The efficacy of magnetic resonance cholangiography for the evaluation of patients with suspected choledocholithiasis before laparoscopic cholecystectomy

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

Factors and Outcomes Associated with MRCP Use prior to ERCP in Patients at High Risk for Choledocholithiasis

Background. Consensus guidelines recommend that patients at high risk for choledocholithiasis undergo endoscopic retrograde cholangiopancreatography (ERCP) without additional imaging. This study evaluates factors and outcomes associated with performing magnetic resonance cholangiopancreatography (MRCP) prior to ERCP among patients at high risk for choledocholithiasis. Methods. An institutional administrative database was searched using diagnosis codes for choledocholithiasis, cholangitis, and acute pancreatitis and procedure codes for MRCP and ERCP. Patients categorized as high risk for choledocholithiasis were evaluated. Results. 224 patients classified as high risk, of whom 176 (79%) underwent ERCP only, while 48 (21%) underwent MRCP prior to ERCP. Patients undergoing MRCP experienced longer time to ERCP (72 hours versus 35 hours, p < 0.0001), longer length of stay (8 days versus 6 days, p = 0.02), higher hospital charges ($23,488 versus $19,260, p = 0.08), and higher radiology charges ($3,385 versus $1,711, p < 0.0001). The presence of common bile duct stone(s) on ultrasound was the only independent factor associated with less use of MRCP (OR 0.09, p < 0.0001). Conclusions. MRCP use prior to ERCP in patients at high risk for choledocholithiasis is common and associated with greater length of hospital stay, higher radiology charges, and a trend towards higher hospital charges.

Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones

BACKGROUND

Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are tests used in the diagnosis of common bile duct stones in patients suspected of having common bile duct stones prior to undergoing invasive treatment. There has been no systematic review of the accuracy of EUS and MRCP in the diagnosis of common bile duct stones using appropriate reference standards.

OBJECTIVES

To determine and compare the accuracy of EUS and MRCP for the diagnosis of common bile duct stones.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov until September 2012. We searched the references of included studies to identify further studies and of systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We included studies that provided the number of true positives, false positives, false negatives, and true negatives for EUS or MRCP. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct or symptom free follow-up for at least six months for a negative test, as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones, with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors independently screened abstracts and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently collected the data from each study. We used the bivariate model to obtain pooled estimates of sensitivity and specificity.

MAIN RESULTS

We included a total of 18 studies involving 2366 participants (976 participants with common bile duct stones and 1390 participants without common bile duct stones). Eleven studies evaluated EUS alone, and five studies evaluated MRCP alone. Two studies evaluated both tests. Most studies included patients who were suspected of having common bile duct stones based on abnormal liver function tests; abnormal transabdominal ultrasound; symptoms such as obstructive jaundice, cholangitis, or pancreatitis; or a combination of the above. The proportion of participants who had undergone cholecystectomy varied across studies. Not one of the studies was of high methodological quality. For EUS, the sensitivities ranged between 0.75 and 1.00 and the specificities ranged between 0.85 and 1.00. The summary sensitivity (95% confidence interval (CI)) and specificity (95% CI) of the 13 studies that evaluated EUS (1537 participants; 686 cases and 851 participants without common bile duct stones) were 0.95 (95% CI 0.91 to 0.97) and 0.97 (95% CI 0.94 to 0.99). For MRCP, the sensitivities ranged between 0.77 and 1.00 and the specificities ranged between 0.73 and 0.99. The summary sensitivity and specificity of the seven studies that evaluated MRCP (996 participants; 361 cases and 635 participants without common bile duct stones) were 0.93 (95% CI 0.87 to 0.96) and 0.96 (95% CI 0.90 to 0.98). There was no evidence of a difference in sensitivity or specificity between EUS and MRCP (P value = 0.5). From the included studies, at the median pre-test probability of common bile duct stones of 41% the post-test probabilities (with 95% CI) associated with positive and negative EUS test results were 0.96 (95% CI 0.92 to 0.98) and 0.03 (95% CI 0.02 to 0.06). At the same pre-test probability, the post-test probabilities associated with positive and negative MRCP test results were 0.94 (95% CI 0.87 to 0.97) and 0.05 (95% CI 0.03 to 0.09).

AUTHORS' CONCLUSIONS

Both EUS and MRCP have high diagnostic accuracy for detection of common bile duct stones. People with positive EUS or MRCP should undergo endoscopic or surgical extraction of common bile duct stones and those with negative EUS or MRCP do not need further invasive tests. However, if the symptoms persist, further investigations will be indicated. The two tests are similar in terms of diagnostic accuracy and the choice of which test to use will be informed by availability and contra-indications to each test. However, it should be noted that the results are based on studies of poor methodological quality and so the results should be interpreted with caution. Further studies that are of high methodological quality are necessary to determine the diagnostic accuracy of EUS and MRCP for the diagnosis of common bile duct stones.

Diagnosis of biliary stone disease: T1-weighted magnetic resonance cholangiography with Gd-EOB-DTPA versus T2-weighted magnetic resonance cholangiography

OBJECTIVE

We aimed to compare diagnostic performance of gadoxetic-acid-enhanced-T1-weighted-MR cholangiography (MRC) with that of conventional T2-weighted-MRC in diagnosing biliary stone disease.

MATERIALS AND METHODS

Ninety patients who underwent MRC for evaluation of biliary disease were included. Presence of stones in extrahepatic duct, gallbladder and intrahepatic duct, and presence of acute cholecystitis were evaluated. Sensitivity, specificity, and accuracy of biliary stone disease diagnosis in each biliary duct location according to each image sets were measured.

RESULTS

There was no significant difference in diagnostic performance between two sets of MRC in diagnosing biliary stone disease.

CONCLUSIONS

Diagnostic performance of T1-MRC with gadoxetic-acid in diagnosing biliary stone disease is comparable to that of T2-MRC.

The Value of Magnetic Resonance Cholangio-Pancreatography (MRCP) in the Detection of Choledocholithiasis

INTRODUCTION

Magnetic Resonance Cholangio-Pancreatography (MRCP) is a non-invasive radiological investigation which can be performed rapidly and which does not expose the patients to ionised radiations or iodinated contrast material. The present study was conducted to evaluate the role of MRCP in detection of Common Bile Duct (CBD) stones in patients with suspected choledocholithiasis.

MATERIAL AND METHODS

This prospective study included 30 patients with a suspicion of choledocholithiasis which was based on clinical evaluation, biochemical or radiological investigations. Ultrasonography and MRCP were performed in all patients. All patients underwent open surgery. CBD exploration was performed in all patients, either due to presence of palpable stones or due to the presence of dilated CBD (> 7 mm). Demonstration of CBD stones intra-operatively was considered the 'gold standard' for their presence, defined as stones visualised and extracted or attempted for extraction during surgical CBD exploration.

RESULTS

Intra-operatively, 21 (70%) out of 30 patients had cholelithiasis. 26 (86.67%) out of 30 patients had dilated CBD stones intra-operatively. In 20 (66.67%) out of 30 patients, choledocholithiasis was detected intra-operatively. The sensitivity, specificity, positive and negative predictive value of ultrasonography in detecting CBD stones in the present study was 65%, 60%, 76.47% and 46.15% respectively. The sensitivity, specificity, positive and negative predictive value of MRCP in diagnosis of CBD stones in the present study was 95%, 90%, 95% and 90% respectively.

CONCLUSIONS

MRCP is a non-invasive investigation without complications and it has high sensitivity, specificity and positive and negative predictive values in detection of CBD stones. MRCP should be done in all cases with a suspicion of CBD stones, where facilities and expertise are available.

Estudo ultrassonográfico morfométrico do fígado e trato biliar de suínos submetidos a obstrução biliar experimental

OBJETIVO: Comparar as alterações anatômicas decorrentes de um quadro de icterícia obstrutiva experimental induzida em suínos nos períodos pré e pós-operatório por meio de exame ultrassonográfico. MATERIAIS E MÉTODOS: Seis suínos da raça Landrace, com 36 dias de idade, foram submetidos a obstrução biliar completa mediante ligadura do ducto colédoco por cirurgia videolaparoscópica. RESULTADOS: Não ocorreram dificuldades na execução dos procedimentos obstrutivos e a recuperação cirúrgica foi eficiente. Decorridos sete dias, os animais apresentaram icterícia, bilirrubinúria e acolia fecal. O exame ultrassonográfico comparativo permitiu visualizar hepatomegalia, colecistomegalia e aumento no calibre do ducto colédoco em todos os animais, assim como alterações decorrentes da colestase. A avaliação morfométrica revelou aumento significativo nos diâmetros da vesícula biliar e do lobo hepático lateral esquerdo. CONCLUSÃO: Os suínos representam um modelo experimental adequado de icterícia obstrutiva, e o exame ultrassonográfico demonstrou-se sensível e relevante no diagnóstico das alterações decorrentes de obstrução biliar extra-hepática nesses animais.

[Laparoscopic endoscopy: a new type of combined technique for select patients]

The authors report a new method which was introduced last year in their unit. In a significant part of cholecystolithiasis, choledocholithiasis also exists. The diagnosis is sometimes fairly difficult, in these cases newly developed imaging methods (magnetic resonance cholangiopancreatography, endoscopic ultrasonography) can help. In cases of choledocholithiasis, when preoperative endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful, laparoscopic endoscopy can be performed. Authors describe this method as well as discuss the international literature, and review the cases of their own ten cases with this method. They emphasize the advantages of the new method in a certain subgroup of patients against the traditional sequential approach (preoperative ERCP than laparoscopic cholecystectomy) and also share their technical experiences. Finally, they underline the importance of the team work which supposes the cooperation of the gastroenterologist, surgeon and anesthesiologist in the indication, organization and implementation of the intervention.

Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy?

PURPOSE

We investigated routinely the bile ducts by magnetic resonance cholangiopancreaticography (MRCP) prior to cholecystectomy. The aim of this study was to analyze the rate of clinically inapparent common bile duct (CBD) stones, the predictive value of elevated liver enzymes for CBD stones, and the influence of the radiological results on the perioperative management.

METHODS

In this prospective study, 465 patients were cholecystectomized within 18 months, mainly laparoscopically. Preoperative MRCP was performed in 454 patients.

RESULTS

With MRCP screening, clinically silent CBD stones were found in 4%. Elevated liver enzymes have only a poor predictive value for the presence of CBD stones (positive predictive value, 21%; negative predictive value, 96%). Compared to the recent literature, the postoperative morbidity in this study was low (0 bile duct injury, 0.4% residual gallstones).

CONCLUSIONS

Although MRCP is diagnostically useful in the perioperative management in some cases, its routine use in the DRG-era may not be justified due to the costs.

Avaliação de complicações relacionadas à CPRE em pacientes com suspeita de coledocolitíase

OBJETIVO: Determinar os fatores preditivos de complicações da colangio-pancreatografia retrógrada endoscópica (CPRE) nos doentes com suspeita diagnóstica de coledocolitíase. MÉTODO: Os dados foram coletados retrospectivamente durante o período de agosto de 1999 a janeiro 2005. Foram incluídos os doentes com suspeita diagnóstica de coledocolitíase submetidos à CPRE internados na Santa Casa de Misericórdia de São Paulo. Os doentes com neoplasia de vias biliares ou de pâncreas foram excluídos. Foram avaliados: o sucesso do procedimento, as complicações como pancreatite, sangramento, colangite, perfuração, vômitos, hiperamilasemia e em quais situações estas complicações se desenvolveram. Os testes t de Student, Qui-quadrado e o teste exato de Fisher foram empregados para análise estatística, considerando-se p< 0,05 como significativo. RESULTADOS: Cento e setenta oito doentes foram incluídos, sendo 52 homens e 126 mulheres com média etária de 54,3 + 19,3. A CPRE confirmou o diagnóstico de coledocolitíase em 124 doentes (69,7%), obtendo sucesso no tratamento endoscópico em 92 casos (74,2%). As complicações foram detectadas em 19 doentes (10,7%), com seis casos de pancreatite aguda (3,4%), quatro (2,2%) que tiveram sangramento durante o procedimento endoscópico, dois (1,1%) doentes que desenvolveram colangite, um (0,6%) com perfuração duodenal, quatro (2,2%) com vômitos sem pancreatite e dois (1,1%) com complicações clinicas. A cateterização do ducto pancreático durante a realização do procedimento endoscópico esteve associada com o desenvolvimento de pancreatite aguda (p=0,004). CONCLUSÃO: A cateterização do pâncreas durante a CPRE constituiu um fator preditivo para o desenvolvimento de pancreatite aguda pós-CPRE.

Role of endoscopic ultrasonography in prevention of unnecessary endoscopic retrograde cholangiopancreatography: a prospective study of 150 patients

OBJECTIVE

The purpose of this study was to evaluate the impact of substituting endoscopic ultrasonography (EUS) for endoscopic retrograde cholangiopancreatography (ERCP) in cases of a low to intermediate risk for choledocholithiasis.

METHODS

During a 16-month period, patients who were referred for suspected choledocholithiasis, biliary colic, or acute biliary pancreatitis on the basis of alterations in liver enzyme values with or without gallstones seen on transabdominal ultrasonography were included. Endoscopic ultrasonography was performed for all patients. Patients with common bile duct stones underwent ERCP. Cholecystectomy was recommended in all patients with symptomatic gallstones. Cases were followed for 12 months.

RESULTS

A total of 150 patients were included. Choledocholithiasis was diagnosed by EUS in 39 patients (26.0%) and was confirmed by ERCP in 30 (77.0%). Fifty-one patients had a normal common bile duct, and follow-up for 12 months showed no abnormalities except in 1 patient. Cholecystectomy without ERCP was recommended for the remaining 60 patients who had symptomatic gallstones or sludge. Endoscopic retrograde cholangiopancreatography was avoided by this approach in 110 patients (73.3%).

CONCLUSIONS

In a low to intermediate risk for choledocholithiasis, EUS can preclude the need for ERCP in most cases.

EFFICACY OF MULTI-SLICE COMPUTED TOMOGRAPHY CHOLANGIOGRAPHY BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

BACKGROUND

Bile duct injury is one of the serious surgical complications of laparoscopic cholecystectomy (LC). Clear biliary tract imaging to detect the anomaly of the bile ducts before operation is thought to be useful to prevent this complication. The objective of this study was to investigate the preoperative feasibility of using multi-slice computed tomography scanning after drip infusion cholangiography-computed tomography (DIC-CT) for LC.

METHODS

Laparoscopic cholecystectomies were carried out in 33 patients and DIC-CT and magnetic resonance cholangiography (MRC) were also carried out in all of these patients. We evaluated the recognition of the junction of the cystic duct and detection of anomalies of the extrahepatic bile ducts using the latter two methods.

RESULTS

In 33 patients, DIC-CT showed the junction of the cystic duct in 31 (94%) and MRC in 25 (76%) patients, respectively. Anomalies of the extrahepatic bile ducts or the cystic duct were detected in four (12%) patients by DIC-CT, but MRC could show only one of these lesions. There were no major adverse reactions in either examination.

CONCLUSION

DIC-CT is an efficacious preoperative technique as compared with MRC for the biliary tract imaging. DIC-CT may be of benefit for both patients scheduled to undergo LC and their surgeons.

Role of Magnetic Resonance Cholangiography in the Diagnosis of Bile Duct Lithiasis

AIM

The aim of our study was to assess diagnostic value of magnetic resonance cholangiography (MRC) in patients with suspected common bile duct (CBD) stones focusing on the capability of this noninvasive method to replace invasive diagnostic procedures in these patients and to limit the use of endoscopic retrograde cholangiography (ERC) to the patients who need simultaneous therapeutic intervention.

MATERIALS AND METHODS

Single-shot fast-spin-echo rapid-acquisition thick-section MRC images were obtained in 310 patients recruited into this prospective study. There were 136 male and 174 female patients aged 21-95 years [mean +/- standard deviation (SD) 64.9 +/- 13.6 years]. Patients were subsequently classified into different risk groups (high, moderate, low) according to biochemical abnormalities or morphological features on abdominal ultrasonography and computed tomography. Direct cholangiography was the reference method of CBD evaluation.

RESULTS

CBD stones were diagnosed in 115 (37%) patients; 86 of 175 patients in the high-risk group, 24 of 83 patients in the moderate-risk group, and 5 of 50 patients in the low-risk group. In dependent risk groups, the mean CBD caliber was 9.7 +/- 4.5, 7.1 +/- 2.0, and 4.8 +/- 1.2 mm, respectively. The difference was significant between all three groups (P < 0.05). The median size of CBD stones was 7 mm (range 3-21 mm). MRC achieved accuracy and positive and negative predictive values of 97%, 94%, and 98%, respectively.

CONCLUSIONS

MRC has a potential to substitute diagnostic ERC in all patients with suspected choledocholithiasis due to its high accuracy, reducing invasive direct cholangiography to patients who require therapeutic intervention.

Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study

BACKGROUND & AIMS

The role and potential benefits of endoscopic ultrasonography (EUS) in the management of acute biliary pancreatitis have not been documented. We report a large prospective randomized study comparing early EUS and endoscopic retrograde cholangiopancreatography (ERCP) in the management of these patients.

METHODS

A prospective randomized study was performed on 140 patients with acute pancreatitis suspected to have a biliary cause. The patients were randomized to have EUS (n = 70) or ERCP (n = 70) within 24 hours from admission. In the EUS group, when EUS detected choledocholithiasis, therapeutic ERCP was performed during the same endoscopy session. In the ERCP group, diagnostic ERCP was performed, followed by therapeutic endoscopy when choledocholithiasis was detected.

RESULTS

Examination of the biliary tree by EUS was successful in all patients in the EUS group, whereas cannulation of the common duct during ERCP was unsuccessful in 10 patients (14%) in the ERCP group (P = .001). Combined percutaneous ultrasonography and ERCP missed detection of cholelithiasis in 6 patients in the ERCP group. The overall morbidity rate was 7% in the EUS group, and that in the ERCP group was 14% (P = .172). The hospital stay and mortality rates were comparable in both groups.

CONCLUSIONS

In selected patients with acute biliary pancreatitis, EUS could safely replace diagnostic ERCP in the management for selecting patients with choledocholithiasis for therapeutic ERCP with a higher successful examination rate, a higher sensitivity in the detection of cholelithiasis, and a comparable morbidity rate.

Compression of the common hepatic duct by the right hepatic artery

Magnetic resonance (MR) cholangiography has been used wildly as preoperative examination before laparoscopic cholecystectomy (LSC). However, cases that suggested the stenotic lesion of extrahepatic bile duct are not so rare in MR cholangiography. When stenosis is found, further examination is needed to avoid the possibility of bile duct cancer. We reported a case in which the stenotic lesion was diagnosed compression of the common hepatic duct by the right hepatic artery by multislice CT (MCT) cholangiography.

Clinico-biochemical prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography

BACKGROUND

Occult biliary stones escape detection on conventional investigations, and clinico-biochemical systems proposed for predicting biliary pancreatitis has low predictive values.

AIM

To evaluate the accuracy of clinico-biochemical parameters for prediction of biliary pancreatitis in patients undergoing endoscopic ultrasonography.

METHODS

Early endoscopic ultrasonography was performed on 139 patients presenting with acute pancreatitis within 24 h of admission. The aetiologies of all patients were determined after complete evaluations, and clinico-biochemical characteristics of patients with a biliary cause (biliary group) and non-biliary causes (non-biliary group) were compared.

RESULTS

Biliary pancreatitis was diagnosed in 107 patients and 32 patients had non-biliary causes. The biliary group belonged to a significantly older age group, had a female predominance, significantly more derangement of liver function and a higher incidence of severe attack of acute pancreatitis. On multivariate analysis, female sex, age >58 years and serum alanine aminotransferase >150 U/L were independent predictive factors for biliary cause of acute pancreatitis. Using these three factors for prediction of biliary cause, the sensitivity was 93% and overall accuracy was 85%.

CONCLUSION

Clinico-biochemical prediction for biliary cause of acute pancreatitis improves in the era of endoscopic ultrasonography with a higher sensitivity and overall accuracy. In centres where endoscopic ultrasonography is inaccessible or local expertise is unavailable, clinico-biochemical prediction of biliary cause of acute pancreatitis may provide a useful alternative in the initial management of this group of patients.

Preoperative evaluation of common bile duct stones in patients with gallstone disease

OBJECTIVE

Our objective was to suggest criteria for selection of a preoperative diagnostic technique for patients with gallstone disease.

CONCLUSION

Use of MR cholangiography preferentially before laparoscopic cholecystectomy, on patients who have a moderate or high risk of common bile duct stones, can significantly reduce purely diagnostic endoscopic retrograde cholangiography.

Short- versus long-sequence MRI cholangiography for the preoperative imaging of the common bile duct in patients with cholecystolithiasis

BACKGROUND

This study aimed to compare an 18-s fast spin echo magnetic resonance image sequence (coronal thick-section two-dimensional breathhold) with a three-dimensional axial and coronal thin-section sequence and its secondary reconstruction, and to assess its value in the diagnosis of bile duct pathologies, particularly common bile duct stones (CBDS) before laparoscopic cholecystectomy.

METHODS

This study prospectively included 72 patients. Because of protocol violations, 14 of these patients had to be excluded. Thus, 58 patients (29 Man and 29 women with a mean age of 51 years) who had cholecystolithiasis or suspected choledocholithiasis were evaluated. Magnetic resonance cholangiopancreatography (MRCP) was performed for all patients with a fast sequence (18 s) and a long sequence (coronal oblique and axial respiratory triggered; 16 min). Two radiologists, blinded with respect to diagnosis, evaluated all the radiographic images. The MRCP results were confirmed for all the patients: 20 by endoscopic retrograde cholangiopancreatography, 46 by intraoperative cholangiography, and 2 by percutaneous transhepatic cholangiography.

RESULTS

According to the findings, 16 patients (28%) had CBDS, 6 patients (10%) had common bile duct stenosis, and 36 patients (62%) had a clear bile duct. With regard to CBDS, the short sequence had 100% specificity, 94% sensitivity, and an overall accuracy of 98%. Its negative predictive value was 98%, and its positive predictive value was 100%. The long sequence had a specificity of 100% and a sensitivity of 100%.

CONCLUSION

Because of its high sensitivity and specifity, MRCP has the potential to be the diagnostic method of choice for CBD evaluation. The short sequence is not suitable for the diagnosis of all CBD pathologies, but in cases of suspected CBDS, more than 80% of the patients could be diagnosed correctly, and the complete sequence could be dropped.

Conversion rate of laparoscopic cholecystectomy after endoscopic retrograde cholangiography in the treatment of choledocholithiasis: does the time interval matter?

BACKGROUND

Preceding endoscopic retrograde cholangiography (ERC) in patients with choledochocystolithiasis impedes laparoscopic cholecystectomy (LC) and increases risk of conversion. We studied the influence of time interval between ERC and LC on the course of LC.

METHODS

All patients treated for choledochocystolithiasis with ERC and LC during 1996-2001 were studied retrospectively, comparing the course of LC in three time interval groups; LC < 2, 2-6, and > 6 weeks after ERC.

PRIMARY OUTCOMES

adhesions, bile duct injury, operating time, and conversion-rate.

RESULTS

Eighty-three patients were studied (group 1, n = 23; group 2, n = 15; group 3, n = 45). Adhesions, operation time, and bile duct damage did not significantly differ between the groups. The conversion rate in group 2 is significantly higher compared to group 1 (p = 0.027, OR 11 (1.13-106.8)) CONCLUSIONS: A higher conversion rate of LC is found 2-6 weeks after ERC compared to LC within 2 weeks. However, further research is needed to gain more reliable data on whether this is caused by timing.

Long-term results after laparoscopic transverse choledochotomy for common bile duct stones

BACKGROUND

The aim of this study was to evaluate the long-term results of laparoscopic transverse choledochotomy (TC) during laparoscopic cholecystectomy (LC).

METHODS

Ductal stones were present in 344 of 3,212 patients (10.7%) who underwent LC. The procedure was completed laparoscopically in 329 cases (95.6%), with a TC in 138 cases (41.9%) (the subjects of this study), and with a transcystic duct approach in 191 cases (58.1%).

RESULTS

Biliary drainage was used in 131 of 138 cases (94.9%). There were major complications in eight patients (5.7%), and one patient died (0.7%). Retained stones were seen in 11 cases (8%). None of the patients was lost to follow-up (mean, 72.3 months; range, 11-145). Ductal stones recurred in five patients (3.6%). No signs of bile stasis and no biliary strictures were observed. In all, 121 patients are alive with no biliary symptoms; 16 have died from unrelated causes.

CONCLUSION

Long-term follow-up after laparoscopic TC during LC proved its safety and efficacy.

MR cholangiopancreatography versus endoscopic sonography in suspected common bile duct lithiasis: a prospective, comparative study

OBJECTIVE

Our purpose was to compare the accuracy of MR cholangiopancreatography and endoscopic sonography for the diagnosis of common bile duct stones in patients with a mild to moderate clinical suspicion of common bile duct stones.

SUBJECTS AND METHODS

Forty-seven patients were prospectively enrolled. Inclusion criteria included acute pancreatitis, subclinical jaundice, and clinical features of common bile duct stone migration. Radial endoscopic sonography and MR cholangiopancreatography with the single-shot fast spin-echo technique were performed a maximum of 48 hr apart. The gold-standard diagnosis was obtained with ERCP (n = 20) or intraoperative cholangiography (n = 14) if the results of endoscopic sonography or MR cholangiopancreatography were abnormal or if a cholecystectomy was performed, or by clinical and biochemical follow-up (n = 11) if the results of endoscopic sonography and MR cholangiopancreatography were normal.

RESULTS

The final diagnosis was common bile duct stones in 16 patients, malignant obstructions in four, and another biliary disease in two (lithiasis migration aspect with papillary edema); 23 patients had no biliary disease. The sensitivity and specificity of MR cholangiopancreatography were, respectively, 90.5% and 87.5% for etiologic diagnosis and 87.5% and 96.6% for the detection of common bile duct stones. The corresponding values for endoscopic sonography were 86.4% and 91.3% for etiologic diagnosis and 93.8% and 96.6% for visualization of choledocholithiasis. Accuracy did not significantly differ between the techniques.

CONCLUSION

In cases of mild to moderate suspicion of choledocholithiasis, the accuracies of endoscopic sonography and MR cholangiopancreatography are similar. Because MR cholangiopancreatography is noninvasive, it may be preferred for this indication.

Evaluation of magnetic resonance cholangiography in patients with suspected common bile duct stones before laparoscopic cholecystectomy

AIM: To evaluate the clinical predictive value of magnetic resonance cholangiography (MRC) in selected patients before laparoscopic cholecystectomy (LC).

METHODS: A total of 267 patients scheduled for elective LC from March 1999 to May 2001, with risk factors for common bile duct (CBD) stones, underwent MRC followed by endoscopic retrograde cholangiography (ERC) or intraoperative cholangiography (IOC) to detect the stones in common bile duct and value accuracy of MRC. Suspected patient selection was based on clinical, ultrasonographic, and laboratory criteria. All those with a history of previous jaundice, previous mild gallstone pancreatitis (acute abdominal pain and at least a fourfold increase in serum amylase activity), abnormal liver function test results (especially abnormal bilirubin result) or a dilated common bile duct (more than 8 mm) on ultrasonography were considered to have high suspicion for choledocholithiasis.

RESULTS: During a 26-month period, 267 patients were studied. MRC identified all patients (78 patients) found to have CBD stones by ERC or laparoscopic cholangiography in the study group. 7 patients were incorrectly diagnosed as having CBD stones by MRC. In our study, MRC had a sensitivity of 100.0%, specificity of 96.3%, positive predictive value of 91.8% and negative predictive value of 100.0% for the detection of common bile duct stones. There were 19 patients (7.1%) occurring the ERC procedure-related complications; 11 patients were cholangitis, 7 pancreatitis, and 1 papillary bleeding. The information obtained from MRC could be utilized to select patients who would benefit from preoperative ERC. Using the information, 68.2% (182/267) patients in our group could be away from ERC and its distress. And the complications of preoperative examination would be minimized significantly.

CONCLUSION: ERC is an invasive technique with a well-documented complication rate. MRC is an accurate and simple non-invasive imaging technique for preoperative screening for CBD stones in at-risk patients, which could minimize the need for non-therapeutic ERC.

Endoscopic retrograde cholangiopancreatography, intraductal ultrasonography, and magnetic resonance cholangiopancreatography in bile duct strictures: a prospective comparison of imaging diagnostics with histopathological correlation

OBJECTIVES

A variety of imaging techniques are available to diagnose bile duct strictures; the most effective imaging technique, however, has not been established yet. In the present study, we compared the impact of endoscopic retrograde cholangiopancreatography (ERCP), intraductal ultrasonography (IDUS), and magnetic resonance cholangiopancreatography (MRCP) with regard to diagnosing bile duct strictures.

METHODS

We prospectively examined 33 patients with jaundice due to bile duct strictures by ERCP plus IDUS and MRCP. The objectives were to assess diagnostic quality of imaging, complete presentation of the bile duct, and differentiation of malignant from benign lesions. Surgical and histopathological correlations, which were used as the gold standard, were available in all cases since all included patients underwent laparotomy.

RESULTS

Diagnostic image quality for ERCP was 88% and 76% for MRCP (p > 0.05). Comparing ERCP and MRCP, complete presentation of the biliary tract was achieved in 94% and 82%, respectively (p > 0.05). ERCP and MRCP allowed correct differentiation of malignant from benign lesions in 76% and 58% (p= 0.057), respectively. By supplementing ERCP with IDUS, the accuracy of correct differentiation of malignant from benign lesions increased significantly to 88% (p= 0.0047).

CONCLUSIONS

Comparing ERCP with MRCP, we found adequate presentation of bile duct strictures in high imaging quality for both techniques. ERCP supplemented by IDUS gives more reliable and precise information about differentiation of malignant and benign lesions than MRCP alone without additional imaging sequences.

Magnetic resonance cholangiography: applications in patients with calculus disease of the biliary tract

Magnetic resonance cholangiography (MRC) is a non-invasive imaging modality that has become widely available. In the short time since its introduction, MRC has been shown to possess excellent accuracy for the diagnosis of various biliary pathologies, including choledocholithiasis. Investigations of the clinical applications of MRC are ongoing. This review summarizes the diagnostic capabilities of MRC and discusses its application in the management of patients with gallstone diseases.

Is laparoscopic intraoperative cholangiogram a matter of routine?

BACKGROUND

Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits.

METHODS

Relevant articles in English were identified from the Medline database, and reviewed.

RESULTS

The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01).

CONCLUSIONS

Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.

MR imaging in abdominal emergencies

The use of MR imaging in the emergency setting is evolving. Clear indications include situations in need of contrast media when iodinated contrast cannot be administered or to facilitate assessments in pregnant patients and children when exposure to ionizing radiation is considered unacceptable. The availability of rapid, motion-immune sequences now makes MR imaging a feasible study in less cooperative patients extending the range of patients for whom a diagnostic study can be achieved. Capitalizing on the unique benefits of MR imaging there is optimism that MR imaging can eliminate test redundancy and impact patient care in a cost-effective manner. Further investigations are needed to identify the diagnostic algorithms for which this favorable use holds true.

Biliary motor function in gallstone patients evaluated by fatty-meal MR cholangiography

PURPOSE

To investigate the possibility of evaluating biliary motor function with magnetic resonance cholangiography (MRC).

MATERIALS AND METHODS

Twenty patients with gallstones and 30 control subjects were studied using fatty-meal MRC. After baseline MRC, they were encouraged to drink 250 mL of milk and underwent postprandial MRC every 10 minutes for 60 minutes. Postprandial changes in gallbladder volume and the diameter of the common duct were assessed as indicators of gallbladder contractility and biliary obstruction, respectively. Postprandial dilatation at 60 minutes was considered indicative of persistent biliary obstruction.

RESULTS

Gallbladder ejection fraction was calculated at 66.0% +/- 12.2% (range, 40.3%-88.6%) in the controls. Gallbladder volume expressed as a percentage of the baseline value was significantly larger at 20-60 minutes in the gallstone patients than in the controls. Gallbladder ejection fraction varied widely (mean, 46.4% +/- 24.4%; range, 2.8%-81.5%) and was significantly reduced in comparison with that of the controls (P < 0.01). In two gallstone patients with co-existing ductal stones, transient postprandial dilatation associated with ampullary impaction was observed. Persistent biliary obstruction was not indicated in any subjects.

CONCLUSION

The results of this study suggest the feasibility of fatty-meal MRC, as well as its potential for evaluating biliary motor function.

Mathematical model for predicting biliary therapeutic endoscopic retrograde pancreatography (ERCP)

INTRODUCTION

Magnetic resonance cholangiopancreatography is as sensitive as endoscopic retrograde pancreatography in the evaluation of biliary tract diseases but does not offer therapeutic options. The aim of the present study was to develop a mathematical model to predict 'therapeutic endoscopic retrograde pancreatography' using clinical variables so that patients with low probability could be more appropriately investigated by magnetic resonance cholangiopancreatography in future.

METHODS

Endoscopic retrograde pancreatography cases between January 1996 to December 1997 were retrospectively reviewed (before introduction of magnetic resonance cholangiopancreatography). Clinical, biochemical and radiological variables were analysed and a model was developed using multiple logistic regression.

RESULTS

Case notes for 573 patients were successfully reviewed. A total of 330 patients underwent therapeutic endoscopic retrograde pancreatography (sphincterotomy or stent insertion). Clinical indications of obstructive jaundice and cholangitis, ultrasonographic findings of dilated common bile duct, and raised liver function tests (two or more elevated parameters) were each found to be predictive for 'therapeutic' endoscopic retrograde pancreatography. Using these variables, the mathematical model in the present study has specificity of 77% and sensitivity of 75% at the probability level of 50% or higher. This model has been tested in a separate group of endoscopic retrograde pancreatography cases carried out in 1998 and was found to have sensitivity 77.6%, specificity 80.3%, positive predictive value 68.5% and negative predictive value 86.6%.

CONCLUSIONS

The model reported in the present study can help clinicians to identify cases for therapeutic endoscopic retrograde pancreatography and diagnostic magnetic resonance cholangiopancreatography.

MR cholangiopancreatography: evaluation of common pancreatic diseases

In the evaluation of common pancreatic diseases, MRCP is a noninvasive alternative to ERCP. Ductal anatomy can be ascertained without risk of complications. MRCP is valuable in defining common anatomic variants, determining the state of the pancreatic duct in pancreatitis, and characterizing neoplasms, especially combined with other MR imaging sequences. With the advent of MRCP, techniques requiring endoscopy and percutaneous access are largely reserved for histologic diagnosis and treatment, or for cases in which MRCP fails to establish a diagnosis.

MR cholangiography in symptomatic gallstones: diagnostic accuracy according to clinical risk group

PURPOSE

To determine the diagnostic accuracy of magnetic resonance (MR) cholangiography in the detection of common bile duct (CBD) stones in patients with symptomatic gallstones.

MATERIALS AND METHODS

Single-shot half-Fourier MR cholangiographic images were obtained in 121 consecutive patients who were referred for MR cholangiography prior to cholecystectomy for symptomatic gallstones. One radiologist interpreted the MR cholangiographic images without prior knowledge of laboratory test results or findings from examinations with other imaging modalities. Patients were retrospectively divided into three groups with high, moderate, and low risk (n = 70, 22, and 29, respectively) for CBD stones. The sensitivity, specificity, and accuracy of MR cholangiography in the detection of CBD stones in each group were calculated. The accuracy of laboratory and sonographic findings in the identification of CBD stones was also calculated.

RESULTS

CBD stones were diagnosed in 49 (70%) of 70 patients in the high-risk group. One false-positive diagnosis was made, and two false-negative diagnoses were made. Of the 22 patients in the moderate-risk group, seven (32%) had CBD stones, and there was one false-positive and one false-negative diagnosis. In the low-risk group, CBD stones were correctly identified with MR cholangiography in one patient, and there was one false-positive diagnosis. A combination of positive laboratory and sonographic findings yielded a sensitivity of 98% but a specificity of only 34% if any unusual finding in any one of the tests was regarded as a positive finding.

CONCLUSION

MR cholangiography is highly accurate in the detection of CBD stones in all patients, regardless of the grade of risk, and should be considered in patients with a moderate to high risk of CBD stones before cholecystectomy.

Role of magnetic resonance cholangiopancreatography in patients with suspected choledocholithiasis

OBJECTIVES

To investigate the diagnostic efficacy of magnetic resonance cholangiopancreatography (MRCP) in choledocholithiasis and to determine whether use of MRCP may eliminate the need for purely diagnostic endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

A total of 116 patients with suspected biliopancreatic pathology were studied prospectively between November 1996 and February 1998. Choledocholithiasis was initially suspected in 61 patients and rated before ERCP and MRCP as being of low, intermediate, or high probability based on clinical, laboratory, and/or imaging findings (Cotton criteria).

RESULTS

The sensitivity of choledocholithiasis diagnosis was 91%, with a global efficacy of 90%. The level of duct stone obstruction was visualized in all patients. Suprastenotic dilatation also showed a good correlation to ERCP. Choledocholithiasis was found in 32 patients (65%) and 3 patients (33%) in the high- and intermediate-probability groups, respectively. None of the low-probability patients had choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed for only a diagnostic (not therapeutic) purpose in 3 patients (6%) and 2 patients (22%) of the high- and intermediate-probability cases, respectively.

CONCLUSIONS

Magnetic resonance cholangiopancreatography seems to be effective in diagnosing choledocholithiasis. It plays a fundamental role in patients with a low or intermediate risk of choledocholithiasis, contributing to the avoidance of purely diagnostic ERCP.

Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis

OBJECTIVES

ERCP is the gold standard for pancreaticobiliary evaluation but is associated with complications. Less invasive diagnostic alternatives with similar capabilities may be cost-effective, particularly in situations involving low prevalence of disease. The aim of this study was to compare the performance of endoscopic ultrasound (EUS) with magnetic resonance cholangiopancreatography (MRCP) and ERCP in the same patients with suspected extrahepatic biliary disease. The economic outcomes of EUS-, MRCP-, and ERCP-based diagnostic strategies were evaluated.

METHODS

Prospective cohort study of patients referred for ERCP with suspected biliary disease. MRCP and EUS were performed within 24 h before ERCP. The investigators were blinded to the results of the alternative imaging studies. A cost-utility analysis was performed for initial ERCP, MRCP, and EUS strategies for these patients.

RESULTS

A total of 30 patients were studied. ERCP cholangiogram failed in one patient, and another patient did not complete MRCP because of claustrophobia. The final diagnoses (N = 28) were CBD stone (mean = 4 mm; range = 3-6 mm) in five patients; biliary stricture in three patients, and normal biliary tree in 20. Two patients had pancreatitis after therapeutic ERCP, one after precut sphincterotomy followed by a normal cholangiogram. EUS was more sensitive than MRCP in the detection of choledocolithiasis (80% vs 40%), with similar specificity. MRCP had a poor specificity and positive predictive value for the diagnosis of biliary stricture (76%/25%) compared to EUS (100%/100%), with similar sensitivity. The overall accuracy of MRCP for any abnormality was 61% (95% CI = 0.41-0.78) compared to 89% (CI = 0.72-0.98) for EUS. Among those patients with a normal biliary tree, the proportion correctly identified with each test was 95% for EUS and 65% for MRCP (p < 0.02). The cost for each strategy per patient evaluated was $1346 for ERCP, $1111 for EUS, and $1145 for MRCP.

CONCLUSIONS

In this patient population with a low disease prevalence, EUS was superior to MRCP for choledocholithiasis. EUS was most useful for confirming a normal biliary tree and should be considered a low-risk alternative to ERCP. Although MRCP had the lowest procedural reimbursement, the initial EUS strategy had the greatest cost-utility by avoiding unnecessary ERCP examinations.

Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients

BACKGROUND

ERCP is the standard for detection of choledocholithiasis in patients with acute biliary pancreatitis, and, if performed early, ERCP decreases morbidity. However, there are procedure-related complications. The aim of the present prospective study was to evaluate the ability of EUS to detect choledocholithiasis in patients presenting with acute pancreatitis.

METHODS

The study group comprised 100 consecutive patients who presented with acute pancreatitis. EUS, and immediately thereafter, ERCP were performed by separate blinded examiners within 24 hours of admission. The diagnostic accuracy of EUS in identifying gallbladder stones was compared with that of transcutaneous US. The diagnostic accuracy of EUS in detecting choledocholithiasis was then compared with that of US and ERCP based on the results of endoscopic instrumentation of the bile duct after sphincterotomy.

RESULTS

EUS was more sensitive than US in detecting gallbladder stones (100% vs. 84%, p < 0.005). The sensitivities of ERCP and EUS for choledocholithiasis were both 97%, and the overall accuracies were 96% and 98%, respectively, with no significant difference. EUS detected the absence of choledocholithiasis in 65 of 66 patients (specificity = 98%). Endosonographic examination was successful in all patients, whereas ERCP was unsuccessful in 5 patients (p > 0.05). Post-endoscopic sphincterotomy bleeding developed in 4 patients; there was no EUS-related morbidity (p > 0.05).

CONCLUSION

EUS is more sensitive than US in detecting biliary stones in patients with acute pancreatitis. It is as accurate as ERCP in detecting choledocholithiasis. EUS can be used to select patients with acute pancreatitis who require therapeutic ERCP, thus avoiding diagnostic ERCP and its associated potential for complications in the majority of patients.

Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy

OBJECTIVE

To assess the utility of triage guidelines for patients with cholelithiasis and suspected choledocholithiasis, incorporating selective use of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy (LC).

SUMMARY BACKGROUND DATA

ERCP is the most frequently used modality for the diagnosis and resolution of choledocholithiasis before LC. MRC has recently emerged as an accurate, noninvasive modality for the detection of choledocholithiasis. However, useful strategies for implementing this diagnostic modality for patient evaluation before LC have not been investigated.

METHODS

During a 16-month period, the authors prospectively evaluated all patients before LC using triage guidelines incorporating patient information obtained from clinical evaluation, serum chemistry analysis, and abdominal ultrasonography. Patients were then assigned to one of four groups based on the level of suspicion for choledocholithiasis (group I, extremely high; group 2, high; group 3, moderate; group 4, low). Group 1 patients underwent ERCP and clearance of common bile duct stones; group 2 patients underwent MRC; group 3 patients underwent LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography.

RESULTS

Choledocholithiasis was detected in 43 of 440 patients (9.8%). The occurrence of choledocholithiasis among patients in the four groups were 92.6% (25/27), 32.4% (12/37), 3.8% (2/52), and 0.9% (3/324) for groups 1, 2, 3, and 4, respectively (P <.001). MRC was used for 8.4% (37/440) of patients. Patient triage resulted in the identification of common bile duct stones during preoperative ERCP in 92.3% (36/39) of the patients. Unsuspected common bile duct stones occurred in six patients (1.4%).

CONCLUSIONS

The probability of choledocholithiasis can be accurately assessed based on information obtained during the initial noninvasive evaluation. Stratification of risks for choledocholithiasis facilitates patient management with the most appropriate diagnostic studies and interventions, thereby improving patient care and resource utilization.