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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 39-50

An international study of interobserver variability of “string sign” of pancreatic cysts among experienced endosonographers


1 Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
2 Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
3 Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
4 Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas Health Science Center, Houston, TX, USA
5 Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
6 Division of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, TX, USA
7 Department of Gastroenterology, Ascension Hospital, Racine, Wisconsin, USA
8 Department of Medicine, LSU Health Sciences Center, New Orleans, LA, USA
9 Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan
10 Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
11 Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyberabad, Telangana, India
12 Division of Endoscopy, Gastro Unit, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
13 Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy, Craiova; Department of Gastroenterology, Ponderas Academic Hospital Bucharest, Romania
14 Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
15 Department of Endoscopy, Institute Paoli-Calmettes, Marseille, France
16 Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

Correspondence Address:
Manoop S Bhutani
Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Bovlevard, Unit 1466, Houston, 77030-4009 TX
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_73_20

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Background and Objectives: No single optimal test reliably determines the pancreatic cyst subtype. Following EUS-FNA, the “string sign” test can differentiate mucinous from nonmucinous cysts. However, the interobserver variability of string sign results has not been studied. Methods: An experienced endosonographer performed EUS-FNA of pancreatic cysts on different patients and was recorded on video performing the string sign test for each. The videos were shared internationally with 14 experienced endosonographers, with a survey for each video: “Is the string sign positive?” and “If the string sign is positive, what is the length of the formed string?” Also asked “What is the cutoff length for string sign to be considered positive?” Interobserver variability was assessed using the kappa statistic (κ). Results: A total of 112 observations were collected from 14 endosonographers. Regarding string sign test positivity, κ was 0.6 among 14 observers indicating good interrater agreement (P < 0.001) while κ was 0.38 when observers were compared to the index endosonographer demonstrating marginal agreement (P < 0.001). Among observations of the length of the string in positive samples, 89.8% showed >5 mm of variability (P < 0.001), indicating marked variability. There was poor agreement on the cutoff length for a string to be considered positive. Conclusion: String sign of pancreatic cysts has a good interobserver agreement regarding its positivity that can help in differentiating mucinous from nonmucinous pancreatic cysts. However, the agreement is poor on the measured length of the string and the cutoff length of the formed string to be considered a positive string sign.


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