Diagnostic Meta-Analysis: Case Study in Surgery

  • Eliana Al Haddad
  • Hutan Ashrafian
  • Thanos AthanasiouEmail author


Surgery and surgical research are continually expanding fields that derive from the increasing global volume of surgical patients and pathology combined with the growth of surgical capability and novel technological innovations. As a result, there are associated diagnostic requirements due to the expansive nature of available surgical techniques, tools, and surgical evidence. Diagnostic accuracy meta-analysis can help clarify diagnostic decisions in all elements of the surgical patient pathway including the quantitative synthesis of evidence for (1) specific elements to the pre-, peri-, and postoperative period, (2) surgical and medical pathology, (3) advances in disease imaging and tissue guidance, and (4) awareness of new devices ranging from operative monitoring/diagnostic devices, stapling instruments, and robots. The process and methodology of diagnosis meta-analysis in surgery is described with contemporary surgical cases. Techniques of data presentation and analysis are reviewed for surgical procedures and pathologies. Barriers and typical problems in surgical diagnostic meta-analysis are also considered and discussed. Diagnostic meta-analytical techniques can offer a prime solution through which to process the ever-increasing volume of surgical outcome data into meaningful information for enhancing clinical outcomes, supporting safety, and developing the next generation of cutting-edge surgical technology.


Diagnostic Meta-analysis Surgery Operation Intraoperative Preoperative Postoperative 


  1. 1.
    Sackett DL, Haynes RB. On the need for evidence-based medicine. EBM Notebook. 1995;1:5–6.Google Scholar
  2. 2.
    Glass GV. Primary, secondary and meta-analysis of research. Educ Res. 1976;5:3–8.CrossRefGoogle Scholar
  3. 3.
    St John ER, Al-Khudairi R, Ashrafian H, Athanasiou T, Takats Z, Hadjiminas DJ, Darzi A, Leff DR. Diagnostic accuracy of intraoperative techniques for margin assessment in breast cancer surgery. Ann Surg. 2017;265:300–10.CrossRefGoogle Scholar
  4. 4.
    Marconi L, Dabestani S, Lam TB, Hofmann F, Stewart F, Norrie J, Bex A, Bensalah K, Canfield SE, Hora M, Kuczyk MA, Merseburger AS, Mulders PF, Powles T, Staehler M, Ljungberg B, Volpe A. Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. Eur Urol. 2016;69:660–73.CrossRefPubMedGoogle Scholar
  5. 5.
    Cousin F, Ortega-Deballon P, Bourredjem A, Doussot A, Giaccaglia V, Fournel I. Diagnostic accuracy of procalcitonin and C-reactive protein for the early diagnosis of intra-abdominal infection after elective colorectal surgery. Ann Surg. 2016;264:252–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Yu C-W, Juan L-I, Wu M-H, Shen C-J, Wu J-Y, Lee C-C. Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis. Br J Surg. 2012;100:322–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Chang S-H, Stoll CRT, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery. JAMA Surg. 2014;149:275.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Holland BJ, Myers JA, Woods CR. Prenatal diagnosis of critical congenital heart disease reduces risk of death from cardiovascular compromise prior to planned neonatal cardiac surgery: a meta-analysis. Ultrasound Obstet Gynecol. 2015;45:631–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Tack P, Victor J, Gemmel P, Annemans L. 3D-printing techniques in a medical setting: a systematic literature review. Biomed Eng Online. 2016;15:115.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Aziz O, Ashrafian H, Jones C, Harling L, Kumar S, Garas G, Holme T, Darzi A, Zacharakis E, Athanasiou T. Laparoscopic ultrasonography versus intra-operative cholangiogram for the detection of common bile duct stones during laparoscopic cholecystectomy: a meta-analysis of diagnostic accuracy. Int J Surg. 2014;12:712–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Sheikhbahaei S, Trahan TJ, Xiao J, Taghipour M, Mena E, Connolly RM, Subramaniam RM. FDG-PET/CT and MRI for evaluation of pathologic response to neoadjuvant chemotherapy in patients with breast cancer: a meta-analysis of diagnostic accuracy studies. Oncologist. 2016;21:931–9.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Lai SW, Roberts DJ, Rabi DM, Winston KY. Diagnostic accuracy of fine needle aspiration biopsy for detection of malignancy in pediatric thyroid nodules: protocol for a systematic review and meta-analysis. Syst Rev. 2015;4:120.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Kelly GA. Meta-analysis: an introduction. Accessed 2 July 2018.
  14. 14.
    Maffione AM, Lopci E, Bluemel C, Giammarile F, Herrmann K, Rubello D. Diagnostic accuracy and impact on management of 18F-FDG PET and PET/CT in colorectal liver metastasis: a meta-analysis and systematic review. Eur J Nucl Med Mol Imaging. 2014;42:152–63.CrossRefPubMedGoogle Scholar
  15. 15.
    Leeflang MM, Deeks JJ, Takwoingi Y, Macaskill P. Cochrane diagnostic test accuracy reviews. Syst Rev. 2013;2:82.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Leeflang MM. Systematic reviews and meta-analyses of diagnostic test accuracy. Clin Microbiol Infect. 2014;20:105–13.CrossRefPubMedGoogle Scholar
  17. 17.
    Habbema J, Eijkemans R, Krijnen P, Knottnerus J. Analysis of data on the accuracy of diagnostic tests. In: Knottnerus J, Buntinx F, editors. The evidence base of clinical diagnosis: theory and methods of diagnostic research. 2nd ed. London: BMJ Publishing Group; 2009. p. 118–45.Google Scholar
  18. 18.
    Wolf FM. Introduction to systematic reviews and meta analysis. Accessed 2 July 2018.
  19. 19.
    Egger M, Smith GD. Potentials and promise. BMJ. 1997;315:1371–4.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Whiting P, Rutjes AWS, Westwood ME, et al., QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–36.CrossRefPubMedGoogle Scholar
  21. 21.
    Meade MO. Selecting and appraising studies for a systematic review. Ann Intern Med. 1997;127:531–7.CrossRefPubMedGoogle Scholar
  22. 22.
    LeLorier J, Grégoire G, Benhaddad A, Lapierre J, Derderian F. Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med. 1997;337:536–42.CrossRefPubMedGoogle Scholar
  23. 23.
    Performance of methods for meta-analysis of diagnostic test accuracy with few studies or sparse data. (n.d.). Accessed 2 July 2018.
  24. 24.
    Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005;58:982–90.CrossRefPubMedGoogle Scholar
  25. 25.
    Rutter CM, Gatsonis C. A hierarchical regression approach to meta-analysis of diagnostic test accuracy evaluations. Stat Med. 2001;20:2865–84.CrossRefPubMedGoogle Scholar
  26. 26.
    Garas G, Ibrahim A, Ashrafian H, Ahmed K, Patel V, Okabayashi K, Skapinakis P, Darzi A, Athanasiou T. Evidence-based surgery: barriers, solutions, and the role of evidence synthesis. World J Surg. 2012;36:1723–31.CrossRefPubMedGoogle Scholar
  27. 27.
    Centre for Evidence Based Medicine. Levels of evidence. Oxford: University of Oxford; 2011.Google Scholar
  28. 28.
    Solomon MJ, McLeod RS. Clinical studies in surgical journals–have we improved? Dis Colon Rectum. 1993;36:43–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Egger M, Smith GD, Phillips AN. Meta-analysis: principles and procedures. BMJ. 1997;315:1533–7.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Egger M, Smith GD. Bias in location and selection of studies. BMJ. 1998;316:61–6.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Treskes N, Persoon AM, Van Zanten ARH. Diagnostic accuracy of novel serological biomarkers to detect acute mesenteric ischemia: a systematic review and meta-analysis. Intern Emerg Med. 2017;12:821–36.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Puli SR. Diagnostic accuracy of endoscopic ultrasound in pancreatic neuroendocrine tumors: a systematic review and meta analysis. World J Gastroenterol. 2013;19:3678.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Waaijer L, Simons JM, Borel Rinkes IHM, Van Diest PJ, Verkooijen HM, Witkamp AJ. Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge. Br J Surg. 2016;103:632–43.CrossRefPubMedGoogle Scholar
  34. 34.
    Meads C, Davenport C, Małysiak S, Kowalska M, Zapalska A, Guest P, Martin-Hirsch P, Borowiack E, Auguste P, Barton P, Roberts T, Khan K, Sundar S. Evaluating PET-CT in the detection and management of recurrent cervical cancer: systematic reviews of diagnostic accuracy and subjective elicitation. BJOG Int J Obstet Gynaecol. 2013;121:398–407.CrossRefGoogle Scholar
  35. 35.
    Thomas B, Guo D. The diagnostic accuracy of evoked potential monitoring techniques during intracranial aneurysm surgery for predicting postoperative ischaemic damage: a systematic review and meta-analysis. World Neurosurg. 2017;103:829–40.CrossRefPubMedGoogle Scholar
  36. 36.
    Thirumala PD, Crammond DJ, Loke YK, Cheng HL, Huang J, Balzer JR. Diagnostic accuracy of motor evoked potentials to detect neurological deficit during idiopathic scoliosis correction: a systematic review. J Neurosurg Spine. 2017;26:374–83.CrossRefPubMedGoogle Scholar
  37. 37.
    Bossers SM, De Boer RDH, Boer C, Peerdeman SM. The diagnostic accuracy of brain microdialysis during surgery: a qualitative systematic review. Acta Neurochir (Wien). 2012;155:345–53.CrossRefGoogle Scholar
  38. 38.
    Burch J, Marson A, Beyer F, Soares M, Hinde S, Wieshmann U, Woolacott N. Dilemmas in the interpretation of diagnostic accuracy studies on presurgical workup for epilepsy surgery. Epilepsia. 2012;53:1294–302.CrossRefPubMedGoogle Scholar
  39. 39.
    Sørensen CG, Karlsson WK, Pommergaard H-C, Burcharth J, Rosenberg J. The diagnostic accuracy of carcinoembryonic antigen to detect colorectal cancer recurrence—a systematic review. Int J Surg. 2016;25:134–44.CrossRefPubMedGoogle Scholar
  40. 40.
    Patel HD, Johnson MH, Pierorazio PM, Sozio SM, Sharma R, Iyoha E, Bass EB, Allaf ME. Diagnostic accuracy and risks of biopsy in the diagnosis of a renal mass suspicious for localized renal cell carcinoma: systematic review of the literature. J Urol. 2016;195:1340–7.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Soubra A, Hayward D, Dahm P, Goldfarb R, Froehlich J, Jha G, Konety BR. The diagnostic accuracy of 18F-fluorodeoxyglucose positron emission tomography and computed tomography in staging bladder cancer: a single-institution study and a systematic review with meta-analysis. World J Urol. 2016;34:1229–37.CrossRefPubMedGoogle Scholar
  42. 42.
    Mojadidi MK, Bogush N, Caceres JD, Msaouel P, Tobis JM. Diagnostic accuracy of transesophageal echocardiogram for the detection of patent foramen ovale: a meta-analysis. Echocardiography. 2013;31:752–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Reiman MP, Goode AP, Cook CE, Hölmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2014;49:811.CrossRefPubMedGoogle Scholar
  44. 44.
    Li B, Li Q, Chen C, Guan Y, Liu S. Diagnostic accuracy of computer tomography angiography and magnetic resonance angiography in the stenosis detection of autologous hemodialysis access: a meta-analysis. PLoS One. 2013;8:e78409.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Eliana Al Haddad
    • 1
  • Hutan Ashrafian
    • 2
  • Thanos Athanasiou
    • 2
    • 3
    Email author
  1. 1.The Division of Cardiac Surgery, Department of SurgeryColumbia UniversityNew YorkUSA
  2. 2.The Department of Surgery and CancerImperial College LondonLondonUK
  3. 3.Department of Cardiac Surgery, Imperial College Healthcare NHS TrustLondonUK

Personalised recommendations