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Context The optimal approach to pre-operative imaging assessment of pancreatic cancer is unknown. Objective The aim ofthis meta-analysis was to assess accuracy and performance characteristics of EUS in determining nodal staging, vascularinvasion, and prediction of resectability of pancreatic cancer. A secondary aim was to perform head to head comparison ofperformance characteristics between EUS and CT for nodal staging, vascular invasion and resectability. Design Data fromEUS studies were pooled according to bivariate generalized random effects model. Pooled estimates for CT were obtainedfrom studies which performed head to head comparison between EUS and CT. Patients Patients with pancreatic cancerundergoing pre-operative imaging assessment. Intervention EUS. Main outcome measure Pooled sensitivity, specificity,positive and negative predictive values of EUS for nodal staging, vascular invasion and resectability. Results Forty-ninestudies were considered of which 29 met inclusion criteria with a total of 1,330 patients. Pooled summary estimates for EUSnodal staging were 69% for sensitivity and 81% for specificity. For vascular invasion, sensitivity was 85% and specificity was 91%. The sensitivity and specificity for resectability was 90% and 86%, respectively. CT scan showed lower sensitivity than EUS for nodal staging (24% vs. 58%) and vascular invasion (58% vs. 86%); however, the specificities for nodal staging (88%vs. 85%) and vascular invasion (95% vs. 93%) were comparable in studies where both imaging techniques were performed. The sensitivity and specificity of CT in determining resectability (90% and 69%) was similar to that of EUS (87% and 89%). Conclusions EUS is an accurate pre-operative tool in the assessment of nodal staging, vascular invasion and resectability in patients with pancreatic cancer.