分析胰腺占位性病变超声漏误诊原因及对策。

回顾性分析2021年1月至12月浙江大学医学院附属第一医院进行手术或穿刺胰腺占位性病变患者术前常规超声报告，以病理结果作为金标准，将病灶分为合格组（包括超声诊断与病理结果完全符合以及超声仅提示“占位”或“建议进一步检查”的病例）、漏诊组（超声未发现胰腺占位，其他影像学检查诊断并进行穿刺或手术的病例）和误诊组（超声诊断胰腺占位，但不符合病理诊断的病例）。收集3组患者一般临床资料和影像学资料，采用t检验或χ²检验比较合格组与漏诊组、误诊组年龄、性别、病灶最大径、病灶部位、超声操作医师年资和病理良恶性的差异。通过对超声科医师进行理论及操作培训同时建立会诊制度提高超声诊断符合率，统计2021年1月至12月超声诊断符合率，并采用χ²检验比较上述措施实施前后（2021年上半年和下半年）超声诊断符合率的差异。

纳入489例胰腺占位性病变（良性/恶性：99/390，男/女：259/230）。合格组428例，漏诊组26例，误诊组35例。漏诊组患者年龄大于合格组[（65.62±7.52）岁 vs（60.49±12.70）岁]，病灶最大径小于合格组[（2.69±1.03）cm vs（3.49±1.74）cm]，诊断医师高年资医师占比低于合格组（15/26 vs 342/428），差异具有统计学意义（t=-2.033，P=0.043；t=2.316，P=0.021；χ²=7.199，P=0.007）；漏诊组与合格组患者性别、病灶部位及病理良恶性比较，差异均无统计学意义（P均>0.05）。漏诊组中18例病灶位于胰头部（其中11例位于钩突部），8例位于体尾部（其中6例位于尾部）；5例病灶由于腹腔气体干扰显示不清晰。误诊组与合格组间患者年龄、性别、病灶部位、最大径、病理良恶性及诊断医师年资差异均无统计学意义（P均>0.05）。2021年1月至12月超声诊断胰腺占位性病变符合率分别为86.54%、86.96%、94.59%、88.89%、85.71%、68.42%、83.93%、92.86%、86.84%、94.12%、92.86%、93.02%。2021年下半年超声诊断符合率高于上半年（89.87% vs 85.50%），差异无统计学意义（P>0.05）。

常规超声诊断胰腺占位性病变有局限性，患者年龄、病灶大小、病灶部位、医师年资都可能造成漏误诊，可以通过加强对医师的培训及完善会诊制度并结合其他检查来提高超声诊断符合率。

To analyze the causes and countermeasures of missed diagnosis and misdiagnosis of pancreatic space-occupying lesions by ultrasound.

A retrospective analysis was performed on the preoperative conventional ultrasound reports of patients with pancreatic space-occupying lesions who underwent surgery or puncture biopsy at the First Affiliated Hospital of Zhejiang University School of Medicine from January 2021 to December 2021. Using the pathological results as the gold standard, the patients were divided into three groups: qualified group (including cases whose ultrasound diagnosis was completely consistent with the pathological results, and those whose ultrasound only suggested "space-occupying lesions" or "further examination"), missed diagnosis group (no pancreatic space-occupying lesions were found by ultrasound, and they were diagnosed by other imaging examinations and underwent puncture biopsy or surgery), and misdiagnosis group (pancreatic space-occupying lesions diagnosed by ultrasound, but it was not in accordance with the pathological diagnosis). The general clinical data and imaging data of the three groups were collected. The t test or chi-square test was used to compare the differences in age, gender, maximum diameter of the lesion, lesion location, seniority of ultrasound doctors, and pathological nature (benign or malignant) between the three groups. The accuary of ultrasound diagnosis was improved by theory and operation training for ultrasound doctors and the establishment of a consultation system. The coincidence rate of ultrasound diagnosis to the pathological results from January to December 2021 was analyzed. The chi-square test was used to compare the difference in the coincidence rate of ultrasound diagnosis to the pathological diagnosis between before and after the implementation (the first half vs second half of 2021) of the measures.

A total of 489 patients with pancreatic space-occupying lesions (benign/malignant: 99/390, male/female: 259/230) were enrolled. There were 428 cases in the qualified group, 26 in the missed diagnosis group, and 35 in the misdiagnosis group. Compared to the qualified group, the age of patients in the missed diagnosis group was significantly older [(65.62±7.52) years vs (60.49±12.70) years, t=-2.033, P=0.043], the maximum diameter of the lesions was significantly smaller [(2.69±1.03) cm vs (3.49±1.74) cm, t=2.316, P=0.021], and the proportion of senior doctors was significantly lower (15/26 vs 342/428, χ²=7.199, P=0.007). There was no significant difference in gender, lesion location or pathological nature (benign or malignant) between the missed diagnosis group and the qualified group (P>0.05 for all). In the missed diagnosis group, 18 lesions were located in the head of the pancreas (11 in the uncinate process), and 8 were located in the body and tail of the pancreas (6 in the tail). In 5 cases, the lesions were not clearly displayed due to the interference of abdominal gas. There was no significant difference in age, gender, lesion location, maximum diameter, pathological nature (benign or malignant), or seniority of doctors between the misdiagnosis group and the qualified group (P>0.05 for all). From January to December 2021, the coincidence rates of ultrasound diagnosis of pancreatic space-occupying lesions to the pathological diagnosis were 86.54%, 86.96%, 94.59%, 88.89%, 85.71%, 68.42%, 83.93%, 92.86%, 86.84%, 94.12%, 92.86%, and 93.02%, respectively. The coincidence rate in the second half of 2021 was higher than that in the first half (89.87% vs 85.50%), but the difference was not statistically significant (P>0.05).

Conventional ultrasound has limitations in the diagnosis of pancreatic space-occupying lesions. Age of patients, lesion size and location, and seniority of doctors may lead to missed diagnosis and misdiagnosis. It is necessary to strengthen the training of doctors, establish the consultation system, and apply other combined examinations to improve the diagnostic coincidence rate.