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Article(id=1322954236157362846, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322954180431847810, articleNumber=null, orderNo=null, doi=10.16016/j.2097-0927.202509098, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1759075200000, receivedDateStr=2025-09-29, revisedDate=1763308800000, revisedDateStr=2025-11-17, acceptedDate=null, acceptedDateStr=null, onlineDate=1793346469200, onlineDateStr=2026-10-30, pubDate=1765728000000, pubDateStr=2025-12-15, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793346469200, onlineIssueDateStr=2026-10-30, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793346469200, creator=13701087609, updateTime=1793346469200, updator=13701087609, issue=Issue{id=1322954180431847810, tenantId=1146029695717560320, journalId=1319373162502258839, year='2025', volume='47', issue='23', pageStart='2881', pageEnd='3008', issueExtLink='null', onlineDate='null', pubDate='1765728000000', pubDateStr='2025-12-15', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793346455915, creator='13701087609', updateTime=1793346455915, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=2943, endPage=2952, ext={EN=ArticleExt(id=1322954238057382559, articleId=1322954236157362846, tenantId=1146029695717560320, journalId=1319373162502258839, language=EN, title=Assessing polyp miss rates and their determinants through same-day tandem colonoscopy in ambulatory care settings, columnId=1320435174995772212, journalTitle=Journal of Army Medical University, columnName=Clinical Medicine, runingTitle=null, highlight=null, articleAbstract=
Objective

To investigate polyp miss rate and influencing factors during colonoscopy using the opportunity of short-interval repeat examinations in day surgery settings.

Methods

This single-center retrospective cohort study consecutively enrolled 1 005 patients undergoing polypectomy at the Endoscopy Center of Army Medical University First Affiliated Hospital(March-June 2023). All patients received initial diagnostic colonoscopy followed by therapeutic colonoscopy(repeat examination). Using repeat examination findings as reference, we calculated patient miss rate, polyp miss rate, and adenoma patient miss rate. Multivariable logistic regression analyzed operator- and patient-related factors influencing patient miss rates.

Results

Patient miss rate, polyp miss rate, and adenoma miss rate were 26.67%(95%CI: 23.95~29.52), 16.45%(95%CI:15.26~17.70), and 15.52%(95%CI:13.34~17.91), respectively. Multivariable analysis identified independent risk factors— operator-related: initial procedure by junior endoscopists(OR=2.07, 95%CI: 1.42~3.03, P<0.001) and afternoon procedures(13:30-16:00; OR=1.68, 95%CI: 1.01~2.81, P=0.047); Patient-related: inadequate bowel preparation(OR=4.16, 95%CI: 2.28~7.61, P<0.001) and flat-type lesions(OR=4.33, 95%CI: 2.49~7.52, P<0.001). Reduced miss rates occurred with polyps 0.3~0.5 cm(OR=0.30, 95% CI: 0.21~0.41, P<0.001) and 0.6~0.9 cm(OR=0.10, 95%CI: 0.04~0.22, P<0.001). Inadequate preparation during therapeutic examination decreased polyp detection(OR=0.23, 95%CI: 0.10~0.53, P<0.001).

Conclusion

Colonoscopy exhibits significant polyp miss rates influenced by operator and patient factors. Standardized repeat examinations in day surgery settings effectively detect missed lesions, supporting long-term quality control.

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目的

利用日间治疗需要短期接受二次结肠镜检查的机会，探究结肠镜检查的息肉漏诊情况及可能的影响因素分析。

方法

本研究为单中心回顾性队列研究。连续纳入2025年3-6月于陆军军医大学第一附属医院消化内镜中心日间病房接受结肠镜下息肉切除术的1 005例患者。所有患者接受首次单纯结肠镜检查及内镜下治疗（二次检查）。将二次检查结果作为参照，计算结直肠息肉患者漏诊率、息肉漏诊率、腺瘤患者漏诊率；采用多因素Logistic回归模型分析操作医生及患者因素对漏诊的影响。

结果

患者漏诊率、息肉漏诊率、腺瘤患者漏诊率分别为26.67%（95%CI：23.95~29.52）、16.45%（95%CI：15.26~17.70）、15.52%（95%CI：13.34~17.91）。多因素分析显示，操作医生相关因素：首次检查由低年资医生操作（OR=2.07，95%CI：1.42~3.03，P<0.001）、首次检查时间段为13：30-16：00（OR=1.68，95%CI：1.01~2.81，P=0.047），患者相关因素：首次检查肠道准备不充分（OR=4.16，95%CI：2.28~7.61，P<0.001）、息肉为平坦型（OR=4.33，95%CI：2.49~7.52，P<0.001）是漏诊的独立危险因素；息肉大小为0.3~0.5 cm（OR=0.30，95%CI：0.21~0.41，P<0.001）、息肉大小为0.6~0.9 cm（OR=0.10，95%CI：0.04~0.22，P<0.001）时漏诊风险显著降低。而治疗时二次检查肠道准备不充分与漏诊息肉检出率显著降低相关（OR=0.23，95%CI：0.10~0.53，P<0.001）。

结论

结肠镜检查存在息肉漏诊的情况，漏诊率受操作医师及患者多个因素影响；日间治疗时的二次检查的标准化可检出漏诊息肉，长期监督结肠镜检查质量。

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陈磊，E-mail：
CHEN Lei，E-mail：
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Expert consensus on intestinal preparation for colonoscopy（2023，Guangzhou） ［J］. Chin J Dig Endosc，2023，40（06）：421-430., articleTitle=Expert consensus on intestinal preparation for colonoscopy（2023，Guangzhou）, refAbstract=null), Reference(id=1322954252888441591, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, doi=10.1055/s-0031-1291666, pmid=null, pmcid=null, year=2012, volume=44, issue=5, pageStart=470, pageEnd=475, url=null, language=null, rfNumber=31, rfOrder=40, authorNames=LEUFKENS A M, VAN OIJEN M G H, VLEGGAAR F P, journalName=Endoscopy, refType=null, unstructuredReference=LEUFKENS A M，VAN OIJEN M G H，VLEGGAAR F P，et al. Factors influencing the miss rate of polyps in a back-to-back colonoscopy study［J］. 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Chin J Dig Endosc，2025（5）：337-347., articleTitle=Expert consensus on outpatient management of colorectal polyps（2025，Chengdu）, refAbstract=null), Reference(id=1322954253186237178, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, doi=10.16016/j.1000-5404.201703077, pmid=null, pmcid=null, year=2017, volume=39, issue=18, pageStart=1832, pageEnd=1835, url=null, language=null, rfNumber=33, rfOrder=43, authorNames=刘俐, 杨梅, 张另, journalName=第三军医大学学报, refType=null, unstructuredReference=刘俐，杨梅，张另. 内镜下治疗结肠息肉在日间病房与住院病房中的回顾性病例对照研究［J］. 第三军医大学学报，2017，39（18）：1832-1835., articleTitle=内镜下治疗结肠息肉在日间病房与住院病房中的回顾性病例对照研究, refAbstract=null), Reference(id=1322954253278511867, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, doi=10.16016/j.1000-5404.201703077, pmid=null, pmcid=null, year=2017, volume=39, issue=18, pageStart=1832, pageEnd=1835, url=null, language=null, rfNumber=33, rfOrder=44, authorNames=LIU L, YANG M, ZHANG L, journalName=J Third Mil Med Univ, refType=null, unstructuredReference=LIU L，YANG M，ZHANG L. Endoscopic surgery for colorectal polyps between one-day ward and hospitalized ward：a retrospective case-control trail［J］. J Third Mil Med Univ，2017，39（18）：1832-1835., articleTitle=Endoscopic surgery for colorectal polyps between one-day ward and hospitalized ward：a retrospective case-control trail, refAbstract=null), Reference(id=1322954253593084668, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, doi=10.5946/ce.2022.037, pmid=null, pmcid=null, year=2022, volume=55, issue=3, pageStart=332, pageEnd=338, url=null, language=null, rfNumber=34, rfOrder=45, authorNames=PARK S B, CHA J M, journalName=Clin Endosc, refType=null, unstructuredReference=PARK S B，CHA J M. Quality indicators in colonoscopy：the chasm between ideal and reality［J］. Clin Endosc，2022，55（3）：332-338., articleTitle=Quality indicators in colonoscopy：the chasm between ideal and reality, refAbstract=null), Reference(id=1322954253681165053, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, doi=10.3760/cma.j.cn321463-20241017-00147, pmid=null, pmcid=null, year=2025, volume=42, issue=5, pageStart=414, pageEnd=420, url=null, language=null, rfNumber=35, rfOrder=46, authorNames=隋玥, 陈星, journalName=中华消化内镜杂志, refType=null, unstructuredReference=隋玥，陈星. 结肠镜检查质量指标及提升方法的研究进展［J］. 中华消化内镜杂志，2025，42（5）：414-420., articleTitle=结肠镜检查质量指标及提升方法的研究进展, refAbstract=null), Reference(id=1322954254369030910, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, doi=10.3760/cma.j.cn321463-20241017-00147, pmid=null, pmcid=null, year=2025, volume=42, issue=5, pageStart=414, pageEnd=420, url=null, language=null, rfNumber=35, rfOrder=47, authorNames=SUI Y, CHEN X, journalName=Chin J Dig Endosc, refType=null, unstructuredReference=SUI Y，CHEN X. Research progress in colonoscopy quality indicators and improvement methods ［J］. Chin J Dig Endosc，2025，42（5）：414-420., articleTitle=Research progress in colonoscopy quality indicators and improvement methods, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1322954239785435809, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, xref=1, ext=[AuthorCompanyExt(id=1322954239793824418, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, companyId=1322954239785435809, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Department of Gastroenterology，First Affiliated Hospital，Army Medical University （Third Military Medical University），Chongqing，China), AuthorCompanyExt(id=1322954239802213027, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, companyId=1322954239785435809, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1陆军军医大学（第三军医大学）第一附属医院消化内科，重庆)])], figs=[ArticleFig(id=1322954244990567109, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=EN, label=Table 1, caption=

Basic characteristics of the patients［n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicAP
（n=1 005）		PWMD
（n=268）		APWMD
（n=156）
Gender
Male542（53.93）150（55.97）90（57.69）
Female463（46.07）118（44.19）66（42.58）
Age/years
≤45225（22.39）51（19.10）20（12.82）
>45~59458（45.57）117（43.66）70（44.87）
≥60322（32.04）100（37.45）66（42.31）
EE（IE）
Senior482（47.96）148（55.22）90（57.69）
Junior523（52.04）120（44.94）66（42.31）
TS（IE）
8：00-11：00600（59.70）147（55.06）79（50.97）
11：01-12：00122（12.14）36（13.48）23（14.84）
13：30-16：00249（24.78）76（28.36）46（29.49）
16：01-17：0034（3.38）9（3.37）8（5.16）
Polyp number
Single424（42.19）97（36.19）51（32.69）
Multiple581（57.81）171（64.04）105（67.74）
BP（IE）
Adequate932（92.74）39（14.55）23（14.74）
Inadequate73（7.26）229（85.77）133（85.81）
BP（SE）
Adequate907（90.25）10（3.75）5（3.23）
Inadequate98（9.75）258（96.27）151（96.79）
PPT
Adenoma468（46.57）122（45.52）122（78.21）
Hyperplastic polyp282（28.06）78（29.10）0
Inflammatory polyp97（9.65）24（8.96）0
Juvenile polyp5（0.50）1（0.37）0
Adenocarcinoma1（0.10）1（0.37）0
Tubulovillous32（3.18）10（3.73）10（6.41）
Tubular adenoma91（9.05）24（8.96）24（15.38）
Serrated polyp28（2.89）8（2.99）0
), ArticleFig(id=1322954245087036102, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=CN, label=表1, caption=

患者基本特征表［例（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicAP
（n=1 005）		PWMD
（n=268）		APWMD
（n=156）
Gender
Male542（53.93）150（55.97）90（57.69）
Female463（46.07）118（44.19）66（42.58）
Age/years
≤45225（22.39）51（19.10）20（12.82）
>45~59458（45.57）117（43.66）70（44.87）
≥60322（32.04）100（37.45）66（42.31）
EE（IE）
Senior482（47.96）148（55.22）90（57.69）
Junior523（52.04）120（44.94）66（42.31）
TS（IE）
8：00-11：00600（59.70）147（55.06）79（50.97）
11：01-12：00122（12.14）36（13.48）23（14.84）
13：30-16：00249（24.78）76（28.36）46（29.49）
16：01-17：0034（3.38）9（3.37）8（5.16）
Polyp number
Single424（42.19）97（36.19）51（32.69）
Multiple581（57.81）171（64.04）105（67.74）
BP（IE）
Adequate932（92.74）39（14.55）23（14.74）
Inadequate73（7.26）229（85.77）133（85.81）
BP（SE）
Adequate907（90.25）10（3.75）5（3.23）
Inadequate98（9.75）258（96.27）151（96.79）
PPT
Adenoma468（46.57）122（45.52）122（78.21）
Hyperplastic polyp282（28.06）78（29.10）0
Inflammatory polyp97（9.65）24（8.96）0
Juvenile polyp5（0.50）1（0.37）0
Adenocarcinoma1（0.10）1（0.37）0
Tubulovillous32（3.18）10（3.73）10（6.41）
Tubular adenoma91（9.05）24（8.96）24（15.38）
Serrated polyp28（2.89）8（2.99）0
), ArticleFig(id=1322954246743786183, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=EN, label=Table 2, caption=

Basic characteristics of the polyps［x¯±s，n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicAll polyps
（n=3 623）		Missed polyps
（n=596）		Non-missed polyps（n=3 027）
Location
Ileocecum98（2.70）16（2.68）82（2.71）
Ascending colon330（9.11）40（6.71）290（9.58）
Hepatic flexure144（3.97）27（4.53）117（3.87）
Transverse colon702（19.38）93（15.60）609（20.12）
Descending colon226（6.24）31（5.20）195（6.44）
Sigmoid colon878（24.23）132（22.15）746（24.64）
Rectum1 245（34.36）257（43.12）988（32.64）
Size0.33±0.190.27±0.170.34±0.19
Size category/cm
0.1~0.21 499（41.37）348（58.39）1 151（38.02）
0.3~0.51 735（47.89）226（37.92）1 509（49.85）
0.6~0.9336（9.27）15（2.52）321（10.60）
1.0~1.949（1.35）6（1.01）43（1.42）
≥2.04（0.11）1（0.17）3（0.10）
Morphology
Protruded634（17.50）35（5.87）599（19.79）
Flat2 989（82.50）561（94.13）2 428（80.21）
), ArticleFig(id=1322954246852838088, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=CN, label=表2, caption=

息肉基本特征表［x¯±s，颗（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicAll polyps
（n=3 623）		Missed polyps
（n=596）		Non-missed polyps（n=3 027）
Location
Ileocecum98（2.70）16（2.68）82（2.71）
Ascending colon330（9.11）40（6.71）290（9.58）
Hepatic flexure144（3.97）27（4.53）117（3.87）
Transverse colon702（19.38）93（15.60）609（20.12）
Descending colon226（6.24）31（5.20）195（6.44）
Sigmoid colon878（24.23）132（22.15）746（24.64）
Rectum1 245（34.36）257（43.12）988（32.64）
Size0.33±0.190.27±0.170.34±0.19
Size category/cm
0.1~0.21 499（41.37）348（58.39）1 151（38.02）
0.3~0.51 735（47.89）226（37.92）1 509（49.85）
0.6~0.9336（9.27）15（2.52）321（10.60）
1.0~1.949（1.35）6（1.01）43（1.42）
≥2.04（0.11）1（0.17）3（0.10）
Morphology
Protruded634（17.50）35（5.87）599（19.79）
Flat2 989（82.50）561（94.13）2 428（80.21）
), ArticleFig(id=1322954246945112777, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=EN, label=Table 3, caption=

Univariate and multivariate analysis of patient miss rate

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicUnivariate analysisMultivariate analysis
Patient miss rate，%（95%CI）χ²PCoefficient（95%CI）OR（95%CI）P
Gender
Male27.68（24.08，31.59）0.610.434reference
Female25.49（21.73，29.65）-0.077（-0.396~0.242）0.93（0.67~1.27）0.637
Age/years
≤4522.67（17.68，28.57）5.310.070reference
45~5925.55（21.77，29.73）0.111（-0.313~0.545）1.12（0.73~1.72）0.611
≥6031.06（26.25，36.31）0.272（-0.181~0.731）1.31（0.83~2.08）0.242
IBE/d
Q124.46（20.58，28.81）2.780.250reference
Q226.28（21.42，31.79）-0.112（-0.558~0.329）0.89（0.57~1.39）0.620
Q329.94（25.14，35.22）0.035（-0.381~0.448）1.04（0.68~1.56）0.869
EE（IE）
Senior22.94（19.55，26.74）7.730.005reference
Junior30.71（26.75，34.96）0.410（0.095~0.727）1.51（1.10~2.07）0.011
TS（IE）
8：00-11：0024.50（21.23，28.10）3.840.280reference
11：01-12：0029.51（22.14，38.13）0.051（-0.481~0.570）1.05（0.62~1.77）0.848
13：30-16：0030.52（25.13，36.50）0.521（0.100~0.945）1.68（1.11~2.57）0.015
16：01-17：0026.47（14.60，43.12）0.119（-0.820~0.991）1.13（0.44~2.69）0.795
Polyp number
Single22.88（19.13，27.11）5.390.020reference
Multiple29.43（25.87，33.26）0.009（-0.327~0.345）1.01（0.72~1.41）0.959
BP（IE）
Adequate24.57（21.92，27.44）28.82<0.001reference
Inadequate53.42（42.10，64.41）1.168（0.623~1.718）3.21（1.86~5.58）<0.001
BP（SE）
Adequate28.45（25.61，31.47）15.05<0.001reference
Inadequate10.20（5.64，17.77）-1.492（-2.258~-0.827）0.22（0.10~0.44）<0.001
PPT
Adenoma26.40（23.00，30.09）0.410.938reference
Hyperplastic polyp27.66（22.77，33.15）0.171（-0.193~0.532）1.19（0.82~1.70）0.354
Inflammatory polyp24.74（17.23，34.18）-0.003（-0.571~0.540）1.00（0.56~1.72）0.991
Others28.57（16.33，45.05）0.242（-0.637~1.057）1.27（0.53~2.88）0.572
), ArticleFig(id=1322954247028998858, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=CN, label=表3, caption=

患者漏诊率单因素及多因素分析

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicUnivariate analysisMultivariate analysis
Patient miss rate，%（95%CI）χ²PCoefficient（95%CI）OR（95%CI）P
Gender
Male27.68（24.08，31.59）0.610.434reference
Female25.49（21.73，29.65）-0.077（-0.396~0.242）0.93（0.67~1.27）0.637
Age/years
≤4522.67（17.68，28.57）5.310.070reference
45~5925.55（21.77，29.73）0.111（-0.313~0.545）1.12（0.73~1.72）0.611
≥6031.06（26.25，36.31）0.272（-0.181~0.731）1.31（0.83~2.08）0.242
IBE/d
Q124.46（20.58，28.81）2.780.250reference
Q226.28（21.42，31.79）-0.112（-0.558~0.329）0.89（0.57~1.39）0.620
Q329.94（25.14，35.22）0.035（-0.381~0.448）1.04（0.68~1.56）0.869
EE（IE）
Senior22.94（19.55，26.74）7.730.005reference
Junior30.71（26.75，34.96）0.410（0.095~0.727）1.51（1.10~2.07）0.011
TS（IE）
8：00-11：0024.50（21.23，28.10）3.840.280reference
11：01-12：0029.51（22.14，38.13）0.051（-0.481~0.570）1.05（0.62~1.77）0.848
13：30-16：0030.52（25.13，36.50）0.521（0.100~0.945）1.68（1.11~2.57）0.015
16：01-17：0026.47（14.60，43.12）0.119（-0.820~0.991）1.13（0.44~2.69）0.795
Polyp number
Single22.88（19.13，27.11）5.390.020reference
Multiple29.43（25.87，33.26）0.009（-0.327~0.345）1.01（0.72~1.41）0.959
BP（IE）
Adequate24.57（21.92，27.44）28.82<0.001reference
Inadequate53.42（42.10，64.41）1.168（0.623~1.718）3.21（1.86~5.58）<0.001
BP（SE）
Adequate28.45（25.61，31.47）15.05<0.001reference
Inadequate10.20（5.64，17.77）-1.492（-2.258~-0.827）0.22（0.10~0.44）<0.001
PPT
Adenoma26.40（23.00，30.09）0.410.938reference
Hyperplastic polyp27.66（22.77，33.15）0.171（-0.193~0.532）1.19（0.82~1.70）0.354
Inflammatory polyp24.74（17.23，34.18）-0.003（-0.571~0.540）1.00（0.56~1.72）0.991
Others28.57（16.33，45.05）0.242（-0.637~1.057）1.27（0.53~2.88）0.572
), ArticleFig(id=1322954247234519755, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=EN, label=Table 4, caption=

Univariate and multivariate analysis of polyp miss rate

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicUnivariate analysisMultivariate analysis
Polyp miss rate，%（95%CI）OR（95%CI）PCoefficient（95%CI）OR（95%CI）P
Gender
Male14.77（13.33~16.34）reference0.363reference
Female18.87（16.96~20.94）1.20（0.81~1.79）0.005（-0.378~0.387）1.00（0.69~1.47）0.981
Age/years
≤4514.11（11.62~17.02）reference0.584reference
45~5917.19（15.42~19.11）1.23（0.83~1.82）0.240（-0.268~0.748）1.27（0.76~2.11）0.354
≥6016.68（14.80~18.74）0.97（0.70~1.35）0.317（-0.221~0.854）1.37（0.80~2.35）0.248
IBE/d
Q115.56（13.85~17.45）reference0.438reference
Q216.38（14.14~18.90）1.08（0.66~1.76）-0.063（-0.601~0.474）0.94（0.55~1.61）0.817
Q317.72（15.61~20.04）1.35（0.85~2.14）0.289（-0.207~0.785）1.34（0.81~2.19）0.253
EE（IE）
Senior13.58（12.15~15.15）reference0.002reference
Junior20.00（18.12~22.02）1.86（1.25~2.75）0.730（0.350~1.109）2.07（1.42~3.03）<0.001
TS（IE）
8：00-11：0016.19（14.72~17.79）reference0.706reference
11：01-12：0015.12（12.04~18.81）1.16（0.63~2.15）0.014（-0.620~0.648）1.01（0.54~1.91）0.966
13：30-16：0017.01（14.66~19.65）1.32（0.82~2.11）0.521（0.008~1.033）1.68（1.01~2.81）0.047
16：01-17：0022.32（15.60~30.88）1.20（0.40~3.58）0.357（-0.726~1.441）1.43（0.48~4.22）0.518
Polyp number
Single35.56（32.00~39.29）reference<0.001reference
Multiple12.21（11.08~13.44）0.35（0.24~0.50）-2.231（-2.669~-1.793）0.11（0.07~0.17）<0.001
BP（IE）
Adequate14.52（13.36~15.77）reference<0.001reference
Inadequate35.10（30.22~40.33）5.15（2.69~9.87）1.426（0.823~2.029）4.16（2.28~7.61）<0.001
BP（SE）
Adequate17.68（16.41~19.02）reference<0.001reference
Inadequate4.68（2.90~7.46）0.17（0.07~0.39）-1.473（-2.311~-0.636）0.23（0.10~0.53）<0.001
Location
Ileocecum16.33（10.31~24.89）reference<0.001reference
Ascending colon12.12（9.03~16.09）0.37（0.15~0.92）-0.484（-1.440~0.472）0.62（0.24~1.60）0.321
Hepatic flexure18.75（13.22~25.91）1.13（0.42~3.00）0.742（-0.293~1.777）2.10（0.75~5.91）0.160
Transverse colon13.25（10.94~15.96）0.66（0.29~1.52）0.173（-0.708~1.053）1.19（0.49~2.87）0.701
Descending colon13.72（9.83~18.81）0.62（0.24~1.61）0.414（-0.600~1.428）1.51（0.55~4.17）0.423
Sigmoid colon15.03（12.82~17.55）0.68（0.30~1.56）0.186（-0.708~1.081）1.20（0.49~2.95）0.683
Rectum20.64（18.49~22.98）1.47（0.65~3.31）0.567（-0.318~1.452）1.76（0.73~4.27）0.209
Size/cm
0.1~0.223.22（21.15~25.42）reference<0.001reference
0.3~0.513.03（11.52~14.69）0.26（0.19~0.35）-1.215（-1.548~-0.882）0.30（0.21~0.41）<0.001
0.6~0.94.46（2.72~7.23）0.04（0.02~0.08）-2.320（-3.109~-1.532）0.10（0.04~0.22）<0.001
≥1.013.21（6.55~24.84）0.43（0.15~1.20）0.126（-1.024~1.276）1.13（0.36~3.58）0.830
Morphology
Protruded5.52（4.00~7.58）reference<0.001reference
Flat18.77（17.41~20.21）7.16（4.55~11.27）1.465（0.912~2.018）4.33（2.49~7.52）<0.001
), ArticleFig(id=1322954247322600140, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=CN, label=表4, caption=

息肉漏诊率单因素及多因素分析

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicUnivariate analysisMultivariate analysis
Polyp miss rate，%（95%CI）OR（95%CI）PCoefficient（95%CI）OR（95%CI）P
Gender
Male14.77（13.33~16.34）reference0.363reference
Female18.87（16.96~20.94）1.20（0.81~1.79）0.005（-0.378~0.387）1.00（0.69~1.47）0.981
Age/years
≤4514.11（11.62~17.02）reference0.584reference
45~5917.19（15.42~19.11）1.23（0.83~1.82）0.240（-0.268~0.748）1.27（0.76~2.11）0.354
≥6016.68（14.80~18.74）0.97（0.70~1.35）0.317（-0.221~0.854）1.37（0.80~2.35）0.248
IBE/d
Q115.56（13.85~17.45）reference0.438reference
Q216.38（14.14~18.90）1.08（0.66~1.76）-0.063（-0.601~0.474）0.94（0.55~1.61）0.817
Q317.72（15.61~20.04）1.35（0.85~2.14）0.289（-0.207~0.785）1.34（0.81~2.19）0.253
EE（IE）
Senior13.58（12.15~15.15）reference0.002reference
Junior20.00（18.12~22.02）1.86（1.25~2.75）0.730（0.350~1.109）2.07（1.42~3.03）<0.001
TS（IE）
8：00-11：0016.19（14.72~17.79）reference0.706reference
11：01-12：0015.12（12.04~18.81）1.16（0.63~2.15）0.014（-0.620~0.648）1.01（0.54~1.91）0.966
13：30-16：0017.01（14.66~19.65）1.32（0.82~2.11）0.521（0.008~1.033）1.68（1.01~2.81）0.047
16：01-17：0022.32（15.60~30.88）1.20（0.40~3.58）0.357（-0.726~1.441）1.43（0.48~4.22）0.518
Polyp number
Single35.56（32.00~39.29）reference<0.001reference
Multiple12.21（11.08~13.44）0.35（0.24~0.50）-2.231（-2.669~-1.793）0.11（0.07~0.17）<0.001
BP（IE）
Adequate14.52（13.36~15.77）reference<0.001reference
Inadequate35.10（30.22~40.33）5.15（2.69~9.87）1.426（0.823~2.029）4.16（2.28~7.61）<0.001
BP（SE）
Adequate17.68（16.41~19.02）reference<0.001reference
Inadequate4.68（2.90~7.46）0.17（0.07~0.39）-1.473（-2.311~-0.636）0.23（0.10~0.53）<0.001
Location
Ileocecum16.33（10.31~24.89）reference<0.001reference
Ascending colon12.12（9.03~16.09）0.37（0.15~0.92）-0.484（-1.440~0.472）0.62（0.24~1.60）0.321
Hepatic flexure18.75（13.22~25.91）1.13（0.42~3.00）0.742（-0.293~1.777）2.10（0.75~5.91）0.160
Transverse colon13.25（10.94~15.96）0.66（0.29~1.52）0.173（-0.708~1.053）1.19（0.49~2.87）0.701
Descending colon13.72（9.83~18.81）0.62（0.24~1.61）0.414（-0.600~1.428）1.51（0.55~4.17）0.423
Sigmoid colon15.03（12.82~17.55）0.68（0.30~1.56）0.186（-0.708~1.081）1.20（0.49~2.95）0.683
Rectum20.64（18.49~22.98）1.47（0.65~3.31）0.567（-0.318~1.452）1.76（0.73~4.27）0.209
Size/cm
0.1~0.223.22（21.15~25.42）reference<0.001reference
0.3~0.513.03（11.52~14.69）0.26（0.19~0.35）-1.215（-1.548~-0.882）0.30（0.21~0.41）<0.001
0.6~0.94.46（2.72~7.23）0.04（0.02~0.08）-2.320（-3.109~-1.532）0.10（0.04~0.22）<0.001
≥1.013.21（6.55~24.84）0.43（0.15~1.20）0.126（-1.024~1.276）1.13（0.36~3.58）0.830
Morphology
Protruded5.52（4.00~7.58）reference<0.001reference
Flat18.77（17.41~20.21）7.16（4.55~11.27）1.465（0.912~2.018）4.33（2.49~7.52）<0.001
), ArticleFig(id=1322954247402291917, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=EN, label=Table 5, caption=

Univariate and multivariate analysis of adenoma patient miss rate

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicUnivariate analysisMultivariate analysis
Adenoma patient miss rate，%（95%CI）χ²PCoefficient（95%CI）OR（95%CI）P
Gender
Male16.61（13.71~19.97）1.050.305reference
Female14.25（11.36~17.73）-0.179（-0.556~0.195）0.84（0.57~1.22）0.350
Age/years
≤458.89（5.83~13.33）13.650.001reference
45~5915.28（12.28~18.87）0.602（0.064~1.179）1.83（1.07~3.25）0.034
≥6020.50（16.45~25.24）0.869（0.310~1.464）2.39（1.36~4.32）0.003
IBE/d
Q113.19（10.28~16.78）5.560.062reference
Q214.60（10.91~19.27）-0.176（-0.714~0.350）0.84（0.49~1.42）0.515
Q319.43（15.43~24.16）0.151（-0.332~0.630）1.16（0.72~1.88）0.539
EE（IE）
Senior12.62（10.04~15.74）7.010.008reference
Junior18.67（15.45~22.39）0.436（0.065~0.811）1.55（1.07~2.25）0.022
TS（IE）
8：00-11：0013.17（10.69~16.11）6.890.076reference
11：01-12：0018.85（12.90~26.70）0.251（-0.362~0.839）1.28（0.70~2.31）0.412
13：30-16：0018.47（14.15~23.76）0.605（0.113~1.099）1.83（1.12~3.00）0.016
16：01-17：0023.53（12.44~40.00）0.753（-0.235~1.662）2.12（0.79~5.27）0.116
Polyp number
Single12.03（9.27~15.47）6.830.009reference
Multiple18.07（15.16~21.41）0.094（-0.308~0.500）1.10（0.73~1.65）0.649
BP（IE）
Adequate14.27（12.17~16.66）15.34<0.001reference
Inadequate31.51（22.00~42.86）0.822（0.228~1.395）2.28（1.26~4.03）0.006
BP（SE）
Adequate16.65（14.37~19.21）8.990.003reference
Inadequate5.10（2.20~11.39）-1.466（-2.540~-0.619）0.23（0.08~0.54）0.002
), ArticleFig(id=1322954247481983694, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322954236157362846, language=CN, label=表5, caption=

腺瘤患者漏诊率单因素及多因素分析

, figureFileSmall=null, figureFileBig=null, tableContent=
CharacteristicUnivariate analysisMultivariate analysis
Adenoma patient miss rate，%（95%CI）χ²PCoefficient（95%CI）OR（95%CI）P
Gender
Male16.61（13.71~19.97）1.050.305reference
Female14.25（11.36~17.73）-0.179（-0.556~0.195）0.84（0.57~1.22）0.350
Age/years
≤458.89（5.83~13.33）13.650.001reference
45~5915.28（12.28~18.87）0.602（0.064~1.179）1.83（1.07~3.25）0.034
≥6020.50（16.45~25.24）0.869（0.310~1.464）2.39（1.36~4.32）0.003
IBE/d
Q113.19（10.28~16.78）5.560.062reference
Q214.60（10.91~19.27）-0.176（-0.714~0.350）0.84（0.49~1.42）0.515
Q319.43（15.43~24.16）0.151（-0.332~0.630）1.16（0.72~1.88）0.539
EE（IE）
Senior12.62（10.04~15.74）7.010.008reference
Junior18.67（15.45~22.39）0.436（0.065~0.811）1.55（1.07~2.25）0.022
TS（IE）
8：00-11：0013.17（10.69~16.11）6.890.076reference
11：01-12：0018.85（12.90~26.70）0.251（-0.362~0.839）1.28（0.70~2.31）0.412
13：30-16：0018.47（14.15~23.76）0.605（0.113~1.099）1.83（1.12~3.00）0.016
16：01-17：0023.53（12.44~40.00）0.753（-0.235~1.662）2.12（0.79~5.27）0.116
Polyp number
Single12.03（9.27~15.47）6.830.009reference
Multiple18.07（15.16~21.41）0.094（-0.308~0.500）1.10（0.73~1.65）0.649
BP（IE）
Adequate14.27（12.17~16.66）15.34<0.001reference
Inadequate31.51（22.00~42.86）0.822（0.228~1.395）2.28（1.26~4.03）0.006
BP（SE）
Adequate16.65（14.37~19.21）8.990.003reference
Inadequate5.10（2.20~11.39）-1.466（-2.540~-0.619）0.23（0.08~0.54）0.002
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利用日间治疗二次检查评估结肠镜息肉漏诊率及其影响因素
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吴萌 , 陈静 , 高志 , 陈磊
陆军军医大学学报 | 临床医学·论著 2025,47(23): 2943-2952
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陆军军医大学学报 |临床医学·论著 2025 , 47 (23) : 2943 -2952
利用日间治疗二次检查评估结肠镜息肉漏诊率及其影响因素
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吴萌, 陈静, 高志, 陈磊
作者信息
  • 1陆军军医大学（第三军医大学）第一附属医院消化内科，重庆
通讯作者:
陈磊，E-mail：
CHEN Lei，E-mail：
Assessing polyp miss rates and their determinants through same-day tandem colonoscopy in ambulatory care settings
Meng WU, Jing CHEN, Zhi GAO, Lei CHEN
Affiliations
  • 1Department of Gastroenterology，First Affiliated Hospital，Army Medical University （Third Military Medical University），Chongqing，China
出版时间: 2025-12-15 doi: 10.16016/j.2097-0927.202509098
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摘要
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目的

利用日间治疗需要短期接受二次结肠镜检查的机会，探究结肠镜检查的息肉漏诊情况及可能的影响因素分析。

方法

本研究为单中心回顾性队列研究。连续纳入2025年3-6月于陆军军医大学第一附属医院消化内镜中心日间病房接受结肠镜下息肉切除术的1 005例患者。所有患者接受首次单纯结肠镜检查及内镜下治疗（二次检查）。将二次检查结果作为参照，计算结直肠息肉患者漏诊率、息肉漏诊率、腺瘤患者漏诊率；采用多因素Logistic回归模型分析操作医生及患者因素对漏诊的影响。

结果

患者漏诊率、息肉漏诊率、腺瘤患者漏诊率分别为26.67%（95%CI：23.95~29.52）、16.45%（95%CI：15.26~17.70）、15.52%（95%CI：13.34~17.91）。多因素分析显示，操作医生相关因素：首次检查由低年资医生操作（OR=2.07，95%CI：1.42~3.03，P<0.001）、首次检查时间段为13：30-16：00（OR=1.68，95%CI：1.01~2.81，P=0.047），患者相关因素：首次检查肠道准备不充分（OR=4.16，95%CI：2.28~7.61，P<0.001）、息肉为平坦型（OR=4.33，95%CI：2.49~7.52，P<0.001）是漏诊的独立危险因素；息肉大小为0.3~0.5 cm（OR=0.30，95%CI：0.21~0.41，P<0.001）、息肉大小为0.6~0.9 cm（OR=0.10，95%CI：0.04~0.22，P<0.001）时漏诊风险显著降低。而治疗时二次检查肠道准备不充分与漏诊息肉检出率显著降低相关（OR=0.23，95%CI：0.10~0.53，P<0.001）。

结论

结肠镜检查存在息肉漏诊的情况，漏诊率受操作医师及患者多个因素影响；日间治疗时的二次检查的标准化可检出漏诊息肉，长期监督结肠镜检查质量。

结肠镜检查  /  息肉漏诊率  /  结肠镜质量控制  /  腺瘤  /  日间手术
Objective

To investigate polyp miss rate and influencing factors during colonoscopy using the opportunity of short-interval repeat examinations in day surgery settings.

Methods

This single-center retrospective cohort study consecutively enrolled 1 005 patients undergoing polypectomy at the Endoscopy Center of Army Medical University First Affiliated Hospital(March-June 2023). All patients received initial diagnostic colonoscopy followed by therapeutic colonoscopy(repeat examination). Using repeat examination findings as reference, we calculated patient miss rate, polyp miss rate, and adenoma patient miss rate. Multivariable logistic regression analyzed operator- and patient-related factors influencing patient miss rates.

Results

Patient miss rate, polyp miss rate, and adenoma miss rate were 26.67%(95%CI: 23.95~29.52), 16.45%(95%CI:15.26~17.70), and 15.52%(95%CI:13.34~17.91), respectively. Multivariable analysis identified independent risk factors— operator-related: initial procedure by junior endoscopists(OR=2.07, 95%CI: 1.42~3.03, P<0.001) and afternoon procedures(13:30-16:00; OR=1.68, 95%CI: 1.01~2.81, P=0.047); Patient-related: inadequate bowel preparation(OR=4.16, 95%CI: 2.28~7.61, P<0.001) and flat-type lesions(OR=4.33, 95%CI: 2.49~7.52, P<0.001). Reduced miss rates occurred with polyps 0.3~0.5 cm(OR=0.30, 95% CI: 0.21~0.41, P<0.001) and 0.6~0.9 cm(OR=0.10, 95%CI: 0.04~0.22, P<0.001). Inadequate preparation during therapeutic examination decreased polyp detection(OR=0.23, 95%CI: 0.10~0.53, P<0.001).

Conclusion

Colonoscopy exhibits significant polyp miss rates influenced by operator and patient factors. Standardized repeat examinations in day surgery settings effectively detect missed lesions, supporting long-term quality control.

colonoscopy  /  polyp miss rate  /  colonoscopy quality control  /  adenoma  /  daycare surgery
吴萌, 陈静, 高志, 陈磊. 利用日间治疗二次检查评估结肠镜息肉漏诊率及其影响因素. 陆军军医大学学报, 2025 , 47 (23) : 2943 -2952 . DOI: 10.16016/j.2097-0927.202509098
Meng WU, Jing CHEN, Zhi GAO, Lei CHEN. Assessing polyp miss rates and their determinants through same-day tandem colonoscopy in ambulatory care settings[J]. Journal of Army Medical University, 2025 , 47 (23) : 2943 -2952 . DOI: 10.16016/j.2097-0927.202509098
正文
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结直肠癌（colorectal cancer，CRC）是全球第三大常见恶性肿瘤，且发病率呈持续上升趋势［1-2］。在我国，结直肠癌已成为第二高发的恶性肿瘤，是发病率最高的消化系统恶性肿瘤［3］。结肠镜检查是结直肠癌早期筛查、诊断和监测的金标准［4］，然而，相关研究提示结肠镜检查并不完全可靠，存在病变漏诊现象［5-6］。结肠镜检查后仍可发生CRC，即结肠镜检查后结直肠癌（post-colonoscopy colorectal cancer，PCCRC）。PCCRC通常指在结肠镜检查后6~36个月内诊断出的CRC，而初次结肠镜检查未发现癌变病变［7］。提升结肠镜的检查质量可预防PCCRC［8］。有文献报道，73%的PCCRC为病变漏检所致［9］，因此，探究结肠镜检查中病变漏诊的情况以及如何避免漏诊是一项值得深入研究的课题。
既往关于结肠镜检查漏诊情况的研究主要通过对比短期内二次结肠镜的检查结果，或由内镜医生主动进行二次进镜检查［10-12］。而临床中少有患者在短期内行多次结肠镜检查，且主动二次进镜检查亦不是常规诊疗流程，因此，基于这两种情况收集到的患者数据可能存在选择偏倚，且在对患者的权益保护方面也受到质疑。目前，随着内镜下治疗日间模式的开展，越来越多的内镜中心采用单纯结肠镜检查+日间病房内镜下治疗的模式，患者在短期内会接受检查+治疗二次内镜下的操作。本研究将内镜下治疗定义为短期内的二次结肠镜检查，分别从内镜医生及患者的层面分析结肠镜检查中息肉漏诊的危险因素，旨在探讨结肠镜检查过程中如何有效减少息肉漏诊，提高病变检出率。
1　对象与方法
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1.1　研究对象
收集2025年3-6月于陆军军医大学第一附属医院消化内镜中心日间病房接受结肠镜内镜下息肉切除术的所有患者为研究对象。纳入标准：①既往结肠镜检查发现患有结直肠息肉的患者；②本次于我院行内镜下息肉切除术；③病历、检查报告等临床资料完整。排除标准：①患者首次结肠镜检查系于外院进行，导致数据不可及；②2次结肠镜检查间隔时间>3个月；③检出息肉总数>15个。本研究经陆军军医大学第一附属医院伦理委员会批准［（A）KY2023112］。
1.2　诊疗过程
首次结肠镜检查均为标准结肠镜检查法。内镜下治疗（二次检查）时使用Olympus CF-H260AI、CF-HQ290或富士EC-720R、EC-760ZP型电子结肠镜，患者均取左侧卧位，采用静脉麻醉下的单人进镜法检查。根据首次结肠镜检查的结果，进镜至最远端病变口侧约30 cm或达盲后缓慢退镜观察，对首次检查发现的息肉逐个进行完整切除，若发现首次检查时漏诊的息肉同样进行切除，保存息肉的常规模式图像及NBI/BLI模式图像，切除物送病理检查。记录息肉的数量、大小、形态、位置及肠道准备情况等相关结果。
1.3　评价指标及标准
将二次结肠镜检查的结果与首次检查对比，新发现的息肉定义为漏诊息肉。
1.3.1　内镜医生数据
内镜医生数据包括：①首次检查时操作医生的年资（根据医生既往结肠镜检查例数进行区分，≥5 000例为高年资，<5 000例为低年资），②首次检查所处的时间段（区分8：00-11：00、11：01-12：00、13：30-16：00、16：01-17：00这4个时间段，即上、下午正常上班和下班前1 h）。
1.3.2　患者数据
患者数据包括：①所有检出息肉的位置、大小及形态。位置分为回盲部、升结肠、肝区、横结肠、脾区、降结肠、乙状结肠、直肠8类；息肉大小按息肉的最大直径计算，在检查时以活检钳开口径（7 mm）参照判定，分为0.1~0.2 cm、0.3~0.5 cm、0.6~0.9 cm、1.0~1.9 mm、≥2.0 cm 5类；息肉形态分为平坦型（包括扁平型、侧向发育型、广基息肉）和隆起型（包括有蒂型、亚蒂型）。②患者的病理结果分为：腺瘤、增生性息肉、炎性息肉、幼年性息肉、腺癌、管状绒毛状腺瘤、管状腺瘤、锯齿状息肉8类；③首次检查检出息肉是否为单发，息肉数量为1为单发、≥2为多发；④2次肠镜检查时患者的肠道清洁程度，根据波士顿评分进行区分，总分≥6分，且每段评分均≥2分为肠道准备充分，否则为肠道准备不充分；⑤患者的年龄、性别、2次检查的间隔天数等。
1.3.3　主要结局指标
患者漏诊率是指在所有入组患者中，首次检查存在漏诊的患者所占的比例；息肉漏诊率是指所有经结肠镜检查发现的息肉中，在首次检查中被漏诊的息肉所占的比例；腺瘤患者漏诊率是指所有入组患者中，病理确诊为腺瘤且在首次检查中存在漏诊的患者所占的比例。
1.4　统计学分析
分类变量以频数与百分比（%）表示，连续变量以x¯±s描述，并按分位数转换为有序变量用于分析。部分病理类型及较大息肉因样本稀疏予以合并，腺瘤、管状绒毛状腺瘤及管状腺瘤统一归为腺瘤。
所有数据分析采用R软件（版本4.4.1）完成。单因素分析中，患者水平指标采用Pearson χ²检验或 Fisher精确检验；息肉水平指标采用混合效应Logistic 回归模型以校正个体内群聚效应。多因素分析中，采用先验全量纳入法，患者水平指标采用多变量Logistic回归，息肉水平指标采用多变量混合效应Logistic回归，模型均检查共线性并合并稀疏分层以避免过拟合。假设检验均为双侧，显著性水平α=0.05；漏诊率以百分比（%）表示，其95%CI采用Wilson score法计算。
2　结果
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2025年3-6月行肠息肉切除术的患者共计1 445例，其中171例患者首次检查系在外院进行，207例患者2次检查间隔时间>3个月，62例患者切除的息肉数量>15个，本研究最终纳入1 005例患者，其中男性542例，女性463例，平均年龄（53.62±11.82）岁，2次结肠镜检查的平均间隔天数为（6.14±14.17） d。共检出息肉3 623颗，其中漏诊息肉596颗。首次结肠镜检查由22位医生完成（高年资8位，低年资14位）。患者漏诊率为26.67%（95%CI：23.95~29.52），息肉漏诊率为16.45%（95%CI：15.26~17.70），腺瘤患者漏诊率为15.52%（95%CI：13.34~17.91）。患者的特征见表1，息肉特征见表2。
2.1　患者漏诊率的相关分析
患者漏诊率为26.67%（95%CI：23.95~29.52），反映了首次结肠镜检查中相当数量的患者存在漏诊。
单因素分析表明患者漏诊率与首次检查医生年资、首次检查息肉是否多发、首次检查肠道准备情况、二次检查肠道准备情况相关，患者年龄组间差异接近显著（≥60岁 vs ≤45岁：31.06% vs 22.67%，P=0.070）。多因素分析中，在调整混杂因素后，首次检查时由低年资医生操作（OR=1.51，95%CI：1.10~2.07，P=0.011）、检查时段为13：30-16：00（OR=1.68，95%CI：1.11~2.57，P=0.015）、肠道准备不充分（OR=3.21，95%CI：1.86~5.58，P<0.001）是漏诊的独立危险因素，而二次检查时肠道准备不充分（OR=0.22，95%CI：0.10~0.44，P<0.001，表3）与漏诊检出率显著降低相关。
2.2　息肉漏诊率的相关分析
息肉漏诊率为16.45%（95%CI：15.26~17.70），反映了首次结肠镜检查中相当数量的息肉存在漏诊。
单因素分析表明息肉漏诊率与首次检查医生年资、首次检查息肉是否多发、首次检查肠道准备情况、二次检查肠道准备情况、息肉位置、息肉大小、息肉形态均相关。多因素混合效应模型（考虑了同一患者息肉的相关性）也进一步证实了上述结果且有新的发现，首次检查由低年资医生操作（OR=2.07，95%CI：1.42~3.03，P<0.001）、首次检查时间为13：30-16：00（OR=1.68，95%CI：1.01~2.81，P=0.047）、首次检查肠道准备不充分（OR=4.16，95%CI：2.28~7.61，P<0.001）、平坦型息肉（OR=4.33，95%CI：2.49~7.52，P<0.001）是漏诊的独立危险因素，而首次检查为多发息肉（OR=0.11，95%CI：0.07~0.17，P<0.001），息肉大小为0.3~0.5 cm（OR=0.30，95%CI：0.21~0.41，P<0.001）、0.6~0.9 cm（OR=0.10，95%CI：0.04~0.22，P<0.001）漏诊风险较低，二次检查时肠道准备不充分（OR=0.23，95%CI：0.10~0.53，P<0.001）与漏诊息肉检出率显著降低相关。息肉漏诊率的相关分析见表4。
2.3　腺瘤患者漏诊率的相关分析
腺瘤患者漏诊率为15.52%（95%CI：13.34~17.91），反映了首次结肠镜检查中相当数量的腺瘤患者存在漏诊。
单因素分析表明腺瘤患者漏诊率与首次检查医生年资、首次检查息肉是否多发、首次检查肠道准备情况、二次检查肠道准备情况相关，同时与患者年龄相关。多因素分析中，在调整混杂因素后，患者年龄为>45~59岁（OR=1.83，95%CI：1.07~3.25，P=0.034）、≥60岁（OR=2.39，95%CI：1.36~4.32， P=0.003）、首次检查医生低年资（OR=1.55，95%CI：1.07~2.25，P=0.022）、首次检查时段为13：30-16：00（OR=1.83，95%CI：1.12~3.00，P=0.016）、首次检查肠道准备不充分（OR=2.28，95%CI：1.86~5.58，P=0.006）是漏诊的独立危险因素，而二次检查时肠道准备不充分（OR=0.23，95%CI：0.08~0.54，P=0.002）与漏诊检出率显著降低相关。腺瘤患者漏诊率的相关分析见表5。
3　讨论
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3.1　日间治疗模式评估结直肠息肉漏诊情况具有可行性
通过结肠镜早期发现和切除腺瘤性息肉是预防CRC的金标准方法，然而目前结肠镜检查并不完全可靠［13］，结肠镜检查存在腺瘤、进展期腺瘤的漏诊，这与PCCRC相关［8］，并且由于诊断的延迟，患者预后较差［14-15］。此次研究提示结肠镜检查存在相当数量的漏诊，患者的漏诊率与既往国内的回顾性研究相当（本研究 vs 既往研究：26.67% vs 34.20%）［16］，而息肉漏诊率略低于既往国内外“背靠背”二次结肠镜检查的随机对照试验报告的范围（本研究 vs 既往研究：16.45% vs 22%~26%）［17-18］，考虑可能的原因为部分首次检查报告不规范，如描述散在、多发息肉而未明确息肉的具体数量，或图像采集不清，导致部分多发息肉的漏诊未能统计。故将日间病房内镜下治疗过程视为二次检查，测算首次检查的漏诊情况，用于结肠镜检查质量评估的方法具有可行性，对内镜医生及患者层面的多因素分析也验证了这一点。
3.2　内镜医生相关因素对结肠镜检查中息肉漏诊的影响
本研究强调了内镜医生在结肠镜检查中的重要作用，三个结局指标的分析均发现低年资医生的漏诊率更高。既往研究表明不同医师的腺瘤检出率（adenoma detection rate，ADR）存在极大差异［19］，而对内镜医生的技术培训、质量监督是改善ADR最有效的方法［20］，这提示在肠镜工作中应加强对内镜医生（特别是低年资医生）的有效培训和监督。内镜医生的疲劳度是结肠镜检查质量中不可忽视的因素，既往医生疲劳度与检查质量的关系存在争议，一项前瞻性随机对照试验表明上午结肠镜检查的ADR显著高于下午（29% vs 21%，P=0.03），推测原因可能为内镜医生下午注意力下降，导致单次结肠镜检查时间缩短［21］，还有研究表明由于疲劳导致内镜医生下午时段的活检阳性率显著低于上午［22］。但另有2个回顾性研究表明上午和下午的息肉检出率、ADR差异无统计学意义（67% vs 66%，29.0% vs 28.2%）［23-24］。因此，本研究在设计时考虑了上午、下午及临近下班1 h对漏诊的影响，结果表明13：30-16：00时段漏诊风险最高（OR=1.68），考虑可能与过短的午休时间（约1 h）有关，这提示在安排结肠镜检查工作计划时应充分考虑医生的检查疲劳度，合理安排每日工作总量及工作间歇。
3.3　患者相关因素对结肠镜检查中息肉漏诊的影响
本研究发现患者年龄、性别、检查间隔天数与患者漏诊率、息肉漏诊率无相关性。目前国内多数医院在行肠息肉切除时，因镜下判断腺瘤可能性低、部分标本无法获取（如采用电凝凝固法切除息肉）、患者经济负担重、手术效率低等原因，未对多发息肉患者的每颗息肉均送检病理，患者仅有一个病理结果，即分为腺瘤患者和非腺瘤患者。考虑到相对于非腺瘤患者，腺瘤患者的漏诊可能会造成更坏的影响，本研究纳入了腺瘤患者漏诊率这个指标，研究发现，年龄越大，腺瘤患者漏诊率越高（>45~59岁：OR=1.83，≥60岁：OR=2.39），而我国结肠腺瘤的患病率随年龄明显增高［25］，二者相吻合。腺瘤患者漏诊率的其余因素分析与患者漏诊率基本一致。患者的肠道清洁程度对于高质量的结肠镜检查非常重要［26-27］，本研究显示肠道准备不充分是患者漏诊（OR=3.21）、息肉漏诊（OR=4.16）的独立危险因素，而在内镜下治疗时会导致漏诊息肉的检出率显著降低（OR=0.23）。此次研究发现首次、二次检查中肠道准备不充分的占比均较高（7.26%、9.75%），二次检查肠道准备合格率更低的原因，可能为日间治疗模式下两次检查间隔过短导致肠道准备不规范，即追加泻药会时间仓促，不追加又可能超出肠道准备与检查间隔的理想时段（4~6 h）［28］。虽然现况尚符合目前指南的推荐（即肠道准备合格率应≥90%）［29］，但仍提示我们应重视肠道清洁程度，注意控制肠道准备与检查的间隔时间。医生的宣教非常重要，视频动画演示、微信推送注意事项是很好的宣教措施［30］。
本研究同时分析了息肉的特征，平坦型息肉漏诊风险更高（OR=4.33），而0.3~0.5 cm（OR=0.30）、0.6~0.9 cm（OR=0.10）的息肉漏诊风险更低，这与既往研究吻合［10，16］。本次研究中≥1 cm的息肉漏诊风险与0.1~0.2 cm的息肉差异无统计学意义，可能因≥1 cm的息肉数量过少引起。单因素分析中不同部位息肉的漏诊率有统计学差异（P<0.001），但在多因素分析中该差异消失，其关联可能受其他混杂变量干扰，如肠道清洁程度、息肉数量等。另外，本研究中多发息肉较单发息肉漏诊风险反而更低（OR=0.11，95%CI：0.07~0.17，P<0.001），与既往研究的结果不一致［10，31］，可能的原因为首次检查的报告不规范导致部分多发息肉的漏诊未能统计。
3.4　日间治疗模式在结肠镜检查质量控制中的潜在优势
单纯检查+日间病房治疗的模式已在多数医院开展，在缩短住院时间、降低成本及提升患者体验等方面具有优势［32-33］。本次研究进一步发现了此模式的潜在优势，治疗时的短期二次检查可有效评估首次结肠镜检查质量且符合伦理要求和临床诊疗实践。最理想的结肠镜检查是能够检出所有结直肠癌的癌前病变，ADR并不是完美的肠镜质控指标［34］。腺瘤漏诊率（adenoma miss rate，AMR）越来越被重视，AMR是指结肠镜检查中漏诊的腺瘤数在腺瘤总数中的占比［35］，但其统计依赖于短期2次结肠镜检查的结果对比，且要求每颗息肉均有病理结果，这导致AMR难以在实际临床中作为肠镜质控的监测指标，而单纯检查+日间模式可以规律统计出患者漏诊率、息肉漏诊率等。作为监测指标，漏诊率对内镜医生的督促力度很有可能会大于检出率，从而促进结肠镜检查质量的提高。
3.5　本研究的优势及局限性
本研究的优势在于样本量较大，调整了多个混杂因素，准确反映了真实世界中的结肠镜检查漏诊的情况及相关因素，并可在日常工作中规律开展。当然，本研究也存在一些局限性。首先，作为一项单中心回顾性研究，选择偏倚无法避免；其次，本研究针对的是所有首次检查至少发现一枚息肉的患者，没有包含首次检查未发现息肉的患者。
综上所述，目前结肠镜检查质量控制的现状欠佳，存在一定的漏诊，高质量的结肠镜检查是降低漏诊风险的关键。本研究创新性地提出将日间病房内镜下治疗作为二次检查评估结肠镜检查中息肉的漏诊情况，证实了其在临床实践中的可行性，单纯检查+日间治疗的模式使系统性地监测和评估漏诊率成为可能，这对于长期监督结肠镜的检查质量具有重要意义。

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doi: 10.16016/j.2097-0927.202509098
  • 接收时间：2025-09-29
  • 首发时间：2026-10-30
  • 出版时间：2025-12-15
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  • 收稿日期：2025-09-29
  • 修回日期：2025-11-17
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    1陆军军医大学（第三军医大学）第一附属医院消化内科，重庆

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