MRCP in patient care: a prospective survey of gastroenterologists

The Role of Laparoscopic Ultrasonography in the Evaluation of Suspected Choledocholithiasis. A Single-Center Experience

Background and objectives: Opinions differ regarding the optimal diagnostic methods for patients with suspected choledocholithiasis. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) and compare it to pre-operative magnetic resonance cholangio-pancreatography (MRCP); Materials and Methods: In all patients with suspected choledocholithiasis LUS was performed during laparoscopic cholecystectomy to evaluate biliary stones. According to availability, part of the patients had pre-operative MRCP. Data for diagnostic accuracy and main outcomes were collected prospectively and analyzed retrospectively; Results: Choledocholithiasis was detected in 178 of 297 patients by LUS (59.93%) and in 39 of 87 patients by MRCP (44.8%), p = 0.041. LUS yielded a sensitivity of 99.4%, a specificity of 94.3%, a positive predictive value of 96.1% and a negative predictive value of 99.1%. However, pre-operative MRCP had a sensitivity of 61.7%, a specificity of 92.3%, a positive predictive value of 94.9% and a negative predictive value of 51.1%. Moreover, of the 47 patients with no choledocholithiasis by MRCP, in 23 cases it was later detected by LUS (a false negative MRCP finding—38.3%), p < 0.001. Median duration of hospitalization was significantly shorter in patients evaluated without pre-operative MRCP—8 days (interquartile range – IQR 11–6) vs. 11 days (IQR 14–9), p = 0.001; Conclusions: LUS may reduce the role of pre-operative MRCP and can become a rational alternative to MRCP as a primary imaging technique for the detection of choledocholithiasis.

Chronic Pancreatitis: What the Clinician Wants to Know from MR Imaging

Diagnosis of chronic pancreatitis requires a complete medical history and clinical investigations, including imaging technologies and function tests. MR imaging/magnetic resonance cholangiopancreatography is the preferred diagnostic tool for detection of ductal and parenchymal changes in patients with chronic pancreatitis. Ductal changes may not be present in the initial phase of chronic pancreatitis. Therefore, early diagnosis remains challenging.

Feasibility of gadoxetate disodium enhanced 3D T1 MR cholangiography (MRC) with a specific inversion recovery prepulse for the assessment of the hepatobiliary system

Aim

To compare the potential of a gadoxetate disodium enhanced navigator-triggered 3D T1 magnetic-resonance cholangiography (MRC) sequence with a specific inversion recovery prepulse to T2-weighted MRCP for assessment of the hepatobiliary system.

Materials and methods

30 patients (12 male, 18 female) prospectively underwent conventional navigator-triggered 3D turbo spin-echo T2-weighted MRCP and 3D T1 MRC with a specific inversion pulse to minimise signal from the liver 30 minutes after administration of gadoxetate disodium on a 1.5 T MRI system. For qualitative evaluation, biliary duct depiction was assessed segmentally following a 5-point Likert scale. Visualisation of hilar structures as well as image quality was recorded. Additionally, the extrahepatic bile ducts were assessed quantitatively by calculation of signal-to-noise ratios (SNR).

Results

The advantages of T1 3D MRC include reduced affection of image quality by bowel movement and robust depiction of the relative position of the extrahepatic bile ducts in relation to the portal vein and the duodenum compared to T2 MRCP. However, overall T1 3D MRC did not significantly (p > 0.05) improve the biliary duct depiction compared to T2 MRCP in all segments: Common bile duct 4.1 vs. 4.4, right hepatic duct 3.6 vs. 4.2, left hepatic duct 3.5 vs. 4.1. Image quality did not differ significantly (p > 0.05) between both sequences (3.6 vs. 3.5). SNR measurements for the hepatobiliary system did not differ significantly (p > 0.05) between navigator-triggered T1 3D MRC and T2 MRCP.

Conclusions

This preliminary study demonstrates that T1 3D MRC of a specific inversion recovery prepulse has potential to complement T2 MRCP, especially for the evaluation of liver structures close to the hilum in the diagnostic work-up of the biliary system in patients receiving gadoxetate disodium.

Utilization trends in inpatient endoscopic retrograde cholangiopancreatography (ERCP): A cross-sectional US experience

Study aims The goal of our study was to determine the current trends for inpatient utilization for endoscopic retrograde cholangiopancreatography (ERCP) and its economic impact in the United States between 2002 and 2013. Patients and methods A Nationwide Inpatient Sample from 2002 through 2013 was examined. We identified ERCPs using International Classification of Diseases (ICD-9) codes; Procedure codes 51.10, 51.11, 52.13, 51.14, 51.15, 52.14 and 52.92 for diagnostic and 51.84, 51.86, 52.97 were studied. Rate of inpatient ERCP was calculated. The trends for therapeutic ERCPs were compared to the diagnostic ones. We analyzed patient and hospital characteristics, length of hospital stay, and cost of care after adjusting for weighted samples. We used the Cochran-Armitage test for categorical variables and linear regression for continuous variables. Results A total of 411,409 ERCPs were performed from 2002 to 2013. The mean age was 59 ± 19 years; 61 % were female and 57 % were white. The total numbers of ERCPS increased by 12 % from 2002 to 2011, which was followed by a 10 % decrease in the number of ERCPs between 2011 and 2013. There was a significant increase in therapeutic ERCPs by 37 %, and a decrease in diagnostic ERCPs by 57 % from 2002 to 2013. Mean length of stay was 7 days (SE = 0.01) and the mean cost of hospitalization was $20,022 (SE = 41). Conclusions Our large cross-sectional study shows a significant shift in ERCPs towards therapeutic indications and a decline in its conventional diagnostic utility. Overall there has been a reduction in inpatient ERCPs.

Secretin-Stimulated Magnetic Resonance Imaging Assessment of the Benign Pancreatic Disorders: Systematic Review and Proposal for a Standardized Protocol

This systemic review summarizes the current literature and general consensus on secretin-stimulated magnetic resonance imaging (s-MRI) of the benign pancreatic disorders and discusses important aspects on how s-MRI is optimally performed. The aim is to provide an overview, for clinicians and radiologist, of the s-MRI protocols and the range of clinical applications. Furthermore, the review will summarize the criteria for evaluation of pancreatic morphology and function based on s-MRI.The literature search indentified 69 original articles and 15 reviews. Chronic pancreatitis was the disease that was most frequently assessed by s-MRI (33%), followed by acute pancreatitis (9%). Dynamic thick-slab 2-dimensional magnetic resonance cholangiopancreatography was the most used imaging sequence (86%). The diameter of the main pancreatic duct (75%) and pancreatic exocrine function based on visual grading of duodenal filling (67%) were the most evaluated pancreatic features. Sufficient similarities between studies were identified to propose the most agreeable standardized s-MRI protocol for morphological and functional assessment of the pancreas. In the future, more research and increased collaboration between centers is necessary to achieve more consensus and optimization of s-MRI protocols.

Safe laparoscopic clearance of the common bile duct in emergently admitted patients with choledocholithiasis and cholangitis

Backgrounds/Aims

Laparoscopic treatment of patients with choledocholithiasis and cholangitis is challenging due to mandatory recovery of the biliary drainage and clearance of the common bile duct (CBD). The aim of our study was to assess postoperative course of cholangitis and biliary sepsis after laparoscopic clearance of the CBD in emergently admitted patients with choledocholithiasis and cholangitis.

Methods

Emergently admitted patients who underwent laparoscopic clearance of the CBD were included prospectively and stratified in 2 groups i.e., cholangitis positive (CH+) or negative (CH-) group. Patient demographics, comorbidities, preoperative imaging data, inflammatory response, surgical intervention, complication rate and outcomes were compared between groups.

Results

Ninety-nine of a total 320 patients underwent laparoscopic clearance of the CBD, of which, 60 belonged to the acute cholangitis group (CH+) and 39 to the cholangitis negative group (CH-). Interventions were done on average 4 days after admission, operation duration was 95-105 min, and the conversion rate was 3-7% without differences in the groups. Preoperative inflammatory response was markedly higher in the CH+ group. Inflammation signs on intraoperative choledochoscopy were more evident in patients with cholangitis. Postoperative inflammatory response did not differ between the groups. The overall complication rate was 8.3% and 5.1%, respectively. Laparoscopic clearance of the CBD resulted in 1 lethal case (CH+ group), resulting in 1% mortality rate and a similar 12-month readmission rate.

Conclusions

Single-stage laparoscopic intraoperative US and choledochoscopy-assisted clearance of the CBD is feasible in emergently admitted patients with choledocholithiasis and cholangitis.