Original article
Endoscopic Ultrasound: A Meta-analysis of Test Performance in Suspected Biliary Obstruction

Presented in part at the American College of Gastroenterology, Honolulu, Hawaii, 2005; World Congress of Gastroenterology, Montreal, Quebec, Canada, 2005; and EUS2006, Amsterdam, Holland, 2006.
https://doi.org/10.1016/j.cgh.2007.02.027Get rights and content

Background & Aims: Endoscopic ultrasound (EUS) achieves high-resolution images of the bile duct and pancreas, while avoiding the risks of ERCP (endoscopic retrograde cholangiopancreatography). It appears comparable to MRCP (magnetic resonance cholangiopancreatography), although its use is less widely disseminated. We aimed to summarize EUS test performance in suspected biliary disease with meta-analysis. Methods: MEDLINE search (January 1987–September 2006), selected reference lists, external experts, and manual search of abstracts were used. Studies permitting (re)construction of 2 × 2 tables for EUS versus a gold standard were used. Random-effects models were used to estimate pooled sensitivity and specificity after adjusting for a number of potential confounders. Summary receiver operating characteristic analysis, with the sensitivity corresponding to the point on the receiver operating characteristic curve where sensitivity equals specificity (Q*) and area under the curve, was performed. The effects of sample size, quality, disease prevalence and spectrum, pancreatitis, echoendoscope type, and EUS era on diagnostic performance were assessed. Performance regarding presence of obstruction, choledocholithiasis, and malignancy was analyzed. Results: Thirty-six eligible, non-overlapping studies met inclusion criteria (3532 subjects). EUS had a high overall pooled sensitivity (88%; 95% confidence interval, 85%–91%) and specificity (90%; 87%–93%) for biliary obstruction (area under the curve = 0.97; Q* = 0.92). EUS had higher sensitivity (89%; 87%–91%) and specificity (94%; 91%–96%) for choledocholithiasis than for malignancy (sensitivity, 78%; 69%–85%; specificity, 84%; 78%–91%). Smaller studies and ones mainly studying patients with suspected strictures were associated with lower test performance. Conclusions: There is excellent overall accuracy for EUS in diagnosing choledocholithiasis, with less impressive results for malignancy (when fine-needle aspiration is not used).

Section snippets

Search Strategy

We searched MEDLINE (from January 1987–May 2006) and bibliographies of relevant papers by using EUS or Endosonography, combined with ERCP, as Medical Subject Headings terms. We also combined each of 2 EUS terms above individually with choledocholithiasis, common bile duct stones, and biliary strictures. We also manually reviewed published abstracts and those from national gastroenterology meetings.

Inclusion Criteria

We included the following articles: (1) studies that compared EUS with a single or composite gold

Included Studies

Our MEDLINE search via PubMed revealed 266 abstracts. We manually reviewed more than 80 complete articles that appeared to preliminarily fulfill the inclusion criteria. The flowchart in Figure 2 summarizes the study exclusion process. We ended up with 36 articles, comprising 3532 individual subjects (Appendix).

EUS was performed in 1997 or later in 18 of 36 (50%) studies. Twenty-five (69%) of 36 were blinded, 22 (61%) had consecutive enrollment, 33 (92%) had a gold standard test performed in all

Discussion

EUS has been available as a less invasive alternative to ERCP for more than 10 years, and the technology was first introduced 20 years ago,49 but its dissemination has been slow as a result of a relative paucity of training programs, reimbursement issues, and a slow accrual of data to support its accuracy.50

We used meta-analysis to systematically summarize the diagnostic ability of EUS in suspected biliary obstruction. Our meta-analysis demonstrates a high accuracy for EUS to detect biliary

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