常规白光内镜检查中结直肠腺瘤漏诊相关因素分析

Risk factors for miss rate of colorectal adenomas during conventional colonoscopy

目的分析结肠镜检查中可能存在的腺瘤漏诊因素。方法回顾性分析2012年11月至2016年3月间在本院消化内镜中心行结肠镜检查后发现息肉，并在半年内接受第2次结肠镜检查，同时切除所发现息肉的患者资料，收集患者性别、年龄、肠镜间隔时间等信息，记录两次结肠镜发现腺瘤的数量、大小、形态、解剖部位、组织类型、退镜时间、肠道准备等情况。先用卡方检验评价分析腺瘤漏诊情况以及相关危险因素，进一步用Logistic回归进行多因素分析。结果共981例患者符合入选标准，其中男604例，漏诊率38．9％（235／604），女377例，漏诊率27．9％（105／377）（P〈0.01）。年龄25～87岁，平均（61．0±9．7）岁，〈65岁的患者中漏诊率为31．5％（195／619），≥65岁的患者中漏诊率为40．1％（145／362）（P〈0.01）。首次结肠镜检查共发现1728枚腺瘤，第2次结肠镜检查共发现2267枚腺瘤，腺瘤漏诊率23．8％（539／2267）。≤5mm腺瘤漏诊311枚，漏诊率42．5％（311／732）；6～9mm腺瘤漏诊194枚，漏诊率17．8％（194／1090）；≥10mm腺瘤漏诊34枚，漏诊率7．6％（34／445）（P〈0.01）。广基型腺瘤漏诊489枚，漏诊率28．4％（489／1720）；亚蒂型腺瘤漏诊24枚，漏诊率9．3％（24／235）；有蒂型腺瘤漏诊12枚，漏诊率6．6％（12／182）；侧向发育型肿瘤漏诊6枚，漏诊率9．0％（6／67）；平坦型腺瘤漏诊8枚，漏诊率20．5％（8／39）（P〉0.05）。漏诊腺瘤较多的部位分别是降结肠、升结肠和横结肠，漏诊率分别为27．8％（64／230）、25．5％（120／470）、25．5％（161／632）。高危腺瘤患者中漏诊率为44．8％（277／618），低危腺瘤患者中漏诊率为17．4％（63／363）（P〈0.01）。漏诊最多的是管状腺瘤，占83．3％，449例漏诊者其漏诊率达到26．9％（449／1671）（P〈0.01）。肠道准备充分者漏诊率30．2％（271／897）；肠道准备不充分者漏诊率82．1％（69／84）（P〈0.01）。退镜观察充分的病例漏诊率24．3％（174／717），退镜观察不充分的病例漏诊率62．9％（166／264）（P〈0．01）。结论男性、65岁以上、腺瘤直径≤5mm、肠道准备差、退镜观察时间不充分、广基腺瘤及高危腺瘤，均是漏诊的危险因素，而腺瘤形态差异、肠道的不同部位并非漏诊的危险因素。

Objective To determine risk factors for the miss rate of colorectal adenomas during colonoscopy. Methods A total of 981 patients, diagnosed as having at least one polyp in colonoscopy, received a second colonoscopy in 6 months from November 2012 to March 2016. All polyps were removed in the second colonoscopy. Bio-information of patients such as sex, age, surveillance interval and features of polyps such as number, size, shape, location, pathology, withdrawal time, bowel preparation was retrospectively analyzed. Factors associated with the miss rates in these patients were analyzed with Chisquare and was also analyzed with Logistic regression model for multiple factors. Results A total of 981 patients were selected according to the inclusion and exclusion criteria, including 604 males and 377 females. Miss rates of males and females were 38.9% （235/604） and 27.9% （105/377） （P〈0. 01 ）respectively. Age ranged from 25 to 87 years with mean age being 61.0±9.7 years. Miss rates of senior patients 〈65 and ≥65 years were 31.5 % （ 195/619） and 40. 1% （ 145/362 ） respectively （ P〈 0. 01 ）. A total of 1 728 adenomas were found in first colonoscopy. A total of 2 267 adenomas were found in the second colonoscopy. The adenoma miss rate was 23.8% （ 539/2 267）. The miss rate of adenoma whose size ≤ 5 mm was 42. 5% （311/732） ; and that of larger size of 6 to 9 mm was 17.8% （ 194/1 090） ; that of even larger size, i.e., ≥ 10 mm, was 7. 6%（34/445） （P〈0. 01）. Miss rates of Is, Isp, Ip, LST and II adenomas in shape were 28.4%（489/1 720）, 9. 3%（24/235）, 6. 6% （ 12/182）, 9. 0% （6/67） 20. 5% （8/39） respectively （P〉 0. 05）. Location with highest adenoma miss rate were descending colon, ascending colon and transverse colon, 27.8%（64/230）, 25.5%（ 120/470）, 25.5% （161/632） respectively. Miss rates of high and low risk adenoma were 44. 8% （ 277/618 ） and 17.4% （ 63/363 ） （ P〈0. 01 ）. The highest adenoma miss rate of all the pathology type was tubular adenoma. The adenoma miss rate was 26. 9%（449/1 671） （P〈0. 01）. Miss rates of good and poor bowel preparation were 30.2% （ 271/897 ） and 82. 1% （69/84） （ P 〈 0.01 ）. Miss rates of adequate and inadequate withdrawal time were 24. 3% （174/717） and 62. 9% （166/264） （P〈0. 01 ）. Conclusion Male, old-age, diameter ≤ 5 mm, poor bowel preparation and inadequate withdrawal time, high risk adenoma are the risk factors for missed adenoma. But the shape and location of adenoma are not the risk factors.