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In Detection of Esophageal Varices in Patients with Cirrhosis: a Meta-Analysis

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In Detection of Esophageal Varices in Patients with Cirrhosis: a Meta-Analysis Submit a Manuscript: http://www.wjgnet.com/esps/ World J Gastroenterol 2017 January 14; 23(2): 345-356 Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx ISSN 1007-9327 (print) ISSN 2219-2840 (online) DOI: 10.3748/wjg.v23.i2.345 © 2017 Baishideng Publishing Group Inc. All rights reserved. META-ANALYSIS Diagnostic accuracy of transient elastography (FibroScan) in detection of esophageal varices in patients with cirrhosis: A meta-analysis Ke Pu, Jing-Hong Shi, Xu Wang, Qian Tang, Xin-Jie Wang, Kai-Lin Tang, Zhong-Qi Long, Xing-Sheng Hu Ke Pu, Zhong-Qi Long, School of Clinical Medicine, Dazhou Manuscript source: Unsolicited manuscript College of Chinese Medicine, Dazhou 635000, Sichuan Province, China Correspondence to: Dr. Xing-Sheng Hu, Department of Oncology, Nanchong Central Hospital (The Second Affiliated Jing-Hong Shi, Department of Immunology, Shaanxi University Hospital of North Sichuan Medical College), No.66 Dabei Road, of Chinese Medicine, Xi’an 712046, Shaanxi Province, China Shunqing District, Nanchong 637000, Sichuan Province, China. [email protected] Xu Wang, Department of Hepatobiliary Surgery, Dachuan Telephone: +86-18123180715 Southern Hospital, Dazhou 635000, Sichuan Province, China Fax: +86-818-2698292 Qian Tang, School of Nursing, Georgia Southern University, Received: July 28, 2016 Statesboro, GA 30458, United States Peer-review started: August 2, 2016 First decision: September 20, 2016 Xin-Jie Wang, School of Life Science, Northwest University, Revised: September 29, 2016 Xi’an 712046, Shaanxi Province, China Accepted: October 31, 2016 Article in press: October 31, 2016 Kai-Lin Tang, General Surgery Department of Jinshan Hospital, Published online: January 14, 2017 The First Affiliated Hospital of Chongqing Medical University, Chongqing 400010, Sichuan Province, China Xing-Sheng Hu, Department of Oncology, Nanchong Central Hospital (The Second Affiliated Hospital of North Sichuan Abstract Medical College), Nanchong 637000, Sichuan Province, China AIM Author contributions: All authors contributed equally to this To investigate the diagnostic accuracy of FibroScan paper with conception and design of the study, literature review (FS) in detecting esophageal varices (EV) in cirrhotic and analysis, drafting and critical revision and editing, and final patients. approval of the version to be published. METHODS Conflict-of-interest statement: The authors declare that there Through a systemic literature search of multiple data- are no conflicts of interest regarding this manuscript. bases, we reviewed 15 studies using endoscopy as a Data sharing statement: No additional data are available. reference standard, with the data necessary to calculate pooled sensitivity (SEN) and specificity (SPE), positive Open-Access: This article is an open-access article which was and negative LR, diagnostic odds ratio (DOR) and area selected by an in-house editor and fully peer-reviewed by external under receiver operating characteristics (AUROC). reviewers. It is distributed in accordance with the Creative The quality of the studies was rated by the Quality Commons Attribution Non Commercial (CC BY-NC 4.0) license, Assessment of Diagnostic Accuracy studies-2 tool. which permits others to distribute, remix, adapt, build upon this Clinical utility of FS for EV was evaluated by a Fagan work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and plot. Heterogeneity was explored using meta-regression the use is non-commercial. See: http://creativecommons.org/ and subgroup analysis. All statistical analyses were licenses/by-nc/4.0/ conducted via Stata12.0, MetaDisc1.4 and RevMan5. WJG|www.wjgnet.com 345 January 14, 2017|Volume 23|Issue 2| Pu K et al . FibroScan for the detection of EV RESULTS the leading cause of death in patients with cirrhosis, In 15 studies (n = 2697), FS detected the presence with an in­hospital mortality of 14.2%­14.5%[2,3]. En­ of EV with the summary sensitivities of 84% (95%CI: doscopic screening for EV is recommended for the 81.0%-86.0%), specificities of 62% (95%CI: 58.0%- diagnosis, prevention, and management in patients 66.0%), a positive LR of 2.3 (95%CI: 1.81-2.94), a with cirrhosis via surveillance with frequency related to negative LR of 0.26 (95%CI: 0.19-0.35), a DOR of the degree and treatment of varices[1]. Nevertheless, 9.33 (95%CI: 5.84-14.92) and an AUROC of 0.8262. a generalized program of periodical and repeated FS diagnosed the presence of large EV with the pooled esophagogastroduodenoscopy (EGD) examination can SEN of 0.78 (95%CI: 75.0%-81.0%), SPE of 0.76 result in unnecessary economic burden, and subject (95%CI: 73.0%-78.0%), a positive and negative the patient to an uncomfortable feeling without general LR of 3.03 (95%CI: 2.38-3.86) and 0.30 (95%CI: anesthesia or profound sedation. All of these reasons 0.23-0.39) respectively, a summary diagnostic OR of lead to decline in patient compliance with treatment 10.69 (95%CI: 6.81-16.78), and an AUROC of 0.8321. A meta-regression and subgroup analysis indicated and follow­ups. Meanwhile, the endoscopy­related complications reported by a related article is close to different etiology could serve as a potential source of [4] heterogeneity in the diagnosis of the presence of EV 0.1% of incidence . group. A Deek’s funnel plot suggested a low probability Moreover, approximately 50% of cirrhotic patients for publication bias. may not develop EV in the 10­year period after the initial cirrhosis diagnosis[5], and prophylactic medication CONCLUSION with beta­blockers or invasive preventive treatments Using FS to measure liver stiffness cannot provide high such as endoscopic sclerosis or band ligation[1] should accuracy for the size of EV due to the various cutoff have been initiated after diagnosis. Actually, according and different etiologies. These limitations preclude to the point prevalence of medium and significant widespread use in clinical practice at this time; there- varices the highest risk of hemorrhage is only 15% to fore, the results should be interpreted cautiously given 25%, and the majority of patients with cirrhosis who its SEN and SPE. undergo screening EGD either do not have varices or have small EV that do not require prophylactic Key words: Transient elastography; FibroScan; Liver therapy[6]. To avoid unnecessary endoscopy in low­risk cirrhosis; Meta-analysis; Esophageal varices patients, more noninvasive tests have been carried out as substitution to replace endoscopy for EV screening. © The Author(s) 2017. Published by Baishideng Publishing Transient elastography (TE) with FibroScan (FS; Group Inc. All rights reserved. Echosens, Paris, France), which measures liver stiffness (LS) depending on the calculation of liver frequency Core tip: Esophageal varices (EV) is the main relevant [7] portosystemic collaterals in cirrhotic patients. He- elastic wave inside the liver , has been recognized as a morrhage from EV remains the leading cause of death rapid, non­invasive technique for evaluating the severity in cirrhosis. Although more non-invasive techniques for of liver disease, and has been found to be useful in the evaluating the severity of EV have been carried out, the diagnosis of the underlying stage of fibrosis in recent [8­11] cutoff value and validity are not clear. Hence, this study studies . Therefore, FS has the potential to be used [12] examining the basis for clinical application of transient for the non­invasive evaluation of EV . elastography [FibroScan (FS)] assessed whether there Although there are few studies that have focused is sufficient evidence to recommend FS to predict EV. on the correlation between LS and the presence of EV The result demonstrates that the cutoff of FS cannot or the severity of EV, the cutoffs and validities vary provide high accuracy due to the various etiologies, in the different factors, including different studies, and the value of FS should be interpreted cautiously. techniques of measuring LS, fibrosis stages and etio­ logies of hepatic cirrhosis[13]. Hence, the aim of this meta­analysis of the basis for clinical application and Pu K, Shi JH, Wang X, Tang Q, Wang XJ, Tang KL, Long ZQ, research was to assess whether there is sufficient Hu XS. Diagnostic accuracy of transient elastography (FibroScan) evidence to recommend FS as a noninvasive screening in detection of esophageal varices in patients with cirrhosis: method as compared with EGD as the reference A meta-analysis. World J Gastroenterol 2017; 23(2): 345-356 standard for predicting the presence of EV and high­ Available from: URL: http://www.wjgnet.com/1007-9327/full/ risk EV in patients with cirrhosis. v23/i2/345.htm DOI: http://dx.doi.org/10.3748/wjg.v23.i2.345 MATERIALS AND METHODS Study selection INTRODUCTION Electronic databases, including PubMed, EMBASE, Web Esophageal varices (EV) is the main relevant porto­ of Science and Cochrane Library, were used to perform systemic collaterals and are present in approximately systematic search for all relevant clinical articles on 50% of cirrhotic patients[1]. Hemorrhage from EV remains evaluation of LS for diagnosis of EV in cirrhotic patients WJG|www.wjgnet.com 346 January 14, 2017|Volume 23|Issue 2| Pu K et al . FibroScan for the detection of EV from the time of database inception to January 1, values on the basis of the sensitivities and specificities 2016 by applying heading terms and key words of “TE”, offered. However, summary statistics observed the “EV” and “liver cirrhosis”. The process of trials selection diagnostic threshold effect analyzed by Spearman’s were assessed by two review authors (Wang XJ, Tang correlation coefficient and P value. If there was no KL) independently and blindly. The references were significant threshold effect, the diagnostic accuracy screened by titles and abstracts firstly and then further was estimated by pooled statistics; on the contrary, the selected by reading the full­text to exclude irrelevant diagnostic accuracy was evaluated by only AUSROC reports according to the inclusion criteria.
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