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结直肠腺瘤是结直肠癌的癌前疾病[1]。结直肠癌主要来自腺瘤和无蒂锯齿状腺瘤的癌变[2]。早期切除是预防结直肠癌的重要手段。切除的标本送病理检查能帮助内镜医生明确后续治疗方案,提出随访建议。目前在肠镜检查中发现息肉将尽量切除并送病理检查,依据肠镜下即时判断息肉组织学类型的光学诊断系统,如NICE分型,国外有较多研究[3-4]探索息肉处理的替代策略,即“切除-丢弃”策略(切除小腺瘤而不送病理检查)和“诊断-离开”策略(直乙结肠的增生性微小息肉(≤0.5 cm)可不处理)。NICE分型适用于放大及非放大NBI内镜,国内外有较多相关研究[5-9]证明其在预判非肿瘤性、肿瘤性结直肠息肉的诊断价值高。
与传统注气肠镜相比,有文献[10-11]表明注水肠镜或注水肠镜联合NBI能提高腺瘤检出率。这可能与注水条件下消除黏膜反光、结直肠息肉病变在水的浮力下更为凸显有关。故注水肠镜可能对非放大窄带成像(NBI)下NICE分型具有一定的积极影响。本研究回顾性分析经我中心日间病房收治并切除的结直肠小息肉病变,比较注水与注气结肠镜下非放大NBI下NICE分型的诊断价值,由此探索更合理高效的日间病房结直肠小息肉治疗策略。
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注水组结直肠息肉病变176枚,其中扁平息肉35枚,病理证实为肿瘤性息肉132枚(检出率75.00%);注气组273枚中扁平息肉32枚,病理证实为肿瘤性息肉219枚(检出率80.22%)。注水组扁平息肉检出率高于注气组(P < 0.05),2组腺瘤检出率和无蒂锯齿状腺瘤检出率差异均无统计学意义(P>0.05)(见图 2、表 1)。
分组 n 形态 病理类型 腺瘤检出 无蒂锯齿状腺瘤检出 0~Ⅰ 0~Ⅱ 非肿瘤性 肿瘤性 注水组 176 141(80.1) 35(19.9) 44(25.0) 132(75.0) 132(75.0) 4(2.3) 注气组 273 241(88.3) 32(11.7) 54(19.8) 219(80.2) 219(80.2) 7(2.6) χ2 — 5.62 1.71 1.71 0.04 P — < 0.05 >0.05 >0.05 >0.05 表 1 2组结直肠息肉检出情况[n;百分率(%)]
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由2名经验丰富的内镜医生分别对449枚结直肠息肉病变图片进行独立诊断,一致性检验结果提示Kappa值=0.807(注水组=0.812,注气组=0.773),一致性较好(见图 3、4,表 2)。最终的NICE分型结果由2名经验丰富的内镜医生共同讨论得出,病理检查证实,449枚结直肠息肉病变中非肿瘤性息肉98枚,肿瘤性息肉(包括4枚高级别上皮内瘤变)351枚,2组NICE分型诊断的敏感性、特异性、准确率见表 3。
分组 n 非肿瘤性 肿瘤性 Kappa 注水组 1 40 36 4 0.812 2 136 8 128 注气组 1 42 39 3 0.773 2 231 15 216 表 2 2组结直肠息肉NICE分型诊断的一致性检验(n)
分组 敏感性 特异性 准确率 阳性
预测值阴性
预测值注水组 97.0 81.8 94.3 94.1 90.0 注气组 98.6 72.0 93.4 93.5 92.9 表 3 2组结直肠息肉NICE分型诊断的敏感性、特异性和准确率(%)
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本研究也邀请了一名初学者,进行短期NICE分型培训后,以非放大NBI下NICE分型对同样的449枚结直肠息肉病变的图片进行诊断。结果显示,注水组、注气组在初学者以非放大NBI下NICE分型预判结直肠小息肉病理类型的准确率分别为56.8%、49.5%,2组差异无统计学意义(χ2=0.13,P>0.05)。以Kappa检验分别比较经验丰富的内镜医生及初学者对于注水组、注气组以非放大NBI下NICE分型预判病理类型的准确性,Kappa值分别为0.199、0.076,一致性均较低(见表 4),以病理结果为标准,其诊断敏感性、特异性和准确率亦均不佳(见表 5)。
分组 n 非肿瘤性 肿瘤性 注水组 1 96 35 64 2 80 12 68 注气组 1 152 34 118 2 121 20 101 表 4 初学者对2组NICE分型诊断(n)
分组 敏感性 特异性 准确率 阳性预测值 阴性预测值 注水组 51.5 72.7 56.8 85.0 33.3 注气组 46.1 63.0 49.5 83.0 22.4 表 5 初学者对2组结直肠息肉NICE分型诊断与病理诊断对照(%)
注水与注气肠镜+非放大NBI下NICE分型对于结直肠小息肉内镜下治疗的临床价值
Clinical value of NICE typing under water injection and gas injection colonoscopy plus non-magnifying narrow-band imaging for endoscopic treatment of small colorectal polyps
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摘要:
目的比较注水与注气结肠镜下非放大窄带成像(NBI)下NICE分型对于结直肠小息肉的诊断价值。 方法回顾性选取449枚结直肠小息肉,其中176枚为注水法肠镜下发现(注水组),273枚为注气法肠镜下发现(注气组)。观察2组病人留取的非放大NBI图像,应用NICE分型预判病理类型,并与病理检查结果进行分析对比。 结果2组腺瘤检出率差异无统计学意义(P>0.05),注水组扁平息肉检出率高于注气组(P < 0.05)。经验丰富的内镜医生对NICE分型诊断结果一致性较高(Kappa值=0.807),对注水组和注气组非放大NBI下NICE分型诊断的敏感性、特异性、准确率分别为97.0%(128/132)、81.8%(36/44)、94.3%(166/176)和98.6%(216/219)、72.0%(39/54)、93.4%(255/273)。初学者对注水组和注气组非放大NBI下NICE分型诊断的敏感性、特异性、准确率分别为51.5%(68/132)、72.7%(32/44)、56.8%(100/176)和46.1%(101/219)、63.0%(34/54)、49.5%(135/273)。初学者和经验丰富的内镜医生对2组NICE分型诊断结果一致性均较低(Kappa值=0.199、0.076)。 结论无论注水还是注气条件,经验丰富的内镜医生以非放大NBI下NICE分型能够很好地区分肿瘤性、非肿瘤性结直肠小息肉,诊断价值高,对于日间病房的息肉治疗策略有很好的指导意义。 Abstract:ObjectiveTo compare the diagnostic value of NICE typing under water injection and gas injection colonoscopy plus non-magnifying narrow-band imaging (NBI) in small colorectal polyps. MethodsA total of 449 small colorectal polyps were enrolled in this study.Among them, 176 cases were found by water injection colonoscopy(water injection group), and 273 cases were found by gas injection colonoscopy(gas injection group).Each lesion was observed by non-magnifying NBI, and the histology was predicted and compared according to NICE typing system. ResultsThere was no statistically significant difference in the examination results in the colorectal adenoma detection rate between the two groups(P>0.05), and the detection rate of flat polyps in the water injection group was higher than that in the gas injection group(P < 0.05).Experienced endoscopists had a high consistency in the diagnosis results of NICE typing(κ=0.807).The sensitivity, specificity and accuracy of NICE typing under non-magnifying NBI in the water injection group and the gas injection group were 97.0%(128/132), 81.8%(36/44), 94.3%(166/176) and 98.6%(216/219), 72.0%(39/54) and 93.4%(255/273), respectively.For novice endoscopists, the sensitivity, specificity and accuracy of NICE typing diagnosis under non-magnifying NBI in water injection group and gas injection group were 51.5%(68/132), 72.7% (32/44), 56.8% (100/176), 46.1%(101/219), 63.0%(34/54), 49.5%(135/273), respectively.The agreement of highly experienced endoscopists and novice endoscopists was low in two groups respectively(κ=0.199, 0.076). ConclusionsBetween whatever water or gas injection colonoscopy, NICE typing under non-magnifying NBI is effective in distinguishing neoplastic from non-neoplastic small colorectal polyps for highly experienced endoscopists, which has high diagnostic value and is instructive for treatment strategy of small colorectal polyps in ambulatory ward. -
表 1 2组结直肠息肉检出情况[n;百分率(%)]
分组 n 形态 病理类型 腺瘤检出 无蒂锯齿状腺瘤检出 0~Ⅰ 0~Ⅱ 非肿瘤性 肿瘤性 注水组 176 141(80.1) 35(19.9) 44(25.0) 132(75.0) 132(75.0) 4(2.3) 注气组 273 241(88.3) 32(11.7) 54(19.8) 219(80.2) 219(80.2) 7(2.6) χ2 — 5.62 1.71 1.71 0.04 P — < 0.05 >0.05 >0.05 >0.05 表 2 2组结直肠息肉NICE分型诊断的一致性检验(n)
分组 n 非肿瘤性 肿瘤性 Kappa 注水组 1 40 36 4 0.812 2 136 8 128 注气组 1 42 39 3 0.773 2 231 15 216 表 3 2组结直肠息肉NICE分型诊断的敏感性、特异性和准确率(%)
分组 敏感性 特异性 准确率 阳性
预测值阴性
预测值注水组 97.0 81.8 94.3 94.1 90.0 注气组 98.6 72.0 93.4 93.5 92.9 表 4 初学者对2组NICE分型诊断(n)
分组 n 非肿瘤性 肿瘤性 注水组 1 96 35 64 2 80 12 68 注气组 1 152 34 118 2 121 20 101 表 5 初学者对2组结直肠息肉NICE分型诊断与病理诊断对照(%)
分组 敏感性 特异性 准确率 阳性预测值 阴性预测值 注水组 51.5 72.7 56.8 85.0 33.3 注气组 46.1 63.0 49.5 83.0 22.4 -
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