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Mattila A, Pynnönen E, Sironen A, Elomaa E, Mrena J, Jalkanen A, Nevalainen M, Helminen O. Routine preoperative MRCP in screening choledocholithiasis in acute cholecystitis compared to selective approach: a population-based study. Updates Surg 2022; 75:563-570. [PMID: 36207660 DOI: 10.1007/s13304-022-01390-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/22/2022] [Indexed: 11/24/2022]
Abstract
Choledocholithiasis is more common in acute cholecystitis than in elective situations. Preoperative diagnosis of choledocholithiasis is essential to facilitate adequate planning of CBD (common bile duct) stone removal, preferably performed as a single-stage procedure. The purpose of this study was to test the feasibility of routine preoperative magnetic resonance cholangiopancreatography (MRCP) in acute cholecystitis followed by consequent cholecystectomy. A total of 180 consecutive patients operated for acute cholecystitis between January 2019 and December 2019 were prospectively enrolled. Preoperative routine MRCP was performed for bile duct evaluation when feasible. The control cohort consisted of 180 consecutive patients undergoing emergency laparoscopic cholecystectomy before the study period. Intraoperative cholangiography was used routinely in both groups when technically achievable. We examined the proportion of patients recruited in preoperative MRCP, possible time delay to MRCP and surgery, and the incidence of CBD stones compared to the control cohort. Routine MRCP in acute cholecystitis was achieved in 114/180 (63%) patients compared to 42/180 (23.3%) patients of the control group. The triage time from emergency to MRCP and the operating theatre was similar in both cohorts. The percentage of patients diagnosed with choledocholithiasis in the study group was notably higher (almost 18% vs 11%), p < 0.05. After a median follow-up time of 2.5 years in the study group and almost 4 years in the control group, recurrent choledocholithiasis was not detected in either group. Routine MRCP in patients with acute cholecystitis can be implemented with a fair execution rate in a population-based setting with minor effects on hospital stay and delays but higher detection of choledocholithiasis. We observed no additional benefit compared to the selective use of MRCP. However, routine preoperative MRCP allows an advantage when considering the appropriate exploration method if choledocholithiasis is detected.
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Affiliation(s)
- Anne Mattila
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland.
| | - Emilia Pynnönen
- Dept. of Radiology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Antti Sironen
- Dept. of Radiology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Eeva Elomaa
- Dept. of Radiology, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Johanna Mrena
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland
| | - Aapo Jalkanen
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland
| | - Mika Nevalainen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Olli Helminen
- Dept. of Surgery, Hospital Nova of Central Finland, Hoitajantie 3, 40620, Jyväskylä, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Staubli SM, Maloca P, Kuemmerli C, Kunz J, Dirnberger AS, Allemann A, Gehweiler J, Soysal S, Droeser R, Däster S, Hess G, Raptis D, Kollmar O, von Flüe M, Bolli M, Cattin P. Magnetic resonance cholangiopancreatography enhanced by virtual reality as a novel tool to improve the understanding of biliary anatomy and the teaching of surgical trainees. Front Surg 2022; 9:916443. [PMID: 36034383 PMCID: PMC9411984 DOI: 10.3389/fsurg.2022.916443] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe novel picture archiving and communication system (PACS), compatible with virtual reality (VR) software, displays cross-sectional images in VR. VR magnetic resonance cholangiopancreatography (MRCP) was tested to improve the anatomical understanding and intraoperative performance of minimally invasive cholecystectomy (CHE) in surgical trainees.DesignWe used an immersive VR environment to display volumetric MRCP data (Specto VRTM). First, we evaluated the tolerability and comprehensibility of anatomy with a validated simulator sickness questionnaire (SSQ) and examined anatomical landmarks. Second, we compared conventional MRCP and VR MRCP by matching three-dimensional (3D) printed models and identifying and measuring common bile duct stones (CBDS) using VR MRCP. Third, surgical trainees prepared for CHE with either conventional MRCP or VR MRCP, and we measured perioperative parameters and surgical performance (validated GOALS score).SettingThe study was conducted out at Clarunis, University Center for Gastrointestinal and Liver Disease, Basel, Switzerland.ParticipantsFor the first and second study step, doctors from all specialties and years of experience could participate. In the third study step, exclusively surgical trainees were included. Of 74 participating clinicians, 34, 27, and 13 contributed data to the first, second, and third study phases, respectively.ResultsAll participants determined the relevant biliary structures with VR MRCP. The median SSQ score was 0.75 (IQR: 0, 3.5), indicating good tolerability. Participants selected the corresponding 3D printed model faster and more reliably when previously studying VR MRCP compared to conventional MRCP: We obtained a median of 90 s (IQR: 55, 150) and 72.7% correct answers with VR MRCP versus 150 s (IQR: 100, 208) and 49.6% correct answers with conventional MRCP, respectively (p < 0.001). CBDS was correctly identified in 90.5% of VR MRCP cases. The median GOALS score was higher after preparation with VR MRCP than with conventional MRCP for CHE: 16 (IQR: 13, 22) and 11 (IQR: 11, 18), respectively (p = 0.27).ConclusionsVR MRCP allows for a faster, more accurate understanding of displayed anatomy than conventional MRCP and potentially leads to improved surgical performance in CHE in surgical trainees.
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Affiliation(s)
- Sebastian M Staubli
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, United Kingdom
| | - Peter Maloca
- Department of Ophthalmology, University of Basel, Basel, Switzerland
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - Christoph Kuemmerli
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Julia Kunz
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Amanda S Dirnberger
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Andreas Allemann
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Julian Gehweiler
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Savas Soysal
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Raoul Droeser
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Silvio Däster
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Gabriel Hess
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Dimitri Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London Hospital, NHS Foundation Trust, London, United Kingdom
| | - Otto Kollmar
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Markus von Flüe
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Martin Bolli
- Clarunis, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Philippe Cattin
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
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Management of Patients With Common Bile Duct Dilatation Without a Sonographic Evident Cause: Evaluating the Yield of Subsequent Magnetic Resonance Imaging and Findings Correlated With Causative Pancreaticobiliary Pathology. J Comput Assist Tomogr 2022; 46:163-168. [PMID: 35297572 DOI: 10.1097/rct.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of the study were to evaluate the yield of magnetic resonance imaging (MRI) in patients with common bile duct (CBD) dilatation without a sonographic evident cause and to investigate sonographic and laboratory findings at presentation that might predict identification of underlying pancreaticobiliary pathology. METHODS Included were consecutive patients in whom MRI was performed for further evaluation of CBD dilatation detected on ultrasound (US), without a sonographic evident cause, from January 1, 2014, to December 31, 2014. Magnetic resonance imaging and clinical data were retrospectively reviewed. Patients were divided into two groups: patients with and without identified underlying causative pancreaticobiliary pathology. Ultrasound findings and laboratory results at presentation were compared between groups to identify findings suggestive of underlying pancreaticobiliary pathology. RESULTS Fifty-seven patients, with a mean age of 54 ± 16 years including 37 females (65%), underwent MRI. Specific pancreaticobiliary causes for CBD dilatation were identified in 38 patients (66%, 31 benign and 7 malignant). In the remaining patients, no cause was identified in 17 (30%) and MRIs were nondiagnostic in 2 patients. Magnetic resonance imaging accuracy for correctly identifying the underlying cause of CBD dilatation was 91%. Patients with associated intrahepatic bile duct dilatation on US and elevated alanine aminotransferase and alkaline phosphatase were more likely to have underlying pancreaticobiliary pathology (P < 0 .05). No patient with initial negative MRI had pancreaticobiliary malignancy. CONCLUSIONS Magnetic resonance imaging seems to be an accurate noninvasive method for identifying the underlying cause in most patients with CBD dilatation on US and in excluding pancreaticobiliary malignancy. Patients with associated intrahepatic bile duct dilatation and/or elevated liver enzymes are at higher risk of harboring underlying pancreaticobiliary pathology.
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Pausawasdi N, Hongsrisuwan P, Kamani L, Maipang K, Charatcharoenwitthaya P. The Diagnostic Value of Endoscopic Ultrasonography for Common Bile Duct Dilatation without Identifiable Etiology Detected from Cross-Sectional Imaging. Clin Endosc 2022; 55:122-127. [PMID: 34974680 PMCID: PMC8831402 DOI: 10.5946/ce.2021.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
Background/Aims Endoscopic ultrasonography (EUS) is warranted when cross-sectional imaging demonstrates common bile duct (CBD) dilatation without identifiable causes. This study aimed to assess the diagnostic performance of EUS in CBD dilatation of unknown etiology.
Methods Retrospective review of patients with dilated CBD without definite causes undergoing EUS between 2012 and 2017.
Results A total of 131 patients were recruited. The mean age was 63.2±14.1 years. The most common manifestation was abnormal liver chemistry (85.5%). The mean CBD diameter was 12.2±4.1 mm. The area under the receiver operating characteristic curve (AUROC) of EUS-identified pathologies, including malignancy, choledocholithiasis, and benign biliary stricture (BBS), was 0.98 (95% confidence interval [CI], 0.95-1.00). The AUROC of EUS for detecting malignancy, choledocholithiasis, and BBS was 0.91 (95% CI, 0.85-0.97), 1.00 (95% CI, 1.00-1.00), and 0.93 (95% CI, 0.87-0.99), respectively. Male sex, alanine aminotransferase ≥3× the upper limit of normal (ULN), alkaline phosphatase ≥3× the ULN, and intrahepatic duct dilatation were predictors for pathological obstruction, with odds ratios of 5.46 (95%CI, 1.74-17.1), 5.02 (95% CI, 1.48-17.0), 4.63 (95% CI, 1.1-19.6), and 4.03 (95% CI, 1.37-11.8), respectively.
Conclusions EUS provides excellent diagnostic value in identifying the etiology of CBD dilatation detected by cross-sectional imaging.
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Affiliation(s)
- Nonthalee Pausawasdi
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Penprapai Hongsrisuwan
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lubna Kamani
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Liaquat National Hospital and Aga Khan University Hospital, Karachi, Pakistan
| | - Kotchakon Maipang
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches. World J Gastroenterol 2021; 27:4536-4554. [PMID: 34366622 PMCID: PMC8326257 DOI: 10.3748/wjg.v27.i28.4536] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/02/2021] [Accepted: 06/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.
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Affiliation(s)
- Pasquale Cianci
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
| | - Enrico Restini
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
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Goldfinger MH, Ridgway GR, Ferreira C, Langford CR, Cheng L, Kazimianec A, Borghetto A, Wright TG, Woodward G, Hassanali N, Nicholls RC, Simpson H, Waddell T, Vikal S, Mavar M, Rymell S, Wigley I, Jacobs J, Kelly M, Banerjee R, Brady JM. Quantitative MRCP Imaging: Accuracy, Repeatability, Reproducibility, and Cohort-Derived Normative Ranges. J Magn Reson Imaging 2020; 52:807-820. [PMID: 32147892 PMCID: PMC7496952 DOI: 10.1002/jmri.27113] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) is an important tool for noninvasive imaging of biliary disease, however, its assessment is currently subjective, resulting in the need for objective biomarkers. PURPOSE To investigate the accuracy, scan/rescan repeatability, and cross-scanner reproducibility of a novel quantitative MRCP tool on phantoms and in vivo. Additionally, to report normative ranges derived from the healthy cohort for duct measurements and tree-level summary metrics. STUDY TYPE Prospective. PHANTOMS/SUBJECTS Phantoms: two bespoke designs, one with varying tube-width, curvature, and orientation, and one exhibiting a complex structure based on a real biliary tree. Subjects Twenty healthy volunteers, 10 patients with biliary disease, and 10 with nonbiliary liver disease. SEQUENCE/FIELD STRENGTH MRCP data were acquired using heavily T2 -weighted 3D multishot fast/turbo spin echo acquisitions at 1.5T and 3T. ASSESSMENT Digital instances of the phantoms were synthesized with varying resolution and signal-to-noise ratio. Physical 3D-printed phantoms were scanned across six scanners (two field strengths for each of three manufacturers). Human subjects were imaged on four scanners (two fieldstrengths for each of two manufacturers). STATISTICAL TESTS Bland-Altman analysis and repeatability coefficient (RC). RESULTS Accuracy of the diameter measurement approximated the scanning resolution, with 95% limits of agreement (LoA) from -1.1 to 1.0 mm. Excellent phantom repeatability was observed, with LoA from -0.4 to 0.4 mm. Good reproducibility was observed across the six scanners for both phantoms, with a range of LoA from -1.1 to 0.5 mm. Inter- and intraobserver agreement was high. Quantitative MRCP detected strictures and dilatations in the phantom with 76.6% and 85.9% sensitivity and 100% specificity in both. Patients and healthy volunteers exhibited significant differences in metrics including common bile duct (CBD) maximum diameter (7.6 mm vs. 5.2 mm P = 0.002), and overall biliary tree volume 12.36 mL vs. 4.61 mL, P = 0.0026). DATA CONCLUSION The results indicate that quantitative MRCP provides accurate, repeatable, and reproducible measurements capable of objectively assessing cholangiopathic change. Evidence Level: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;52:807-820.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - J. Michael Brady
- Perspectum LtdOxfordUK
- Department of Oncology, Medical Sciences DivisionUniversity of OxfordOxfordUK
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Muglia R, Lanza E, Poretti D, Colapietro F, Solbiati L, D'Antuono F, Gennaro N, Ceriani R, Pedicini V. Percutaneous transhepatic endoscopic lithotripsy of biliary stones with holmium laser for the treatment of recurrent cholangitis. Abdom Radiol (NY) 2020; 45:2561-2568. [PMID: 32367249 DOI: 10.1007/s00261-020-02554-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of percutaneous transhepatic endoscopic holmium laser biliary lithotripsy (PTBL) to treat recurrent cholangitis due to intra/extrahepatic stones, in patients not candidate for traditional endoscopic treatment. MATERIALS AND METHODS We retrospectively evaluated 28 patients (M:F = 19:9, mean age = 65 years, SD = 14) undergoing 43 PTBL for stone-related recurrent cholangitis from January 1, 2012 to January 31, 2019 in a single academic center. Data collected included demographics, location and number of stones, clinical success after one (primary) or more than one (secondary) PTBL, procedure time, duration of hospital stay, number of retreatments and post-procedural complications. Clinical success was defined as the resolution of cholangitis at 30-day follow-up. RESULTS PTBL were successful for 23/28 (82%) patients, 16 (57%) with one and 7 (88%) with repeat procedures. The remaining 5 (18%) patients were finally treated with surgery (3, 11%) or further antibiotics (2, 7%). PTBL were performed to treat intrahepatic stones (22 treatments, 51%), extrahepatic (14, 33%), and both intra/extrahepatic (7, 16%). One to three stones were found in 12/43 (28%) PTBL, more than three in 31/43 (72%). Single PTBL was performed in 20/28 (71%) patients, two in 3/28 (11%), three in 3/28 (11%), and four in 2/28 (7%). Median procedure duration was 115 (29-210, 95% CI 101-129) minutes; median hospital stay was 5.5 (2-42) days. The only major complication was the breakage of a guidewire tip, surgically retrieved; minor complications included one aspiration pneumonia and three instances of intrahepatic hemorrhage, treated conservatively. CONCLUSIONS PTBL was clinically successful in the 82% of patients not candidate for endoscopic treatment, with a low complication rate.
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Affiliation(s)
- Riccardo Muglia
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Ezio Lanza
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center - IRCCS, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Dario Poretti
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center - IRCCS, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesca Colapietro
- Training School in Internal Medicine, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Luigi Solbiati
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Felice D'Antuono
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center - IRCCS, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Nicolò Gennaro
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Roberto Ceriani
- Department of Internal Medicine, Humanitas Clinical and Research Center - IRCCS, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Vittorio Pedicini
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center - IRCCS, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
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The Role of Laparoscopic Ultrasonography in the Evaluation of Suspected Choledocholithiasis. A Single-Center Experience. MEDICINA-LITHUANIA 2020; 56:medicina56050246. [PMID: 32443814 PMCID: PMC7279262 DOI: 10.3390/medicina56050246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/02/2022]
Abstract
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.
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Ribeiro BJ, Alves AMA, de Oliveira RS, Velloni F, D'Ippolito G. The role of gadoxetic acid-enhanced magnetic resonance cholangiography in the evaluation of postoperative bile duct injury: pictorial essay. Radiol Bras 2019; 52:403-407. [PMID: 32047335 PMCID: PMC7007050 DOI: 10.1590/0100-3984.2018.0089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Iatrogenic lesion of the bile ducts is a relatively common occurrence during liver surgery, increasing morbidity and mortality rates. T2-weighted magnetic resonance cholangiography and gadoxetic acid-enhanced functional magnetic resonance cholangiography (fMRC) with administration of hepatobiliary-specific contrast medium (gadoxetic acid) are fundamental to the diagnostic imaging approach in patients with such lesions. Here, we present a review of the literature and suggest an imaging approach to biliary tract injury, focusing on clinical cases in which fMRC had an impact on the decision-making process for the management of the affected patients.
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Affiliation(s)
- Bruno Jucá Ribeiro
- Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Aldo Maurici Araújo Alves
- Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | | | - Fernanda Velloni
- Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | - Giuseppe D'Ippolito
- Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
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10
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The accuracy of 3T magnetic resonance cholangiopancreatography in suspected choledocholithiasis. Pol J Radiol 2019; 84:e419-e423. [PMID: 31969960 PMCID: PMC6964331 DOI: 10.5114/pjr.2019.89689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/23/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this study was to investigate interobserver agreement during magnetic resonance cholangio-pancreatography (MRCP) evaluation and the sensitivity and specificity of MRCP obtained with 3T scanners in cases of bile duct obstruction. Material and methods A total of 37 patients who had MRCP and endoscopic retrograde cholangiography (ERCP) were included. Choledochal pathology was divided into two groups regarding the presence of stones as "there is stone or not". MRCPs were performed with a 3-Tesla system using respiratory triggered HASTE technique in axial and coronal planes and with T2 SPACE sequence in the coronal plane. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated separately for each observer. The average of both observers was calculated for comparison with other studies. Results Thirty-seven patients were in the study population. Agreement between the observers was analysed, and Cohen's κ value was evaluated as 0.84. For two observers, the sensitivity of MRCP was 93%, whereas the specificity was 75% for the first observer and 62% for the second. Conclusions In this study we found a high level of interobserver agreement in evaluating MRCP. MRCP has a high sensitivity in detecting choledocholithiasis.
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Pereira R, Eslick G, Cox M. Endoscopic Ultrasound for Routine Assessment in Idiopathic Acute Pancreatitis. J Gastrointest Surg 2019; 23:1694-1700. [PMID: 31197695 DOI: 10.1007/s11605-019-04272-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) is one of the most common general acute surgical presentations. Current recommendations are that idiopathic acute pancreatitis (IAP) should account for no more than 20% of AP cases. Some studies suggest gallbladder microlithiasis is the aetiology in up to 75% of IAP patients. Endoscopic ultrasound (EUS) has been reported to be effective in the detection of microlithiasis and choledocholithiasis as well as pancreatic parenchymal, ductal and ampullary disorders. The aims of this study were to evaluate the usefulness of EUS in establishing aetiology in IAP patients and to assess if there is a role for EUS in the selection criteria for laparoscopic cholecystectomy to treat a potential biliary cause in IAP patients. METHODS A systematic review following PRISMA guideline was performed to gather data on patients with IAP undergoing EUS for further investigation. Three databases (MEDLINE, PubMed, and EMBASE) were searched to 28 July 2018. RESULTS Our systematic review included 28 studies, comprising 1850 patients with an initial diagnosis of IAP prior to having EUS. Diagnosis of a potential aetiology or associated pancreatic pathology was established in 1095 (62%, p < 0.001) of cases. A biliary aetiology (microlithiasis or choledocholithiasis) was found in 37%. Chronic pancreatitis and associated pancreatic findings (dilated pancreatic duct, pancreatic duct stricture or stone) were found in 21%. Pancreatic neoplasms were found in 6%. Of the patients who had identifiable biliary pathology on EUS that proceeded to cholecystectomy, 2% had a recurrence of AP during a mean follow-up period of 20.5 months. CONCLUSIONS There is a likely role for the routine use of EUS in the assessment of patients with IAP. The routine use of EUS may decrease the proportion of cases with a diagnosis of IAP. EUS may provide better selection criteria for laparoscopic cholecystectomy in patients with an initial diagnosis of IAP.
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Affiliation(s)
- Ryan Pereira
- The Whiteley-Martin Research Unit, Discipline of Surgery, The University of Sydney, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia.,Department of Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Guy Eslick
- The Whiteley-Martin Research Unit, Discipline of Surgery, The University of Sydney, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia
| | - Michael Cox
- The Whiteley-Martin Research Unit, Discipline of Surgery, The University of Sydney, Clinical Sciences Building, Nepean Hospital, P. O. Box 67, Penrith, NSW, 2751, Australia. .,Department of Surgery, Nepean Hospital, Sydney, NSW, Australia.
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Peponis T, Panda N, Eskesen TG, Forcione DG, Yeh DD, Saillant N, Kaafarani HM, King DR, de Moya MA, Velmahos GC, Fagenholz PJ. Preoperative endoscopic retrograde cholangio-pancreatography (ERCP) is a risk factor for surgical site infections after laparoscopic cholecystectomy. Am J Surg 2019; 218:140-144. [DOI: 10.1016/j.amjsurg.2018.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/14/2018] [Accepted: 09/24/2018] [Indexed: 12/27/2022]
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13
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Leal CA, Ortega DJ, Pedraza M, Cabrera LF, Sánchez S. Eficacia de la colangiopancreatografía por resonancia magnética para el diagnóstico de coledocolitiasis de probabilidad intermedia. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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14
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Cappell MS, Stavropoulos SN, Friedel D. Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography. World J Gastrointest Endosc 2018; 10:308-321. [PMID: 30364767 PMCID: PMC6198312 DOI: 10.4253/wjge.v10.i10.308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/13/2018] [Accepted: 08/27/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.
METHODS Systematic computerized literature search performed using PubMed with the key words “ERCP” and “pregnancy”. Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.
RESULTS Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.
CONCLUSION This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
- Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
| | | | - David Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY 11501, United States
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15
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Bali M, Pezzullo M, Pace E, Morone M. Benign biliary diseases. Eur J Radiol 2017; 93:217-228. [DOI: 10.1016/j.ejrad.2017.05.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 02/07/2023]
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16
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Badger WR, Borgert AJ, Kallies KJ, Kothari SN. Utility of MRCP in clinical decision making of suspected choledocholithiasis: An institutional analysis and literature review. Am J Surg 2016; 214:251-255. [PMID: 27986260 DOI: 10.1016/j.amjsurg.2016.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/21/2016] [Accepted: 10/30/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND The ideal treatment algorithm for suspected choledocholithiasis is not yet well defined. Imaging options include magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative cholangiogram (IOC). MRCP is diagnostic, while the other two modalities can also be therapeutic. Each of these modalities for diagnosis and treatment carries its own set of risks, benefits, and institutional costs. We hypothesized that there would be a significant difference between the biochemical profiles and characteristics of patients who undergo ERCP vs. MRCP vs. operative intervention as the initial choice of treatment/imaging modality. METHODS We performed a retrospective review of the electronic medical records for all patients with a coded diagnosis of choledocholithiasis from 2011 to 2014. The initial diagnostic modality was assessed for each hospital encounter. The statistical characteristics of MRCP as compared to fluoroscopic imaging of the biliary tree (ERCP, IOC) were analyzed. RESULTS Overall, 527 hospital encounters were identified. Initial intervention included ERCP in 63%, MRCP in 12%, and cholecystectomy in 25% of patients. Patients undergoing cholecystectomy first, compared to MRCP or ERCP, tended to have lower values for alkaline phosphatase (P < 0.001) and AST (P = 0.002) as well as be of younger age (P < 0.0001). Of the patients that underwent MRCP as their initial procedure, 82% subsequently underwent either ERCP or laparoscopic cholecystectomy. In patients who underwent an initial MRCP followed by either ERCP or IOC, the predictive performance of MRCP was as follows: sensitivity = 0.90, specificity = 0.86, positive predictive value = 0.97, negative predictive value = 0.60, agreement (Cohen's Kappa) = 0.64. CONCLUSIONS There is a significant difference in the laboratory evaluation and demographics of patients undergoing ERCP, MRCP, and laparoscopic cholecystectomy. MRCP was followed with a more invasive test a majority of the time. Since MRCP did not change the management of patients with suspected choledocholithiasis, its utility in this patient population should be questioned. Further research is needed to better define the pretest characteristics which would predict which patients do not need further intervention after MRCP as well as defining the most cost-effective strategy.
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Affiliation(s)
- Wesley R Badger
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Shanu N Kothari
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
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Qiu Y, Yang Z, Li Z, Zhang W, Xue D. Is preoperative MRCP necessary for patients with gallstones? An analysis of the factors related to missed diagnosis of choledocholithiasis by preoperative ultrasound. BMC Gastroenterol 2015; 15:158. [PMID: 26577949 PMCID: PMC4650402 DOI: 10.1186/s12876-015-0392-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 11/10/2015] [Indexed: 02/07/2023] Open
Abstract
Background The diagnosis of associated choledocholithiasis prior to cholecystectomy for patients with gallstones is important for the surgical decision and treatment efficacy. However, whether ultrasound is sufficient for preoperative diagnosis of choledocholithiasis remains controversial, with different opinions on whether routine magnetic resonance cholangiopancreatography (MRCP) is needed to detect the possible presence of common bile duct (CBD) stones. Methods In this study, a total of 413 patients with gallstones who were admitted to the Department of General Surgery of the First Affiliated Hospital of Harbin Medical University in China for a period of 3 years and underwent both ultrasound and MRCP examinations were retrospectively analysed. After reviewing and screening these cases according to the literature, 11 indicators including gender, age, alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, indirect bilirubin, alkaline phosphatase, γ-aminotransferase, CBD diameter, and concurrent acute cholecystitis were selected and comparatively analysed. Results Among the 413 patients, a total of 109 cases showed concurrent gallstones and choledocholithiasis, accounting for 26.39 % of all cases. Among them, 60 cases of choledocholithiasis were revealed by ultrasound examination, accounting for 55.05 %, while 49 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP instead (the missed diagnosis rate of ultrasound was 44.95 %). The results of statistical analysis suggested that alanine aminotransferase, acute cholecystitis, and CBD diameter were the three most relevant factors for missed diagnosis by ultrasound. Conclusion The accuracy of preoperative ultrasonography for the diagnosis of associated CBD stones for patients with gallstones is not high. However, elevated alanine aminotransferase, concurrent acute cholecystitis, and CBD diameter were identified as key factors that may affect the accuracy of the diagnosis. Thus, routine preoperative MRCP examination is suggested for patients with gallstones to rule out possible concomitant CBD stones.
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Affiliation(s)
- Yan Qiu
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Zhengpeng Yang
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Zhituo Li
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Weihui Zhang
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
| | - Dongbo Xue
- Department of General Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng St., Nangang Dist., 150001, Harbin, China.
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