making, but PEUGIC occurred (16.9 %); B - lesion detected, inadequate assessment or decision-making (34.8 %); C - possible missed lesion, endoscopy and decision-making adequate (8.9 %); D - possible missed lesion, endoscopy or decision-making inadequate (33.7 %); E - deviated from management pathway but appropriate (5.6 %); F - deviated inappropriately from management pathway (3.4 %). The majority of PEUGICs (71 %) were potentially avoidable and in 45 % the cancer outcome could have been different if it had been diagnosed on the initial endoscopy. There was a negative correlation between endoscopists' mean annual number of endoscopies and the technically attributable PEUGIC rate (correlation coefficient -0.57; = 0.004). CONCLUSION : Missed opportunities to avoid PEUGIC were identified in 71 % of cases. Root cause analysis can standardize future investigation of PEUGIC and guide quality improvement efforts.
在内镜检查中漏诊上消化道癌（UGIC）可能会妨碍进行根治性治疗。我们开发了一种针对内镜检查时可能漏诊的UGIC（内镜检查后UGIC [PEUGIC]）的根本原因分析系统，以确定最合理的解释。
检查了两家国民医疗服务体系提供者处UGIC患者的电子记录。PEUGIC被定义为在内镜检查未诊断出癌症后的6至36个月内被诊断出的UGIC。开发了一种基于世界内镜组织结肠镜检查后结直肠癌算法的算法，对潜在可避免的PEUGIC进行分类和识别。
在研究的1327例UGIC中，89例（6.7%）为PEUGIC（内镜检查时患者年龄中位数[四分位间距]为73.5岁[63.5 - 81.0岁]；男性占60.7%）。在PEUGIC中，40%在患有巴雷特食管的患者中被诊断出来。PEUGIC被分类为：A - 病变被检测到，评估和决策充分，但仍发生了PEUGIC（16.9%）；B - 病变被检测到，评估或决策不充分（34.8%）；C - 可能漏诊的病变，内镜检查和决策充分（8.9%）；D - 可能漏诊的病变，内镜检查或决策不充分（33.7%）；E - 偏离管理路径但合理（5.6%）；F - 不适当偏离管理路径（3.4%）。大多数PEUGIC（71%）是潜在可避免的，如果在初次内镜检查时就诊断出癌症，45%的癌症结局可能会有所不同。内镜医师的年均内镜检查次数与技术上可归因的PEUGIC发生率之间存在负相关（相关系数 -0.57；P = 0.004）。
在71%的病例中发现了避免PEUGIC的错失机会。根本原因分析可以规范未来对PEUGIC的调查，并指导质量改进工作。
