Elsevier

Gastrointestinal Endoscopy

Volume 67, Issue 2, February 2008, Pages 235-244
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
EUS: a meta-analysis of test performance in suspected choledocholithiasis

https://doi.org/10.1016/j.gie.2007.09.047Get rights and content

Background

EUS has been proposed as a less invasive means of diagnosing choledocholithiasis and may eliminate the need for ERCP and its associated risks. The literature pertaining to EUS for the diagnosis of choledocholithiasis reports widely varying sensitivities and specificities.

Objective

To more precisely estimate the diagnostic accuracy of EUS in suspected choledocholithiasis.

Design

MEDLINE and EMBASE databases were used to identify prospective cohort studies in which the results of EUS were compared with the results of an acceptable criterion standard, including ERCP, intraoperative cholangiography, or surgical exploration. Two independent reviewers extracted standardized data and assessed trial quality. A random effects model was used to estimate the sensitivity, specificity, likelihood, and diagnostic odds ratio (DOR), and a summary receiver operating characteristic curve was constructed. All predefined potential sources of heterogeneity were explored by subgroup analysis and meta-regression.

Patients

A total of 2673 patients with suspected choledocholithiasis were reported in 27 studies that satisfied the inclusion criteria.

Results

EUS had a high overall pooled sensitivity of 0.94 (95% CI, 0.93-0.96), a specificity of 0.95 (95% CI, 0.94–0.96), and an area under the curve of 0.98. Three variables appeared to yield a higher DOR: a higher disease prevalence, an adequate time interval between index test and criterion standards, and the presence of verification bias.

Limitations

Misclassification of patients by imperfect criterion standards could potentially underestimate the performance of an EUS.

Conclusions

An EUS is a noninvasive test, with excellent overall sensitivity and specificity for diagnosing choledocholithiasis. An EUS should, therefore, be used to select patients for a therapeutic ERCP to minimize the risk of complications associated with unnecessary diagnostic ERCP.

Section snippets

Search strategy

The systematic review was performed according to developed guidelines for conducting diagnostic reviews.44 We searched MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, and the Database of Reviews of Effectiveness. Medical subject headings “endosonography” and “choledocholithiasis” were combined with free-text terms, screening title, abstract, and subject heading for endoscopic ultrasound,

Literature search

A total of 165 studies were initially identified by using the search strategy. Two independent reviewers excluded 128 studies after a preliminary review of titles and abstracts, which left 37 for detailed evaluation. Of these 37 potentially eligible studies, 25 published articles that met the inclusion and exclusion criteria were identified. Two additional unpublished studies in abstract form were identified by a manual search. In total, 27 studies were deemed appropriate for the meta-analysis.

Discussion

This systematic review of EUS for patients with suspected CBDS found that an EUS had excellent diagnostic accuracy, with an AUC of 0.98. Our findings suggest that EUS results can be taken as conclusive evidence for both ruling in (positive LR 22.41) and ruling out (negative LR 0.09) the diagnosis of CBDS. Because an EUS offers high resolution (0.1 mm), it is likely that the superiority of an EUS compared with an MRCP or an ERCP is primarily evident in the detection of small stones.

Acknowledgments

The authors wish to thank the two international content experts for this study: Pascal Burtin (France) and Laurent Palazzo (France).

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  • Cited by (0)

    Presented at Digestive Disease Week, May 20-23, 2007, Washington DC (Gastrointest Endosc 2007;65:AB360).

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