全視野內窺鏡提高炎症性腸病患者異形增生的篩查檢出率

健康 05-06

全視野結腸鏡與傳統前視內鏡相比，可提高IBD患者異形增生的檢出率。

翻譯及點評丨北京協和醫院消化內科李玥

封面圖片丨中山大學附屬第六醫院彭翔

來源｜醫學界消化頻道（CCCF—IBD學習驛站出品）

Full-spectrum Endoscopy Improves Surveillance for Dysplasia in Patients With Inflammatory Bowel Diseases

Rupert W. Leong, AGAF, Professor, Dr Marie Ooi, FRACP, Dr Crispin Corte,FRACP, Dr Yunki Yau, PhD, Ms Melissa Kermeen, RN, Peter H. Katelaris, AGAF,Associate Professor, Dr Charles McDonald, FRACP, Meng Ngu

炎症性腸病（IBD）患者並髮結直腸癌的發生風險增高。推薦採用結腸鏡聯合色素內鏡的方法進行篩查。但傳統前視結腸鏡檢查（FVC）對於異形增生性病變檢出的敏感性低。全視野內窺鏡（FUSE）在傳統的前向鏡頭的兩邊分別整合了側向鏡頭，使得操作者可觀察結腸皺襞後方和其他盲點，從而提高異形增生檢出率。本研究旨在於對比FUSE和FVC對於IBD患者結腸異形增生性病變的檢出率。這是一項前瞻性、隨機、交叉串聯研究，比較FVC與FUSE對於52例澳大利亞IBD患者異形增生的檢出率（23例為克羅恩結腸炎，29例為潰瘍性結腸炎，中位年齡45.0歲，60％為男性，平均IBD病程16.4年）。27名患者被隨機分配到先FVC後FUSE檢查組，25名分配到先FUSE後FVC檢查組。所有受試者第一次內鏡檢查在白光下退鏡，第二次內鏡檢查退鏡時採用噴洒色素內鏡技術。所有檢查均於2014年2月至2015年12月進行。檢查中進行隨機活檢以及可見病變的靶向活檢。主要終點是由第二次結腸鏡檢測到的第一次結腸鏡漏檢的異形增生性病變。異形增生由對結腸鏡檢查分組設盲的消化病理專家診斷，並由第二位病理專家核查。結果顯示，按病變數統計，FVC漏診71.4%異形增生，而FUSE漏診25%（P=.0001）。按病例數統計，FVC漏診75.0%異形增生，FUSE漏診25%（P=.046）。二者的檢查時間是相近的（FUSE 平均21.2min，FVC平均19.1min；P=.32），但退鏡時間FUSE（15.8min）比FVC（12.0min）明顯延長（P=.03）。按每家單位退鏡時間校正後，每例患者異形增生性病變漏診率FUSE（0.19）明顯低於FVC（0.83；P

本文源自： Gastroenterology 2017;152 (6):1337-1344

Abstract

Background & Aims: Inflammatory bowel diseases (IBD) increase the risk of colorectalcancer. Surveillance colonoscopy with chromoendoscopy is recommended, but conventionalforward-viewing colonoscopy (FVC) detects dysplasia with low levels of sensitivity. Fullspectrum endoscopy (FUSE) incorporates 2 additional lateral cameras to the forward camera of the colonoscope, allowing endoscopists to view behind folds and in blind spots, which mightincrease dysplasia detection. We compared FUSE vs FVC in the detection of dysplasia in patients with IBD.

Methods: We performed a prospective randomized crossover tandem colonoscopy study comparing FVC vs FUSE in 52 subjects with IBD undergoing surveillance for neoplasia in Australia (23 with Crohn』s colitis, 29 with ulcerative colitis; median age 45.0 years; 60% male; mean IBD duration 16.4 years). All subjects met national IBD surveillance inclusion criteria; 27 were randomly assigned to groups that underwent FVC followed by FUSE, and 25 were assigned to groups that underwent FUSE followed by FVC. All procedures were performed from February 2014 through December 2015. Random biopsies were collected and visible lesions were collected; all were analyzed histologically. The primary endpoint was dysplasia missed by the first colonoscopy detected by the second colonoscopy. Dysplasia was diagnosed by an expert gastrointestinal pathologist blinded to the colonoscope allocation in consensus with a second expert pathologist.

Results: FVC missed 71.4% of dysplastic lesions perlesion whereas FUSE missed 25.0% per lesion (P=.0001); FVC missed 75.0% of dysplastic lesions persubject and FUSE missed 25.0% per subject (P=.046). FUSE identified a mean 0.37 dysplastic lesions and FVC identified a mean 0.13 dysplastic lesions (P=.044). The total colonoscopy times were similar (21.2 min for FUSE vs 19.1 min for FVC; P=.32) but withdrawal time was significantly longer for FUSE (15.8 min) than for FVC (12.0 min) (P=.03). Correcting for per-unit withdrawal time, the mean dysplasia miss rate per subject was significantly lower for FUSE (0.19) than for FVC (0.83; P

Conclusions: In a prospective crossover study of IBD patients undergoing surveillance colonoscopy, we found panoramic views obtained by full-spectrum endoscopy increased the number of dysplastic lesions detected, compared with conventional forward-viewing colonoscopy.

譯者點評

炎症相關性結直腸癌是長程IBD患者最嚴重的併發症，IBD患者發生結直腸癌風險是普通人群的2倍。發病年齡越早，病程越長，發生結直腸癌的累計危險度越高。內鏡檢查是IBD癌變最重要的篩查手段。本文通過前瞻性、隨機、交叉串聯研究對比發現，新型全視野內窺鏡（FUSE）比傳統前向視野內鏡（FVC）顯著降低IBD患者異形增生的漏診率。FUSE (Full Spectrum Endoscopy)是美國EndoChoice公司研發的新型高清內鏡，由於增加了兩個側向鏡頭使得內鏡視野由傳統170度擴展至330度（圖示）。視野的擴展使得腸管側壁、皺襞後方等盲點位置得以清晰顯現，明顯降低結腸腺瘤的漏診率。本文也提出，由於IBD癌變的特殊性，如扁平病變、邊界不清晰等，FUSE並不能替代染色內鏡技術，二者的聯合應用可進一步降低漏診率。同時，靶向活檢優於隨機活檢。筆者有幸在2016年參觀日本東京國立癌中心時，現場觀摩了FUSE內鏡操作，由於同時觀察三塊顯示屏，退鏡時間確實因此延長。隨著新型內鏡技術的誕生和未來更多研究結果的出現，當前指南關於病程超過8年的高危患者每年篩查結腸鏡的時間間隔有望被改寫，如FUSE聯合染色內鏡技術並靶向活檢用於炎症相關性結直腸癌篩查。

全視野內窺鏡提高炎症性腸病患者異形增生的篩查檢出率