Magnitude, Risk Factors, and Factors Associated With Adenoma Miss Rate of Tandem Colonoscopy: A Systematic Review and Meta-analysis

Shengbing Zhao; Shuling Wang; Peng Pan; Tian Xia; Xin Chang; Xia Yang; Liliangzi Guo; Qianqian Meng; Fan Yang; Wei Qian; Zhichao Xu; Yuanqiong Wang; Zhijie Wang; Lun Gu; Rundong Wang; Fangzhou Jia; Jun Yao; Zhaoshen Li; Yu Bai

doi:10.1053/j.gastro.2019.01.260

Magnitude, Risk Factors, and Factors Associated With Adenoma Miss Rate of Tandem Colonoscopy: A Systematic Review and Meta-analysis

Gastroenterology. 2019 May;156(6):1661-1674.e11. doi: 10.1053/j.gastro.2019.01.260. Epub 2019 Feb 6.

Authors

Shengbing Zhao¹, Shuling Wang², Peng Pan², Tian Xia³, Xin Chang², Xia Yang⁴, Liliangzi Guo⁵, Qianqian Meng⁶, Fan Yang², Wei Qian², Zhichao Xu², Yuanqiong Wang², Zhijie Wang², Lun Gu², Rundong Wang², Fangzhou Jia², Jun Yao⁷, Zhaoshen Li⁸, Yu Bai⁹

Affiliations

¹ 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.
² Department of Gastroenterology, Changhai Hospital, Second Military Medical University and Naval Medical University, Shanghai, China.
³ 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.
⁴ Department of Gastroenterology, Changhai Hospital, Second Military Medical University and Naval Medical University, Shanghai, China; Department of Gastroenterology, Number 905 Hospital of The Chinese PLA, Shanghai, China.
⁵ Department of Gastroenterology, Shenzhen People's Hospital, Shenzhen, China.
⁶ 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 Quality Control Center of Digestive Endoscopy, Shanghai, China.
⁷ Department of Gastroenterology, Shenzhen People's Hospital, Shenzhen, China. Electronic address: yj_1108@126.com.
⁸ 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; National Quality Control Center of Digestive Endoscopy, Shanghai, China. Electronic address: li.zhaoshen@hotmail.com.
⁹ 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. Electronic address: baiyu1998@hotmail.com.

PMID: 30738046
DOI: 10.1053/j.gastro.2019.01.260

Abstract

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.

Keywords: Interval Cancer; Missed Lesions; Prevention; Quality Indicators.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review

MeSH terms

Adenoma / diagnostic imaging*
Adenoma / pathology
Colon / pathology
Colonic Polyps / diagnostic imaging*
Colonic Polyps / pathology
Colonoscopy*
Colorectal Neoplasms / diagnostic imaging*
Colorectal Neoplasms / pathology
Diagnostic Errors / statistics & numerical data*
Humans
Risk Factors
Tumor Burden