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Diagnostic Test Accuracy Review

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Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

  1. Victoria B Allen1,
  2. Kurinchi Selvan Gurusamy2,*,
  3. Yemisi Takwoingi3,
  4. Amun Kalia4,
  5. Brian R Davidson2

Editorial Group: Cochrane Upper GI and Pancreatic Diseases Group

Published Online: 25 NOV 2013

Assessed as up-to-date: 13 SEP 2012

DOI: 10.1002/14651858.CD009323.pub2


How to Cite

Allen VB, Gurusamy KS, Takwoingi Y, Kalia A, Davidson BR. Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD009323. DOI: 10.1002/14651858.CD009323.pub2.

Author Information

  1. 1

    Oxford University Hospitals NHS Trust, Oxford University Clinical Academic Graduate School, Oxford, UK

  2. 2

    Royal Free Campus, UCL Medical School, Department of Surgery, London, UK

  3. 3

    University of Birmingham, Public Health, Epidemiology and Biostatistics, Birmingham, UK

  4. 4

    University College London, London, UK

*Kurinchi Selvan Gurusamy, Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK. k.gurusamy@ucl.ac.uk.

Publication History

  1. Publication Status: New
  2. Published Online: 25 NOV 2013

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Characteristics of included studies [ordered by study ID]
Ahmed 2006

Study characteristics

Patient samplingSample size: 37

Females: not stated

Age: not stated


Patient characteristics and settingPatients with potentially resectable histologically confirmed pancreatic adenocarcinoma (after CT scan)

Setting: Surgical centre in US


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Tumours were considered locally advanced and unresectable if laparoscopic examination revealed peritoneal or liver metastasis, coeliac artery or para-aortic lymph node involvement, or tumour invasion or encasement of the coeliac axis or hepatic artery


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Tumours were considered locally advanced and unresectable if laparoscopic examination revealed peritoneal or liver metastasis, coeliac artery or para-aortic lymph node involvement, or tumour invasion or encasement of the coeliac axis or hepatic artery


Flow and timingNumber of indeterminates for whom the results of reference standard was available: not stated

Number of patients who were excluded from the analysis: 22 (37.3%)


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?No
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

Arnold 1999

Study characteristics

Patient samplingSample size: 33

Females: not stated

Age: not stated


Patient characteristics and settingPatients with potentially resectable pancreatic adenocarcinoma (after CT scan)

Setting: Germany (setting not clear)


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: not stated

Number of patients who were excluded from the analysis: 14 (29.8%)


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?No
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

Arnold 2001a

Study characteristics

Patient samplingSample size: 61

Females: not stated

Age: not stated


Patient characteristics and settingPatients with potentially resectable pancreatic adenocarcinoma (after CT scan)

Setting: Germany (setting not clear)


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: not stated

Number of patients who were excluded from the analysis: not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Unclear
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?Unclear

Brooks 2002

Study characteristics

Patient samplingSample size: 144

Females: not stated

Age: not stated


Patient characteristics and settingPatients with potentially resectable periampullary carcinoma other than pancreatic cancer

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Patients were deemed unresectable at diagnostic laparoscopy or laparotomy if they were found to have histologically proved peritoneal or hepatic metastases, distant nodal involvement, arterial involvement, or local extension outside the resection field


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Patients were deemed unresectable at diagnostic laparoscopy or laparotomy if they were found to have histologically proven peritoneal or hepatic metastases, distant nodal involvement, arterial involvement, or local extension outside the resection field


Flow and timingNumber of indeterminates for whom the results of reference standard was available: 10 (6.9%)

Number of patients who were excluded from the analysis: not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Unclear
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?Unclear

Contreras 2009

Study characteristics

Patient samplingSample size: 25.

Females: 12 (32.5%)

Age: 68 years


Patient characteristics and settingPatients with potentially resectable pancreatic adenocarcinoma (after CT scan)

Setting: Surgical referral centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: 52 (67.5%)


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?No
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

Fernandez-Castillo 1995

Study characteristics

Patient samplingSample size: 109

Females: Not stated

Age: Not stated


Patient characteristics and settingPatients with potentially resectable pancreatic adenocarcinoma (on CT scan) without gastric outlet obstruction

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: not stated

Number of patients who were excluded from the analysis: 5 (4.2%)


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Yes
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?No
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

John 1995

Study characteristics

Patient samplingSample size: 40

Females: 22 (100%)

Age: 59 years


Patient characteristics and settingPatients with potentially resectable pancreatic or periampullary carcinoma

Setting: Tertiary referral centre in UK


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: The criteria used to define primary tumour advancement and locoregional unresectability were as follows:

1. Tumour size of 5 cm or greater

2. Extrapancreatic invasion of adjacent tissues (i.e. duodenum, stomach, common bile duct, retroperitoneum) and

3. Occlusion or stenosis of the portal or superior mesenteric veins, or major branches of the coeliac trunk or superior mesenteric artery


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: Not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Unclear
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?Unclear

Kishiwada 2002

Study characteristics

Patient samplingSample size: 16

Females: Not stated

Age: Not stated


Patient characteristics and settingPatients with potentially resectable pancreatic cancer (only patients with more than 2 cm diameter tumours were subject to diagnostic laparoscopy)

Setting: Surgical centre in Japan


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: Not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?No
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Unclear
High

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

Lavy 2012

Study characteristics

Patient samplingSample size: 52

Females: Not stated

Age: Not stated


Patient characteristics and settingPatients with potentially resectable pancreatic adenocarcinoma (after CT scan and EUS)

Setting: Surgical centre in Israel


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: Not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Yes
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Yes
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?Unclear

Menack 2001

Study characteristics

Patient samplingSample size: 27

Females: 10 (100%)

Age: 66 years


Patient characteristics and settingPatients with potentially resectable pancreatic or periampullary cancer (after CT scan)

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Patients were considered unresectable if they had histologically proven metastatic disease or carcinomatosis


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: Not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Unclear
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?Unclear

Merchant 1998

Study characteristics

Patient samplingSample size: 303

Females: Not stated

Age: Not stated


Patient characteristics and settingPatients with potentially resectable pancreatic or periampullary cancer (after CT scan)

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Unresectable if one or more of the following were confirmed histopathologically:

1. Hepatic, serosal/peritoneal, or omental metastases

2. Extrapancreatic extension of tumor (i.e. mesocolic involvement)

3. Celiac or high portal nodal involvement by tumour and

4. Invasion or encasement of the celiac axis, hepatic artery, or superior mesenteric artery


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated.

Number of patients who were excluded from the analysis: 36 (10.6%)


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Yes
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?No
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?Unclear

Reddy 1999

Study characteristics

Patient samplingSample size: 98

Females: 47 (49%)

Age: 65 years


Patient characteristics and settingPatients with potentially resectable pancreatic cancer (on CT scan)

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: 1 (1%)


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Yes
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?No
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

Reed 1997

Study characteristics

Patient samplingSample size: 11

Females: Not stated

Age: Not stated


Patient characteristics and settingPatients with potentially resectable pancreatic cancer (on CT scan)

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: Not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Unclear
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?Unclear

Shah 2008

Study characteristics

Patient samplingSample size: 19

Females: Not stated

Age: Not stated


Patient characteristics and settingPatients with potentially resectable pancreatic cancer (on CT scan)

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: 30 (61.2%)


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Yes
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?No
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

Warshaw 1986

Study characteristics

Patient samplingSample size: 40

Females: Not stated

Age: Not stated


Patient characteristics and settingPatients with potentially resectable pancreatic adenocarcinoma (after CT scan)

Setting: Surgical centre in USA


Index testsDiagnostic laparoscopy

Criteria for positive diagnosis: Biopsies of lesions suspicious of metastases


Target condition and reference standard(s)Target condition: Unresectability

Reference standard: Laparotomy for patients with no evidence of metastases on laparoscopy; biopsy with histolopathological confirmation of spread for patients with suspected metastases

Criteria for positive diagnosis: Not stated


Flow and timingNumber of indeterminates for whom the results of reference standard was available: Not stated

Number of patients who were excluded from the analysis: Not stated


Comparative


Notes


Methodological quality

ItemAuthors' judgementRisk of biasApplicability concerns

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?Unclear
Was a case-control design avoided?Yes
Did the study avoid inappropriate exclusions?Unclear
Low

DOMAIN 2: Index Test All tests

Were the index test results interpreted without knowledge of the results of the reference standard?Yes
Low

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?Unclear
Were the reference standard results interpreted without knowledge of the results of the index tests?No
Low

DOMAIN 4: Flow and Timing

Was there an appropriate interval between index test and reference standard?Unclear
Did all patients receive the same reference standard?No
Were all patients included in the analysis?No

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Abdalla 2003Insufficient diagnostic test accuracy data available for diagnostic laparoscopy

Altieri 1982Wrong target condition

Andren-Sandberg 1998Includes patients who were considered to be unresectable by CT scan

Arnold 2001Not a diagnostic accuracy study

Atanov 1972No separate data available for pancreatic or periampullary cancers

Awad 1997Includes patients who were considered to be unresectable by CT scan

Balcom 2000Not a diagnostic accuracy study

Barabino 2011No diagnostic test accuracy data available for diagnostic laparoscopy

Barrat 1998No separate data available for pancreatic or periampullary cancers

Barreiro 2002Not a diagnostic accuracy study

Barthet 2007Not a diagnostic accuracy study

Baumgarten 1984No diagnostic test accuracy data available for diagnostic laparoscopy

Beger 1997Not a diagnostic accuracy study

Belagyi 2000Not a diagnostic accuracy study

Bemelman 1995No diagnostic test accuracy data available for diagnostic laparoscopy

Bohmig 2001Not a diagnostic accuracy study

Borbath 2005No diagnostic test accuracy data available for diagnostic laparoscopy

Boselli 2000No diagnostic test accuracy data available for diagnostic laparoscopy

Bottger 1998No diagnostic test accuracy data available for diagnostic laparoscopy

Boyce 1992Not a diagnostic accuracy study

Caldironi 1996The proportion of patients who were considered to be resectable after CT scan is not known

Callery 1997No separate data available for pancreatic or periampullary carcinoma

Callery 2009Not a diagnostic accuracy study

Camacho 2005Not a diagnostic accuracy study

Carmichael 1995Not a diagnostic accuracy study

Carpenter 1996Not a diagnostic accuracy study

Catheline 1998No diagnostic test accuracy data available for diagnostic laparoscopy

Catheline 1999No diagnostic test accuracy data available for diagnostic laparoscopy

Chambon 1995No diagnostic test accuracy data available for diagnostic laparoscopy

Champault 1996No diagnostic test accuracy data available for diagnostic laparoscopy

Champault 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Charukhchyan 1998No diagnostic test accuracy data available for diagnostic laparoscopy

Cipollone 2012No diagnostic test accuracy data available for diagnostic laparoscopy

Conlon 1997The number of patients with pancreatic or periampullary cancers is not stated

Conlon 1999Not a diagnostic accuracy study

Conlon 2002Not a diagnostic accuracy study

Connor 2004Not a diagnostic accuracy study

Croome 2009Insufficient diagnostic test accuracy data available for diagnostic laparoscopy

Croome 2010Insufficient diagnostic test accuracy data available for diagnostic laparoscopy

Cuesta 1993No diagnostic test accuracy data available for diagnostic laparoscopy

Cuschieri 1978No diagnostic test accuracy data available for diagnostic laparoscopy

Cuschieri 1988The proportion of patients who were considered to be resectable after CT scan is not known

D'Angelica 2003Wrong target condition

Dadan 1980Insufficient diagnostic test accuracy data available for diagnostic laparoscopy

Doran 2004No diagnostic test accuracy data available for diagnostic laparoscopy

Doucas 2007No diagnostic test accuracy data available for diagnostic laparoscopy

Duffy 2008Not a diagnostic accuracy study

Durup Scheel-Hincke 1999No diagnostic test accuracy data available for diagnostic laparoscopy

Eigler 1999Not a diagnostic accuracy study

Ellsmere 2005No diagnostic test accuracy data available for diagnostic laparoscopy

Enestvedt 2008Includes patients who were considered to be unresectable by CT scan

Fernandez-Del 1994Not a diagnostic accuracy study

Fernandez-del 1998Not a diagnostic accuracy study

Ferrone 2006No diagnostic test accuracy data available for diagnostic laparoscopy

Feussner 2000No separate data available for pancreatic or periampullary cancer

Fevery 1985No separate data available for pancreatic or periampullary cancer

Fockens 1993Not a diagnostic accuracy study

Friess 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Friess 1998No separate data available for pancreatic or periampullary cancer

Fristrup 2006No diagnostic test accuracy data available for diagnostic laparoscopy

Fukumoto 1989No separate data available for pancreatic or periampullary cancer

Garcea 2012No diagnostic test accuracy data available for diagnostic laparoscopy

Garofalo 2009No diagnostic test accuracy data available for diagnostic laparoscopy

Gouma 1996No diagnostic test accuracy data available for diagnostic laparoscopy

Gouma 1999Not a diagnostic accuracy study

Gouma 2002Not a diagnostic accuracy study

Hann 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Healthcare 1999Not a diagnostic accuracy study

Heger 2008Not a diagnostic accuracy study

Hernandezguio 1965Not a diagnostic accuracy study

Herrera 2003No diagnostic test accuracy data available for diagnostic laparoscopy

Hidalgo 2004Not a diagnostic accuracy study

Hohenberger 2000Not a diagnostic accuracy study

Holzman 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Hunerbein 1999Not a diagnostic accuracy study

Hunerbein 2001No diagnostic test accuracy data available for diagnostic laparoscopy

Ialongo 2010Not a diagnostic accuracy study

Ido 1982No diagnostic test accuracy data available for diagnostic laparoscopy

Ihse 1984Not a diagnostic accuracy study

Ishida 1983No diagnostic test accuracy data available for diagnostic laparoscopy

Ishida 1984Wrong target condition

Ivanov 1989No diagnostic test accuracy data available for diagnostic laparoscopy

Jackowski 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Jakobs 1999Not a diagnostic accuracy study

Jarnagin 2000Wrong target condition

Jerby 1998Not a diagnostic accuracy study

Jimenez 2000Not a diagnostic accuracy study

Jimenez 2000aNo diagnostic test accuracy data available for diagnostic laparoscopy

John 1999No diagnostic test accuracy data available for diagnostic laparoscopy

Juzkow 1996Not a diagnostic accuracy study

Kadar 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Kanazawa 1983No separate data available for pancreatic or periampullary cancer

Kaplan 1979Not a diagnostic accuracy study

Karachristos 2005Intervention between index test and reference standard

Kellokumpu 1996Not a diagnostic accuracy study

Kelly 2009No diagnostic test accuracy data available for diagnostic laparoscopy

Khamdanov 1983Not a diagnostic accuracy study

Kiyonaga 1982Wrong target condition

Klingler 2000No diagnostic test accuracy data available for diagnostic laparoscopy

Krahenbuhl 1997Not a diagnostic accuracy study

Krustev 1998No diagnostic test accuracy data available for diagnostic laparoscopy

Kubyshkin 2000No diagnostic test accuracy data available for diagnostic laparoscopy

Kuster 1967No diagnostic test accuracy data available for diagnostic laparoscopy

Kwon 2002No diagnostic test accuracy data available for diagnostic laparoscopy

Lavonius 2001Includes patients who were considered to be unresectable by CT scan

Lightdale 1992Not a diagnostic accuracy study

Liu 2004Not a diagnostic accuracy study

Long 2005Not a diagnostic accuracy study

Luque-de 1998No diagnostic test accuracy data available for diagnostic laparoscopy

Luque-de 1999No diagnostic test accuracy data available for diagnostic laparoscopy

Macutkiewicz 2009No diagnostic test accuracy data available for diagnostic laparoscopy

Madsen 1994No separate data available for pancreatic or periampullary cancer

Madsen 1994aNo separate data available for pancreatic or periampullary cancer

Maire 2004No diagnostic test accuracy data available for diagnostic laparoscopy

Maithel 2008No diagnostic test accuracy data available for diagnostic laparoscopy

Meduri 1994The proportion of patients who were considered to be resectable after CT scan is not known

Metcalfe 2003Not a diagnostic accuracy study

Meyer 1973No diagnostic test accuracy data available for diagnostic laparoscopy

Misra 2012No diagnostic test accuracy data available for diagnostic laparoscopy

Molnar 2010The proportion of patients who were considered to be resectable after CT scan is not known

Morak 2009No diagnostic test accuracy data available for diagnostic laparoscopy

Morganti 2005No diagnostic test accuracy data available for diagnostic laparoscopy

Mortensen 1996No diagnostic test accuracy data available for diagnostic laparoscopy

Muntean 2009No diagnostic test accuracy data available for diagnostic laparoscopy

Munteanu 2010No diagnostic test accuracy data available for diagnostic laparoscopy

Murugiah 1993The proportion of patients who were considered to be resectable after CT scan is not known

Nagy 1999Not a diagnostic accuracy study

Nieveen 1996No diagnostic test accuracy data available for diagnostic laparoscopy

Nieveen 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Nieveen 1998No diagnostic test accuracy data available for diagnostic laparoscopy

Nieveen 1999No diagnostic test accuracy data available for diagnostic laparoscopy

Nieveen 2000No diagnostic test accuracy data available for diagnostic laparoscopy

Nieveen 2003No diagnostic test accuracy data available for diagnostic laparoscopy

Nieveen 2003aNo diagnostic test accuracy data available for diagnostic laparoscopy

Occelli 1999No diagnostic test accuracy data available for diagnostic laparoscopy

Palanivelu 2001Not a diagnostic accuracy study

Parks 2000Not a diagnostic accuracy study

Pedrazzoli 1994No diagnostic test accuracy data available for diagnostic laparoscopy

Pelton 1998Insufficient diagnostic test accuracy data available for diagnostic laparoscopy

Pietrabissa 1996No diagnostic test accuracy data available for diagnostic laparoscopy

Pietrabissa 1996aNo diagnostic test accuracy data available for diagnostic laparoscopy

Pietrabissa 1999Includes patients who were considered to be unresectable by CT scan

Pisters 2001Not a diagnostic accuracy study

Potkonjak 1974No diagnostic test accuracy data available for diagnostic laparoscopy

Ramshaw 1999Not a diagnostic accuracy study

Ribero 1994No diagnostic test accuracy data available for diagnostic laparoscopy

Rodgers 2003No separate data available for pancreatic or periampullary cancer

Rothlin 1996Not a diagnostic accuracy study

Rumstadt 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Rumstadt 1997aNo diagnostic test accuracy data available for diagnostic laparoscopy

Saeian 1999Not a diagnostic accuracy study

Sand 1996No separate data available for pancreatic or periampullary cancer

Santoro 2012No information on whether the distant metastases were confirmed histologically as metastases

Sato 1985Not a diagnostic accuracy study

Satoi 2011No diagnostic test accuracy data available for diagnostic laparoscopy

Schachter 1999Wrong target condition

Schmidt 1997No diagnostic test accuracy data available for diagnostic laparoscopy

Schmied 2000Not a diagnostic accuracy study

Schmielau 1997Not a diagnostic accuracy study

Schneider 2003The proportion of patients who were considered to be resectable after CT scan is not known

Schrenk 1994Number of patients with pancreatic or periampullary cancer was not reported

Schrenk 1995No diagnostic test accuracy data available for diagnostic laparoscopy

Schwab 1996Includes patients with unresectable cancers on CT scan

Sperlongano 2005Not a diagnostic accuracy study

Sperlongano 2006Not a diagnostic accuracy study

Tang 2001No separate data available for pancreatic or periampullary cancer

Tapper 2011No diagnostic test accuracy data available for diagnostic laparoscopy

Taylor 2001No diagnostic test accuracy data available for diagnostic laparoscopy

Terrosu 2000Number of patients with pancreatic or periampullary cancer was not reported

Thomson 2006No diagnostic test accuracy data available for diagnostic laparoscopy

Tilleman 2004Not a diagnostic accuracy study

Tilleman 2004aNo diagnostic test accuracy data available for diagnostic laparoscopy

van Delden 1996No diagnostic test accuracy data available for diagnostic laparoscopy

van Dijkum 1997The proportion of patients who were considered to be resectable after CT scan is not known

Velanovich 1998No separate data available for pancreatic or periampullary cancer

Velanovich 2004No diagnostic test accuracy data available for diagnostic laparoscopy

Velasco 2000The proportion of patients who were considered to be resectable after CT scan is not known

Vollmer 2002Includes patients who were considered to be unresectable by CT scan

Warshaw 1990Not a diagnostic accuracy study

Warshaw 1990aIncludes patients who were considered to be unresectable by CT scan

Watanabe 1993No diagnostic test accuracy data available for diagnostic laparoscopy

Weiner 1995No separate data available for pancreatic or periampullary cancer

White 2001Intervention between index test and reference standard

White 2004Not a diagnostic accuracy study

White 2008Wrong target condition

Wilson 2010Not a diagnostic accuracy study

Yoshida 2002No diagnostic test accuracy data available for diagnostic laparoscopy

Zhao 2003No diagnostic test accuracy data available for diagnostic laparoscopy

 
Tests. Data tables by test
 
Table 1. QUADAS-2 classification

Domain 1: Patient selectionPatient samplingPatients with pancreatic and periampullary cancer considered eligible for surgical resection following a CT scan

Was a consecutive or random sample of patients enrolled?Yes: If a consecutive sample or a random sample of patients with pancreatic and periampullary cancer eligible for surgical resection after CT scan was included in the study
No: If a consecutive sample or a random sample of patients with pancreatic and periampullary cancer eligible for surgical resection after CT scan was not included in the study
Unclear: If this information was not available

Was a case-control design avoided?Yes: If a cohort of patients about to undergo surgical resection were studied
No: If patients who underwent unsuccessful laparotomy (cases) were compared with patients who underwent successful surgical resection (controls). Such studies were excluded
Unclear: We anticipated that we would be able to determine whether the design was case-control

As anticipated, we were able to determine the study design and were able to exclude all case-control studies. So, all studies included in this review were classified as 'yes' for this item

Did the study avoid inappropriate exclusions?Yes: If all patients with pancreatic and periampullary cancer eligible for surgical resection were included
No: If the study excluded patients based on high probability of resectability (for example, small tumours)
Unclear: If this information was not available

Could the selection of patients have introduced bias?Low risk of bias: If 'yes' classification for all the above 3 questions; high risk of bias: if 'no' classification for any of the above 3 questions; unclear risk of bias: if 'unclear' classification for any of the above 3 questions but without a 'no' classification for any of the above three questions

Patient characteristics and settingYes: We included only patients with pancreatic and periampullary cancer who were considered eligible for surgical resection following a CT scan. So, we anticipated all the included studies to be classified as 'yes'
No: We excluded studies where patients were considered unsuitable for surgery after a CT scan. So, we did use this classification
Unclear: We excluded studies in which it was not clear whether the patients had undergone CT scan following which they were still considered suitable for surgical resection

Are there concerns that the included patients and setting do not match the review question?Considering the inclusion criteria of this review, we anticipated that all the included studies would be classified as 'low concern'. However, this was not the case as shown in Figure 5

Domain 2: Index testIndex test(s)Diagnostic laparoscopy with histologic confirmation of metastases

Were the index test results interpreted without knowledge of the results of the reference standard?The index test would always be conducted and interpreted before the reference standard. So, this classification was always 'yes'

If a threshold was used, was it pre-specified?Not applicable

Could the conduct or interpretation of the index test have introduced bias?We anticipated to classify all studies as 'low risk of bias' because diagnostic laparoscopy indicates that structures within the abdomen were inspected, diagnostic laparoscopy would be conducted and interpreted before reference standard and because we excluded any studies without histological confirmation of the metastatic spread

As anticipated, all the studies were classified as 'low risk of bias' for this domain

Are there concerns that the index test, its conduct, or interpretation differ from the review question?Considering the inclusion criteria for this review, we anticipated that all the included studies will be classified as 'low concern'

As anticipated, all the studies were classified as 'low concern' for this domain

Domain 3: Target condition and reference standardTarget condition and reference standard(s)Unresectability. The reasons for unresectability include involvement of adjacent structures or distant metastases. There is currently no universal criteria for unresectability. Consensus exists for the definition of borderline resectable cancers (Abrams 2009). Therefore where there is less tissue involvement than in a borderline resectable cancer the tumour can be considered as resectable
Positive reference standard: confirmation of liver or peritoneal involvement by histopathological examination of suspicious (liver or peritoneal) lesions (irrespective of how the tissues were obtained for histopathological examination). We accepted only paraffin section histology as the reference standard. We also accepted the surgeons judgement of unresectability on laparotomy when biopsy confirmation was not possible (for example, the surgeon may not resect the tumour if it invaded the adjacent blood vessels but will not obtain a biopsy confirmation of this because of the danger posed by resecting a part of a large blood vessel)
Negative reference standard: Cancer was fully resected i.e. clear resection margins on histology

Is the reference standards likely to correctly classify the target condition?Yes: If histological confirmation of distant spread or local infiltration of adjacent structures making the cancer unresectable was obtained. The report on the resection margins showed clearly that the cancer was completely resected. We did not anticipate any studies to meet these criteria because of the danger that biopsy of infiltration of adjacent structures poses
No: If resection margins were not clear of cancer
Unclear: If surgeons' judgement was used to assess unresectability or if the information about the resection margins was not available. We anticipated that most studies will classified as 'unclear' because surgeons' judgement is generally used as a criterion for unresectability in clinical practice

As anticipated, all the studies were classified as 'unclear' for this item

Were the reference standard results interpreted without knowledge of the results of the index tests?It is not possible to perform the reference standard without the knowledge of the results of the index test. However, only patients with suspicious lesions on laparoscopy undergo biopsy and only patients with negative laparoscopy would undergo laparotomy. The results of the index test are unlikely to influence the results of the reference standard. All studies were classified as 'no' for this question

Could the reference standard, its conduct, or its interpretation have introduced bias?Risk of bias was determined as 'low' if the answer to the first question was 'yes', 'high' if the answer to the first question was 'no', and 'unclear' if the answer to the first question was 'unclear'

Are there concerns that the target condition as defined by the reference standard does not match the question?Considering the inclusion criteria for this review, we anticipated that all the included studies would be classified as 'low concern'

As anticipated, all the studies were classified as 'low concern' for this domain

Domain 4: Flow and timingFlow and timingThe cancer may progress if there is long time interval between diagnostic laparoscopy and laparotomy. So, we had chosen an arbitrary time interval of '2' months as an acceptable time interval between diagnostic laparoscopy and laparotomy

Was there an appropriate interval between index test and reference standard?Yes: If the time interval between diagnostic laparoscopy and laparotomy was less than 2 months
No: If the time interval between diagnostic laparoscopy and laparotomy was more than 2 months
Unclear: If the time interval between diagnostic laparoscopy and laparotomy was unclear

Did all patients receive the same reference standard?Yes: If all the patients received the same reference standard (we anticipated that all the studies are classified as 'yes')
No: If different patients received different reference standards.Unclear: If this information was not clear

Were all patients included in the analysis?Yes: If all the patients were included in the analysis irrespective of whether the results were uninterpretable
No: If some patients were excluded from the analysis because of uninterpretable results
Unclear: If this information was not clear

Could the patient flow have introduced bias?Low risk of bias: If 'yes' classification for all the above 3 questions; high risk of bias: if 'no' classification for any of the above 3 questions; unclear risk of bias: if 'unclear' classification for any of the above 3 questions but without a 'no' classification for any of the above three questions

 
Table 2. Prior testing and unresectability

Study nameType of CT scanPrior testing in addition to CT scanProbability of CT resectable disease identified as unresectable by diagnostic laparoscopy or laparotomy

(Pre-test probability)
Number of patients (N) and reasons for CT resectable disease identified as unresectable by diagnostic laparoscopyProbability of CT and diagnostic laparoscopy resectable disease identified as unresectable at laparotomy

(Post-test probability of negative diagnostic laparoscopy)
Number of patients (N) and reasons for CT and diagnostic laparoscopy resectable disease identified as unresectable at laparotomy

Ahmed 2006Helical CT scanNone described35.1N = 9

Liver metastases = 6

Peritoneal metastases = 1

Peritoneal and liver metastases = 2
14.3N = 4

Metastatic disease = 2

Locally advanced disease (1 coeliac artery lymph node, 1 mesenteric vascular involvement) = 2

Arnold 1999No further information on CT scan was availableAll patients underwent endoscopy and ultrasound. Some patients underwent EUS, proportion unclear45.5N = 11

Liver metastases = 6

Peritoneal metastasis = 1

Peritoneal and liver metastases = 3

Peritoneal and omental metastases = 1
18.2N = 4

Liver metastases = 2

Peritoneal metastases = 1

Liver and peritoneal metastases = 1

Arnold 2001No further information on CT scan was availableEndoscopy, ultrasound and MRI. Proportion of patients who received each modality is unclear31.1N = 14

Liver metastases = 8

Peritoneal metastases = 2

Liver and peritoneal metastases = 4
10.6N = 5

Liver metastases = 3

Peritoneal metastases = 2

Metastases in the omentum and mesocolon = 2

Some had spread to more than one location

Brooks 2002Contrast enhanced, thin slice85% of patients underwent ERCP17.4N = 13

Liver metastases = 6

Peritoneal metastases = 5

Other metastatic disease = 2
9.2N = 10

Liver metastases = 3

Vascular invasion = 3

Peritoneal metastases = 1

Local extension = 1

Benign disease = 2

Contreras 2009Pancreas protocol CT scanEUS used in some patients, proportion unclear40.0N = 7

Liver metastases = 4

Peritoneal metastases = 2

Gross regional lymphadenopathy = 1
16.7N = 3

Aortocaval node disease = 1

Liver metastases = 1

Coeliac node disease = 1

Fernandez-Castillo 1995Further details not knownNone described72.4N = 27

Liver metastases = 11

Peritoneal metastases = 3

Omental metastases = 2

Metastases in more than 1 site = 11
63.4N = 87

Vascular invasion at subsequent angiography and did not undergo laparotomy = 42

Peritoneal disease at laparotomy = 2

Reasons for unresectability at laparotomy not stated = 43

John 1995Contrast enhanced dynamic CT scanVarious scanning techniques used. Exact techniques and proportion who received them were unclear70.0N = 14

Liver metastases = 10

Peritoneal metastases = 8

Hilar lymph node involvement = 2

Some had spread to more than one location
53.8N = 14

Metastatic disease = 2

Locally advanced and metastatic disease = 1

Locoregional spread = 11

Kishiwada 2002Helical CT scan All patients received ultrasound62.5Reasons for unresectability not stated0Reasons for unresectability at laparotomy not stated

Lavy 2012No further information on CT scan was availableAll patients received EUS26.9Peritoneal metastases = 519.1N = 9

Metastatic disease = 2

Locally advanced cancer = 7

Menack 2001Contrast enhanced CT scan with thin slices of pancreasTransabdominal ultrasound, EUS and ERCP performed in some patients. Proportion unclear33.3Reasons for unresectability not stated21.7N = 5

Portal vein occlusion = 1

Metastatic disease in the lymph nodes or liver on laparoscopic ultrasound and biopsy = 2

Portal vein encasement = 1

Locally advanced disease at laparotomy = 1

Merchant 1998Further details not knownUltrasound, ERCP and angiography performed on some patients. Proportion unclear40.3N = 104

Liver metastases = 48

Extrapancreatic spread = 41

Nodal spread = 20

Vascular invasion = 37

Some had spread to more than one location
9.0N = 18

Liver metastases = 6

Extrapancreatic disease = 3

Positive nodal disease = 3

Vascular invasion = 2

Benign disease = 4

Reddy 1999Further details not knownNone described37.8N = 29

Liver metastases = 23

Liver and peritoneal metastases = 3

Hepatic, peritoneal and mesenteric metastases = 1

Mesenteric involvement = 2
11.6N = 6

Liver metastases = 4

Peripancreatic lymph node involvement = 2

Reed 1997Further details not knownNone described81.8Reasons for unresectability not stated.77.8N= 7

Local tumour spread = 5

Omental spread = 1

Unclear = 1

Shah 2008Multi-detector row CT using pancreatic protocolNone described63.2N = 9

Metastases = 6

Locally advanced disease = 3
12.5Liver metastasis = 1

Warshaw 1986Further details not knownAll patients received chest roentgenography, transhepatic
cholangiography or ERCP and abdominal ultrasound. Some received coeliac and superior mesenteric angiography
42.5N = 14

Liver metastases = 6

Parietal peritoneal metastases = 7

Omental metastatic disease = 1
11.5Liver metastases = 3

 DL = diagnostic laparoscopy; ERCP = endoscopic retrograde cholangio pancreatography; EUS = endoscopic ultrasound; MRI = magnetic resonance imaging.
All probabilities in the table are reported as percentages.