Miss rate for colorectal neoplastic polyps: a prospective multicenter study of back-to-back video colonoscopies

Background and study aim: Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination.

Patients and methods: 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas.

Results: The miss rates for polyps, adenomas, polyps ≥ 5 mm, adenomas ≥ 5 mm, and advanced adenomas were, respectively, 28 %, 20 %, 12 %, 9 % and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 % and 26 % but the corresponding rates were 23 % and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (≥ 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate.

Conclusions: We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

References

• 1 Hixson L J, Fennerty M B, Sampliner R E. et al . Prospective study of the frequency and size distribution of polyps missed by colonoscopy.  J Natl Cancer Inst. 1990;  82 1769-1772
• 2 Rex D K, Cutler C S, Lemmel G T. et al . Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies.  Gastroenterology. 1997;  112 24-28
• 3 Bensen S, Mott L A, Dain B. et al . The colonoscopic miss rate and true one-year recurrence of colorectal neoplastic polyps.  Am J Gastroenterol. 1999;  94 194-199
• 4 Kasugal K, Miyata M, Hashimoto T. et al . Assessment of miss and incidence rates of neoplastic polyps at colonoscopy.  Dig Endosc. 2005;  17 44-49
• 5 Winawer S J, Zauber A G, Ho M N. et al. . Prevention of colorectal cancer by colonoscopic polypectomy.  N Engl J Med. 1993;  329 1977-1981
• 6 Winawer S J, Zauber A G. Colonoscopic polypectomy and the incidence of colorectal cancer.  Gut. 2001;  48 753-754
• 7 Brenner H, Chang-Claude J, Seiler C M. et al . Does a negative screening colonoscopy ever need to be repeated?.  Gut. 1996;  55 1145-1150
• 8 Rex D K, Bond J H, Feld A D. Medical-legal risks of incident cancers after clearing colonoscopy.  Am J Gastroenterol. 2001;  96 952-957
• 9 Rex D K, Lieberman D A. Feasibility of colonoscopy screening: discussion of issues and recommendations regarding implementation.  Gastrointest Endosc. 2001;  54 662-667
• 10 Haseman J H, Lemmel G T, Rahmani E Y, Rex D K. Failure of colonoscopy to detect colorectal cancer; evaluation of 47 cases in 20 hospitals.  Gastrointest Endosc. 1997;  45 451-455
• 11 Bressler B, Paszat L F, Winden C. et al . Colonoscopic miss rates for right-sided colon cancer; a population-based analysis.  Gastroenterology. 2004;  127 452-456
• 12 Schoen R E. Surveillance after positive and negative colonoscopy examinations; issues, yields, and use.  Am J Gastroenterol. 2003;  98 1237-1246
• 13 Pabby A, Schoen R E, Weissfeld J L. et al . Analysis of colorectal cancer occurrence during surveillance colonoscopy in the dietary polyp prevention trial.  Gastrointest Endosc. 2005;  61 385-391
• 14 Graham M, Jegendirabose P, Leiper K. WED-E-278 colonoscopic miss-rate for colorectal cancer in usual clinical practice.  Endoscopy. 2005;  37 A275
• 15 Panadès A, Seoane A, Torra S. et al . MON-G-274 colonoscopic miss rates for colorectal cancer.  Gut. 2005;  54 A139
• 16 Robertson D J, Mott L, Baron J A,. the Polyp Prevention Study Group . Colorectal cancer after ”clearing” colonoscopy: experience from 3 large adenoma chemoprevention trials.  Am J Gastroenterol. 2003;  98 S123
• 17 Lieberman D. Quality and colonoscopy; a new imperative.  Gastrointest Endosc. 2005;  61 392-394
• 18 Ee H C, Semmens J B, Hoffman N E. for the Perth Teaching Hospitals Endoscopy Group . Complete colonoscopy rarely misses cancer.  Gastrointest Endosc. 2002;  55 167-171
• 19 Pickhardt P J, Choi J R, Hwang I. et al . Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults.  New Engl J Med. 2003;  349 2191-2200
• 20 Cotton P B, Durkalski V L, Pineau B C. et al . Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia.  JAMA. 2004;  291 1713-1719
• 21 Van Rijn J, Reitsma J B, Stoker J. et al . Polyp miss rate determined by tandem colonoscopy: a systematic review.  Am J Gastroenterol. 2006;  101 343-350
• 22 Church J M. Clinical significance of small colorectal polyps.  Dis Colon Rectum. 2004;  47 481-485
• 23 Gschwantler M, Kriwanek S, Langner E. et al . High-grade dysplasia and invasive carcinoma in colorectal adenomas: a multivariate analysis of the impact of adenoma and patient characteristics.  Eur J Gastroenterol Hepatol. 2002;  14 183-188
• 24 Nusko G, Mansmann U, Altendorf-Hofmann A. et al . Risk of invasive carcinoma in colorectal adenomas assessed by size and site.  Int J Colorect Dis. 1997;  12 267-271
• 25 Butterly L F, Chase M P, Pohl H, Fiarman G S. Prevalence of clinically important histology in small adenomas.  Clin Gastroenterol Hepatol. 2006;  4 343-348
• 26 Bressler B, Paszat L, Rothwell D. et al . Predictors of missed colorectal cancer during colonoscopy: a population-based analysis.  Gastrointest Endosc. 2006;  61 AB107
• 27 Sanchez W, Harewood G C, Petersen B T. Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy.  Am J Gastroenterol. 2004;  99 1941-1945
• 28 Barclay R I, Vicari J J, Doughty A S. et al . Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.  N Engl J Med. 2006;  355 2533-2541
• 29 Rex D K. Colonoscopic withdrawal technique is associated with adenoma miss rates.  Gastrointest Endosc. 2000;  51 33-36
• 30 Simmons D T, Harewood G C, Baron T H. et al . Impact of endoscopist withdrawal speed on polyp yield: implications for optimal colonoscopy withdrawal time.  Aliment Pharmacol Ther. 2006;  24 965-971