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This review aimed at assessing current guidelines' methodological quality systematically for pancreatic cancer's diagnosis and to reveal the heterogeneity of the recommendations among the evaluated guidelines. A systematic search was conducted to find the latest guidelines for pancreatic cancer's diagnosis. The Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to assess the qualified guidelines' feature. We extracted the main recommendations for the diagnosis of pancreatic cancer from the guidelines and performed a heterogeneity evaluation. The highest-level evidence that supported these recommendations was further extracted and analysed. Nine guidelines for the diagnosis of pancreatic cancer were included in this study. Four of the guidelines had an overall score of more than 60% and thus are recommended for clinical use. Further analysis of the heterogeneity of the main recommendations for the diagnosis of pancreatic cancer in the guidelines revealed that the recommendations vary greatly among the different guidelines. The main reasons for the great differences include the neglect of symptoms and signs, great differences in the items involved in recommendations for the diagnosis of pancreatic cancer, inconsistent recommendations for some indicators (carbohydrate antigen 19-9 and ERCP), the unreasonable citation of evidence, and the failure of some recommendations to provide evidence supporting the recommendations. For most recommendations, there was a low level of evidence and a dearth of high-quality study evidence. Recommendations for pancreatic cancer diagnosis have been significantly inconsistent over the past five years. The quality of the guidelines for diagnosing pancreatic cancer also varies. The improvement by the guideline creators of the factors that contribute to the differences mentioned above will be a shortcut to update the guidelines for the diagnosis of pancreatic cancer., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/gs-20-676). The authors declare that they have no competing interests., (2021 Gland Surgery. All rights reserved.)

Background: Recently a small cohort study demonstrated that intravoxel incoherent motion (IVIM) diffusion MRI can detect early stage liver fibrosis. Using modified IVIM data acquisition parameters, the current study aims to confirm this finding., Methods: Twenty-six healthy volunteers, three patients of chronic viral hepatitis-b but without fibrosis and one mild liver steatosis subject, and 12 viral hepatitis-b patients with fibrosis (stage 1-2=7, stage 3-4=5) were included in this study. With a 1.5-T MR scanner and respiration-gating, IVIM diffusion imaging was acquired using a single-shot echo-planar sequence with a b -value series of 2, 0, 1, 15, 20, 30, 45, 50, 60, 80, 100, 200, 300, 600, 800 s/mm 2 . Signal measurement was performed on right liver parenchyma. The first three very low b -values were excluded to improve the curve fitting stability, and bi-exponential segmented fitting was performed using the 12 b -values of 15~800 s/mm 2 . Both threshold b -values of 60 s/mm 2 and 200 s/mm 2 were tested. With a 3-dimensional tool, Dslow ( D ), PF ( f ) and Dfast ( D* ) values were placed along the x-axis, y-axis, and z-axis, and a plane was defined to separate healthy volunteers from liver fibrosis patients., Results: Threshold b -value of 60 s/mm 2 was preferred over 200 s/mm 2 for separating healthy volunteers and liver fibrosis patients. The IVIM measures of the four patients without fibrosis resembled those of healthy volunteers. When threshold b -value =60 s/mm 2 was applied, PF (PF <6.49%) could differentiate healthy livers and all fibrotic livers with 100% sensitivity and specificity. For the patients' measurement, PF and Dfast were highly correlated with a Pearson correlation coefficient r of 0.865 (P<0.001); while the correlations between slow diffusion compartment (Dslow) and fast diffusion compartment (Dfast or PF) were not statistically significant., Conclusions: This study confirms previous report that IVIM diffusion MRI has high diagnostic performance in detecting viral hepatitis-b induced liver fibrosis., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.