大连提高内镜下腺瘤检出率的一些经验
提高内镜下腺瘤检出率的一些经验
腺瘤检出率（ADR）是所有内镜医师持续监控的关键质量指标[1]。根据近期指标推荐，患者初次筛查结肠镜时，男性的目标腺瘤检出率≥30%，而女性≥20%[1-2]。而最新推荐指标，要求男性腺瘤检出率＞50%，女性≥20%[3]。较高的腺瘤检出率是至关重要的，Corley和同事们的报告显示，腺瘤检出率每提高1%，在随后十年内患者结肠癌风险下降3%[4]。
内镜医师的腺瘤检出率水平可以通过多种方法提高。首先，是肠道准备情况进行评估。多项研究结果显示，腺瘤检出受限于肠道准备是否充分，中高质量的结肠准备可以提高结肠腺瘤检出率[5-6]。最近质量监控要求充分的肠道准备必须达到85%以上。一项充分研究的评分系统，即波士顿肠道准备评分系统（Boston Bowel Preparation Scale System）可以对肠道准备进行标准的评估[7]。这种评分迅速允许内镜医师对患者肠道准备情况评估，确定是否可检出足够的腺瘤，或重新行肠道准备。
第二，是在结肠镜检查过程中对右半结肠评估。研究显示右半结肠癌的漏诊率较高[8-9]。通常来说，升结肠的粘膜褶皱较深而导致难以评估，特别是对于无蒂的锯齿样腺瘤。一种可以提高腺瘤检出率的重要的操作步骤是在右半结肠检查时翻转内镜视野，但目前支持这项检查技术的研究仍有限。Hewett和Rex研究报道称，与翻转内镜视野操作相比，右半结肠内镜检查中正向视野检查的漏诊率达9.8%[10-11]。
同样重要的是，观查屏幕发现腺瘤的人数。Aslanian和同事们指出，当护士同时被要求协助内镜医师共同查找腺瘤时，腺瘤检出率提高了1.28倍[12]。
多项研究评估ADR和退镜时间之间的关系。一些初始研究显示，较高ADR要求最少退镜时间为7-9分钟[13-14]。Sawhney和同事们的研究报道，在ADR方面退镜时间为7min和大于7min之间并无差异[15]。
其他一些提高ADR的技术包括结肠镜检查进行录像，提供内镜医师自己的ADR报告单，同时将他们的报告单与同行进行比较[16-17]。虽然还未开始广泛开展，目前侧重结肠镜设备来提高腺瘤检出率已在进行。这包括更新的结肠镜，Third Eye Retroscope（Avantis Medical Systems,Inc.，Sunnyvale，CA）、第三只眼全景结肠镜，和全光谱内镜检查（FUSE；EndoChoice，Inc.，Alpharetta，GA）均可以增强内镜下结肠粘膜的观察并且可以提供结肠粘膜更加全面的检查信息[18-20]。类似的，内镜下透明帽辅助检查（Endocuff；ARC Medical，Leeds，UK）、EndoRings（Endo-Aid，Caesarea，Israel）和气囊辅助结肠镜检查（NaviAid G-EYE；Smart Medical Systems，Ra’anana，Israel）均可以很好地观察粘膜皱襞平坦型病变，从而获得更好的观察效果及腺瘤检出率[21-22]。所有这些措施均需花费较高成本，为达到要求的较高腺瘤检出率，内镜医师也需要一个学习的曲线过程。
最后，对于结肠癌筛查来说，最重要的是足够多的结肠腺瘤检出。另外在结肠镜检查方面没有比全面细致的全结肠粘膜观察更加重要。
参考文献：
[1]Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2015;110(1):72-90.
[2]Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the us multi-society task force on colorectal cancer. Am J Gastroenterol. 2002;97(6):1296-1308.
[3]Kahi CJ, Vemulapalli KC, Johnson CS, Rex DK. Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience. Gastrointest Endosc. 2014;79(3):448-454.
[4]Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370(14):1298-1306.
[5]Chokshi RV, Hovis CE, Hollander T, et al. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest Endosc. 2012;75(6):1197-1203.
[6]Lebwohl B, Kastrinos F, Glick M, et al. The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. Gastrointest Endosc. 2011;73(6):1207-1214.
[7]Lai EJ, Calderwood AH, Doros G, et al. The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc. 2009;69(3):620-625.
[8]Brenner H, Hoffmeister M, Arndt V, et al. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst. 2010;102(2):89-95.
[9]Bressler B, Paszat LF, Vinden C, et al. Colonoscopic miss rates for right-sided colon cancer: a population-based analysis. Gastroenterology. 2004;127(2):452-456.
[10]Hewett DG, Rex DK. Miss rate of right-sided colon examination during colonoscopy defined by retroflexion: an observational study. Gastrointest Endosc. 2011;74(2):246-252.
[11]Kushnir VM, Oh YS, Hollander T, et al. Impact of retroflexion vs. second forward view examination of the right colon on adenoma detection: a comparison Study. Am J Gastroenterol. 2015;110(3):415-422.
[12]Aslanian HR, Shieh FK, Chan FW, et al. Nurse observation during colonoscopy increases polyp detection: a randomized prospective study. Am J Gastroenterol. 2013;108(2):166-172.
[13]Barclay RL, Vicari JJ, Doughty AS, et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med. 2006;355(24):2533-2541.
[14]Butterly L, Robinson CM, Anderson JC, et al. Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the new hampshire colonoscopy registry. Am J Gastroenterol. 2014;109(3):417-426.
[15]Sawhney MS, Cury MS, Neeman N, et al. Effect of institution-wide policy of colonoscopy withdrawal time ≥ 7 minutes on polyp detection. Gastroenterology. 2008;135(6):1892-1898.
[16]Rex DK, Hewett DG, Raghavendra M, Chalasani N. The impact of videorecording on the quality of colonoscopy performance: a pilot study. Am J Gastroenterol. 2010;105(11):2312-2317.
[17]Kahi CJ, Ballard D, Shah AS, et al. Impact of a quarterly report card on colonoscopy quality measures. Gastrointest Endosc. 2013;77(6):925-931.
[18]Gralnek IM, Siersema PD, Halpern Z, et al. Standard Forward-Viewing Colonoscopy Versus Full-Spectrum Endoscopy: An International, Multicentre, Randomised, Tandem Colonoscopy Trial. Lancet Oncol. 2014;15(3):353-360.
[19]Rubin M, Bose KP, Kim SH. Mo1517 successful deployment and use of Third Eye Panoramic? a novel side viewing video cap fitted on a standard colonoscope. Gastrointest Endosc. 2014;79(5):AB466.
[20]DeMarco DC, Odstrcil E, Lara LF, et al. Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: The Third Eye Retroscope Study Group. Gastrointest Endosc. 2010;71(3):542-550.
[21]Biecker E, Floer M, Heinecke A, et al. Novel endocuff-assisted colonoscopy significantly increases the polyp detection rate: a randomized controlled trial [published online June 20, 2014]. J Clin Gastroenterol. doi: 10.1097/MCG.0000000000000166.
[22]Hasan N, Gross SA, Gralnek IM, et al. A novel balloon colonoscope detects significantly more simulated polyps than a standard colonoscope in a colon model. Gastrointest Endosc. 2014;80(6):1135-1140.
编译自：MY APPROACH to Endoscopic Techniques to Improve the Adenoma Detection Rate，PracticeUpdate，April 14，2015
来源：医脉通
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