Characteristics of Missed Simultaneous Gastric Lesions Based on Double-Check Analysis of the Endoscopic Image

Abstract

Background/aims: The detection of multifocal lesions is important for the successful management of gastric neoplasms. We investigated the characteristics of missed simultaneous lesions and the reason for the missed diagnoses.

Methods: A total of 140 patients who underwent repeat endoscopy before endoscopic resection between June 2013 and June 2014 were retrospectively reviewed. We classified simultaneous lesions into three groups based on a review of earlier images: group 1, no images of the location of simultaneous lesions were taken; group 2, no corresponding lesion was evident in the previous images; and group 3, simultaneous lesions were visible in the earlier images but a biopsy was not performed.

Results: Simultaneous lesions were found in 12 patients (8.6%) with 13 lesions, comprising 10 dysplasia (76.9%) and three adenocarcinoma (23.1%). Regarding the reasons for missed diagnoses, seven lesions (53.8%) were classified as group 3, five (38.5%) as group 1, and the remaining lesion (7.7%) as group 2. There were no significant differences in the characteristics of the patients with and without simultaneous lesions.

Conclusions: Lesions disregarded or unnoticed during endoscopic examination were the main reason for missed diagnosis of simultaneous lesions. Endoscopists should consider the possibility of simultaneous lesions and attempt to meticulously evaluate the entire gastric mucosa.

Keywords: Endoscopy; Quality; Stomach neoplasms.

Fig. 1.

Flowchart of the study.

Fig. 2.

Representative images of each level of quality. (A, B) Poor: the image of the antrum is blurry and more than half of the gastric mucosa is covered with mucus and gastric contents. (C, D) Fair: the image of the gastric body is relatively clear, but the antrum has a hazy appearance. (E, F) Good: all images are clear and the gastric mucosa is well-visualized.

Fig. 3.

Classification of simultaneous lesions detected on repeat endoscopy. (A, B) When images of the location where the simultaneous lesion was detected were available but the corresponding lesion was not evident at the time of the previous examination, the case was classified as group 2. (C-E) When images of a simultaneous lesion were available but the lesion was not biopsied, the case was classified as group 3. (A) The dysplastic lesion was not clearly defined at the time of previous endoscopy. (B) Repeat endoscopy showed a flat elevated lesion with a slightly whitish color on the lesser curvature of the midbody. (C) Endoscopic image acquired during prior endoscopic examination showing a flat hyperemic lesion in the lesser curvature of the antrum and a whitish discolored lesion in the antrum anterior wall; however, the latter lesion was not biopsied. (D, E) Repeat endoscopy with biopsy led to a diagnosis of low-grade dysplasia; the two lesions were treated simultaneously using endoscopic resection.