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Rampersad FS, Chan A, Persaud S, Maharaj P, Maharaj R. Choledocholithiasis in Pregnancy: A Case Report. Cureus 2022; 14:e22610. [PMID: 35371811 PMCID: PMC8958046 DOI: 10.7759/cureus.22610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/08/2022] Open
Abstract
Cholelithiasis during pregnancy and the postpartum period has an incidence of 12%, with pregnancy being an important risk factor for gallstones. Patients with choledocholithiasis can experience complications, such as obstructive jaundice, cholangitis, and pancreatitis, which may be detrimental to both mother and fetus. A case of cholelithiasis in a second-trimester pregnancy was complicated by choledocholithiasis and obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography (MRCP), along with serial blood tests, confirmed the diagnosis. Treatment was safely achieved using endoscopic retrograde cholangiopancreatography (ERCP). In pregnancy, complicated cholelithiasis is investigated using blood tests, ultrasonography, and cholangiography. Evidence supports the use of intraoperative or endoscopic cholangiography for the management of such complicated gallstone disease in pregnancy.
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Virzì V, Ognibene NMG, Sciortino AS, Culmone G, Virzì G. Routine MRCP in the management of patients with gallbladder stones awaiting cholecystectomy: a single-centre experience. Insights Imaging 2018; 9:653-659. [PMID: 29978345 PMCID: PMC6206385 DOI: 10.1007/s13244-018-0640-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/25/2018] [Accepted: 05/28/2018] [Indexed: 01/14/2023] Open
Abstract
Objectives To assess the frequency of choledocolithiasis and the role of preoperative laboratory findings, ultrasound (US) and magnetic resonance cholangio-pancreatography (MRCP) in the detection of choledocolithiasis in patients with gallbladder stones awaiting cholecystectomy. Methods A consecutive sample of 104 patients underwent MRCP prior to cholecystectomy. The patients were classified into different groups on the basis of the risk of choledocolithiasis. A specialised doctor with more 10 years of experience performed the US interpretation and a radiologist performed the MRCP interpretation blinded to US or aspartate aminotransferase (AST)/alanine aminotransferase (ALT)/alkaline phosphatase (ALP) results. A chi-square (χ2) test was performed to assess the statistical significance of differences in the frequency of choledocolithiasis based on laboratory findings, choledocal diameter on US and group risk. Results MRCP showed calculi in 7 out of 104 patients (6.7%), with no statistically significant differences between the high/moderate risk and low/no risk groups and between the patients with normal and altered laboratory findings or choledocal diameter on preoperative US. The sensitivity and specificity of AST/ALT [positive predictive value (PPV): 12%; negative predictive value (NPV): 94%], ALP (PPV: 7%; NPV: 94%), total serum bilirubin (PPV: 6%; NPV: 93%) and choledocal diameter (PPV: 20%; NPV: 94%) were, respectively, 28.6 and 94.8%, 85.7 and 17.5%, 14.3 and 93.8%, and 14.3 and 95.9%. Conclusions MRCP is a reliable evaluation for the detection of common bile duct (CBD) stones, reducing the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and US examination. Main messages • MRCP is a non-invasive method for the detection of CBD stones. • Preoperative MRCP reduces the misdiagnosis of retained choledocholithiasis. • Detection of choledocholithiasis is mandatory prior to cholecystectomy to avoid surgical morbidity
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Affiliation(s)
- Valentina Virzì
- Department of Radiology, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | | | - Antonio Salvatore Sciortino
- Department of Surgery, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | - Glenda Culmone
- "Regina Pacis" Clinic, Skema Iniziative Sanitarie, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | - Giuseppe Virzì
- Department of Surgery, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
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Factors and Outcomes Associated with MRCP Use prior to ERCP in Patients at High Risk for Choledocholithiasis. Can J Gastroenterol Hepatol 2016; 2016:5132052. [PMID: 27446845 PMCID: PMC4904705 DOI: 10.1155/2016/5132052] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/01/2015] [Indexed: 02/07/2023] Open
Abstract
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.
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Chen W, Mo JJ, Lin L, Li CQ, Zhang JF. Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis. World J Gastroenterol 2015; 21:3351-3360. [PMID: 25805944 PMCID: PMC4363767 DOI: 10.3748/wjg.v21.i11.3351] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/26/2014] [Accepted: 10/15/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in patients with choledocholithiasis.
METHODS: We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane databases for studies reporting on the sensitivity, specificity and other accuracy measures of diagnostic effectiveness of MRCP for detection of common bile duct (CBD) stones. Pooled analysis was performed using random effects models, and receiver operating characteristic curves were generated to summarize overall test performance. Two reviewers independently assessed the methodological quality of studies using standards for reporting diagnostic accuracy and quality assessment for studies of diagnostic accuracy tools.
RESULTS: A total of 25 studies involving 2310 patients with suspected choledocholithiasis and 738 patients with CBD stones met the inclusion criteria. The average inter-rater agreement on the methodological quality checklists was 0.96. Pooled analysis of the ability of MRCP to detect CBD stones showed the following effect estimates: sensitivity, 0.90 (95%CI: 0.88-0.92, χ2 = 65.80; P < 0.001); specificity, 0.95 (95%CI: 0.93-1.0, χ2 = 110.51; P < 0.001); positive likelihood ratio, 13.28 (95%CI: 8.85-19.94, χ2 = 78.95; P < 0.001); negative likelihood ratio, 0.13 (95%CI: 0.09-0.18, χ2 = 6.27; P < 0.001); and diagnostic odds ratio, 143.82 (95%CI: 82.42-250.95, χ2 = 44.19; P < 0.001). The area under the receiver operating characteristic curve was 0.97. Significant publication bias was not detected (P = 0.266).
CONCLUSION: MRCP has high diagnostic accuracy for the detection of choledocholithiasis. MRCP should be the method of choice for suspected cases of CBD stones.
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Giljaca V, Gurusamy KS, Takwoingi Y, Higgie D, Poropat G, Štimac D, Davidson BR. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev 2015; 2015:CD011549. [PMID: 25719224 PMCID: PMC6464848 DOI: 10.1002/14651858.cd011549] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Vanja Giljaca
- Clinical Hospital Centre RijekaDepartment of GastroenterologyKresimirova 42RijekaCroatia51000
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Yemisi Takwoingi
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - David Higgie
- North Bristol NHS TrustFrenchay HospitalBristolUKBS16 1LE
| | - Goran Poropat
- Clinical Hospital Centre RijekaDepartment of GastroenterologyKresimirova 42RijekaCroatia51000
| | - Davor Štimac
- Clinical Hospital Centre RijekaDepartment of GastroenterologyKresimirova 42RijekaCroatia51000
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Choi IY, Yeom SK, Cha SH, Lee SH, Chung HH, Hyun JJ, Kim BH. Diagnosis of biliary stone disease: T1-weighted magnetic resonance cholangiography with Gd-EOB-DTPA versus T2-weighted magnetic resonance cholangiography. Clin Imaging 2013; 38:164-9. [PMID: 24359645 DOI: 10.1016/j.clinimag.2013.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 10/08/2013] [Accepted: 11/04/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- In Young Choi
- Department of Radiology, Korea University Ansan Hospital, Korea University Ansan Hospital, 425-707, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do, Korea
| | - Suk Keu Yeom
- Department of Radiology, Korea University Ansan Hospital, Korea University Ansan Hospital, 425-707, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do, Korea.
| | - Sang Hoon Cha
- Department of Radiology, Korea University Ansan Hospital, Korea University Ansan Hospital, 425-707, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do, Korea
| | - Seung Hwa Lee
- Department of Radiology, Korea University Ansan Hospital, Korea University Ansan Hospital, 425-707, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do, Korea
| | - Hwan Hoon Chung
- Department of Radiology, Korea University Ansan Hospital, Korea University Ansan Hospital, 425-707, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do, Korea
| | - Jong Jin Hyun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan hospital, Korea University Ansan Hospital, 425-707, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do, Korea
| | - Baek Hyun Kim
- Department of Radiology, Korea University Ansan Hospital, Korea University Ansan Hospital, 425-707, Gojan 1-dong, Danwon-gu, Ansan-si, Gyeonggi-do, Korea
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Mandelia A, Gupta AK, Verma DK, Sharma S. The Value of Magnetic Resonance Cholangio-Pancreatography (MRCP) in the Detection of Choledocholithiasis. J Clin Diagn Res 2013; 7:1941-5. [PMID: 24179904 DOI: 10.7860/jcdr/2013/6158.3365] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/01/2013] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Ankur Mandelia
- Senior Resident, Department of Paediatric Surgery, All India Institute of Medical Sciences , New Delhi 110029, India
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Preoperative MRCP to detect choledocholithiasis in acute calculous cholecystitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:458-64. [PMID: 21983892 PMCID: PMC3399076 DOI: 10.1007/s00534-011-0456-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE There are risks of common bile duct (CBD) stones in acute cholecystitis, and there is a move among surgeons to identify choledocholithiasis before surgery. Magnetic resonance cholangiopancreaticography (MRCP) has the potential to accurately detect choledocholithiasis in patients with acute cholecystitis. The aim of this study was to evaluate the predictive values of MRCP and elevated biochemical predictors for choledocholithiasis in patients with acute cholecystitis. METHODS Between September 2006 and August 2008, of 84 patients with acute cholecystitis based on the diagnosis criteria of the Tokyo guidelines, 57 had MRCP preoperatively. The predictive values of six biochemical predictors for choledocholithiasis were also evaluated. RESULTS Of the 57 patients, seven (12.28%) had choledocholithiasis, of whom three had CBD stones in nondilated ducts. The smallest stone detected in a dilated CBD and nondilated duct was 3.19 and 4.55 mm in diameter, respectively. None of our patients whose MRCP showed a clear CBD returned with symptomatic choledocholithiasis during the follow-up period. All biochemical predictors and CBD diameter had limited positive predictive values. CONCLUSIONS Magnetic resonance cholangiopancreaticography is a reliable evaluation technique for the detection of choledocholithiasis. It reduces the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and prevents the risk of overlooking choledocholithiasis. No single predictor or combined markers have been found to be reliable for including/excluding the presence of choledocholithiasis.
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Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy. Surg Endosc 2009; 23:950-6. [PMID: 19266236 DOI: 10.1007/s00464-009-0339-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 12/19/2008] [Accepted: 01/01/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recurrent attacks of acute biliary pancreatitis (RABP) are prevented by (laparoscopic) cholecystectomy. Since the introduction of endoscopic retrograde cholangiopancreaticography (ERCP), several series have described a similar reduction of RABP after endoscopic sphincterotomy (ES). This report discusses the different treatment options for preventing RABP including conservative treatment, cholecystectomy, ES, and combinations of these options as well as their respective timing. METHODS A search in PubMed for observational studies and clinical (comparative) trials published in the English language was performed on the subject of recurrent acute biliary pancreatitis and other gallstone complications after an initial attack of acute pancreatitis. RESULT Cholecystectomy and ES both are superior to conservative treatment in reducing the incidence of RABP. Cholecystectomy provides additional protection for gallstone-related complications and mortality. Observational studies indicate that cholecystectomy combined with ES is the most effective treatment for reducing the incidence of RABP attacks. CONCLUSION From the literature data it can be concluded that ES is as effective in reducing RABP as cholecystectomy but inferior in reducing mortality and overall morbidity. The combination of ES and cholecystectomy seems superior to either of the treatment methods alone. A prospective randomized clinical trial comparing ES plus cholecystectomy with cholecystectomy alone is needed.
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Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy? Langenbecks Arch Surg 2008; 394:1005-10. [PMID: 19084990 DOI: 10.1007/s00423-008-0447-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2008] [Accepted: 09/16/2008] [Indexed: 12/20/2022]
Abstract
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.
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Mercer S, Singh S, Paterson I. Selective MRCP in the management of suspected common bile duct stones. HPB (Oxford) 2007; 9:125-30. [PMID: 18333127 PMCID: PMC2020789 DOI: 10.1080/13651820701216190] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is controversial whether selective endoscopic sphincterotomy or routine laparoscopic bile duct exploration is the optimal treatment for choledocholithiasis. Magnetic resonance cholangio-pancreatography (MRCP) is a safe and accurate imaging modality; this study evaluated its use in a clinical algorithm for the management of suspected choledocholithiasis. PATIENTS AND METHODS Consecutive patients presenting with suspected common bile duct (CBD) stones were managed according to an algorithm involving the selective use of MRCP to identify patients who required endoscopic sphincterotomy and bile duct clearance. Following radiological demonstration of a clear CBD, all patients were considered for cholecystectomy. RESULTS From 157 consecutive patients, 68 proceeded straight to endoscopic sphincterotomy, which was therapeutic in 59. Of 89 who underwent MRCP, choledocholithiasis was demonstrated in 29; subsequent endoscopic sphincterotomy was therapeutic in 22. MRCP demonstrated a clear CBD in the remaining 60 patients. Seventy-four patients subsequently underwent cholecystectomy, with a conversion rate of 9% and a median postoperative stay of 1 day. There were no instances of post-sphincterotomy pancreatitis or haemorrhage requiring transfusion. CONCLUSION An algorithm involving selective MRCP with endoscopic sphincterotomy is a safe, effective means of managing suspected choledocholithiasis, particularly where the expertise, equipment or theatre time for laparoscopic bile duct exploration is not routinely available.
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Morera FJ, Ripoll F, García-Granero M, Martín J, García Mingo J, Millan J, Checa F. [Utility of magnetic resonance cholangiography prior to cholecystectomy in acute biliary pancreatitis]. Cir Esp 2006; 80:27-31. [PMID: 16796950 DOI: 10.1016/s0009-739x(06)70912-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AIM To analyze the role of magnetic resonance cholangiography (MRC) in candidates for cholecystectomy after acute biliary pancreatitis (ABP). METHODS We performed a prospective study of patients with mild ABP (Atlanta criteria) admitted to our hospital from January 2004 to March 2005. Diagnosis of ABP was based on clinical features, serum amylase levels more than 3 times higher than the upper level of normality, and gallstones detected by ultrasonography. In all patients, MRC was performed preoperatively. If positive for common bile duct stones (CBDS), endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was performed, followed by laparoscopic cholecystectomy (LC). When MRC was negative, LC was performed directly. Intraoperative cholangiography was not routinely performed . RESULTS Of the 31 patients admitted, 27 were included (mean age 66.4 +/- 18 years, 78% female). Four patients were excluded: 2 refused to undergo cholecystectomy and two had severe ABP. The mean interval between onset of ABP and cholecystectomy was 1.7 months +/- 1.2. Three patients (11.1%) experienced recurrence within 4 weeks of the index admission. MRC revealed CBDS in four patients (14.8%). In 3 patients, all the gallstones were removed by ERCP and ES. In one patient, 12 gallstones were retrieved but attempts to remove a stone from the cystic duct were unsuccessful. One patient with preoperative CBDS was readmitted 4 weeks after cholecystectomy due to recurrence. Another patient with negative findings on preoperative MRC was also readmitted with postcholecystectomy ABP. Twenty-five of the 27 patients (93%) have remained asymptomatic after cholecystectomy (median follow-up: 16 months [8-22 months]). CONCLUSIONS MRC should not be routinely used in the preoperative evaluation of patients with ABP but is an accurate tool in selected patients with this disease.
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Affiliation(s)
- Francisco José Morera
- Servicio de Cirugía General, Hospital General de Requena, Requena, Valencia, España.
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Kaltenthaler EC, Walters SJ, Chilcott J, Blakeborough A, Vergel YB, Thomas S. MRCP compared to diagnostic ERCP for diagnosis when biliary obstruction is suspected: a systematic review. BMC Med Imaging 2006; 6:9. [PMID: 16907974 PMCID: PMC1579209 DOI: 10.1186/1471-2342-6-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 08/14/2006] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction. The use of MRCP, a non-invasive procedure, may prevent the use of unnecessary invasive procedures. The aim of the study was to compare the findings of MRCP with those of ERCP by the computation of accuracy statistics. METHODS Thirteen electronic bibliographic databases, covering biomedical, science, health economics and grey literature were searched. A systematic review of studies comparing MRCP to diagnostic ERCP in patients with suspected biliary obstruction was conducted. Sensitivity, specificity, likelihood ratios, acceptability and adverse events were reported. RESULTS 25 studies were identified reporting several conditions including choledocholithiasis (18 studies), malignancy (four studies), obstruction (three studies), stricture (two studies) and dilatation (five studies). Three of the 18 studies reporting choledocholithiasis were excluded from the analysis due to lack of data, or differences in study design. The sensitivity for the 15 studies of choledocholithiasis ranged from 0.50 to 1.00 while specificity ranged from 0.83 to 1.00. The positive likelihood ratio ranged: from 5.44-47.72 and the negative likelihood ratio for the 15 studies ranged from 0.00-0.51. Significant heterogeneity was found across the 15 studies so the sensitivities and specificities were summarised by a Receiver Operating Characteristic (ROC) curve. For malignancy, sensitivity ranged from 0.81 to 0.94 and specificity from 0.92 to 1.00. Positive likelihood ratios ranged from 10.12 to 43 and negative likelihood ratios ranged from 0.15 to 0.21, although these estimates were less reliable. CONCLUSION MRCP is a comparable diagnostic investigation in comparison to ERCP for diagnosing biliary obstruction.
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Affiliation(s)
- Eva C Kaltenthaler
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | - Stephen J Walters
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | - Jim Chilcott
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | | | | | - Steven Thomas
- Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
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Miletic D, Uravic M, Mazur-Brbac M, Stimac D, Petranovic D, Sestan B. Role of Magnetic Resonance Cholangiography in the Diagnosis of Bile Duct Lithiasis. World J Surg 2006; 30:1705-12. [PMID: 16850153 DOI: 10.1007/s00268-005-0459-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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16
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Uchiyama K, Tani M, Kawai M, Ueno M, Hama T, Yamaue H. Preoperative evaluation of the extrahepatic bile duct structure for laparoscopic cholecystectomy. Surg Endosc 2006; 20:1119-23. [PMID: 16703426 DOI: 10.1007/s00464-005-0689-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Accepted: 12/12/2005] [Indexed: 01/24/2023]
Abstract
BACKGROUND The incidence of aberrant bile duct injury associated with laparoscopic cholecystectomy (LC) has not yet been adequately examined. This study aimed to clarify the types of normal cystic ducts and the incidence of aberrant extrahepatic bile ducts, and to search for a method of avoiding injuries during LC. METHODS Aberrant hepatic ducts were retrospectively categorized into five types according to the pattern of the cystic ducts and the accessory hepatic ducts by preoperative endoscopic retrograde cholangiography or multidetector three-dimensional computed tomography using drip infusion cholangiography. The aberrant bile ducts were classified as type A (merging at the right side of the common bile duct), type B (merging at the anterior side), or type C (merging at the posterior left side). RESULTS The intrahepatic bile ducts and cystic duct were clearly shown for 1,044 of the 1,278 patients who underwent LC. Secondary branches of aberrant cystic ducts were observed in 37 cases (3.5%), and accessory hepatic ducts were observed in 30 cases (2.9%). A comparison of the difficulties encountered with LC for each type based on the merging patterns of cystic ducts showed that type C needed a much longer operation time for LC than the other types. CONCLUSIONS A preoperative evaluation of the bile duct tract and the accessory hepatic duct before LC is important. Patients with a cystic duct merging normally into the posterior left side of the common hepatic duct (type C) experienced difficulty when undergoing LC. The authors have safely performed LC with the use of an endoscopic nasobiliary drainage tube in type D cases (cystic duct merging with the right hepatic duct), in type IV cases (cystic duct merging with an accessory hepatic duct).
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Affiliation(s)
- K Uchiyama
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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Mutlu H, Basekim CC, Silit E, Pekkafali Z, Erenoglu C, Kantarci M, Karsli AF, Kizilkaya E. Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2005; 15:195-8; discussion 198-201. [PMID: 16082305 DOI: 10.1097/01.sle.0000174553.17543.fa] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Laparoscopic cholecystectomy (LC) is the preferred treatment of symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC is used to show cystic ducts that are not seen by MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with nonvisualized cystic ducts by MRC. To our knowledge, this is the first study of visualization of cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.
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Affiliation(s)
- Hakan Mutlu
- Department of Radiology, Gulhane Military Medical Academy Haydarpasa Teaching Hospital, Istanbul, Turkey.
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Mutlu H, Basekim CC, Silit E, Pekkafali Z, Erenoglu C, Kantarci M, Karsli AF, Kizilkaya E. Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2005; 15:133-6; discussion 136-8. [PMID: 15956896 DOI: 10.1097/01.sle.0000166968.56898.44] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Laparoscopic cholecystectomy (LC) is the preferred treatment for symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC was used to show cystic ducts that are not seen on MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with cystic ducts not seen on MRC. To our knowledge, this is the first study of visualization of a cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.
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Affiliation(s)
- Hakan Mutlu
- Department of Radiology, Gulhane Military Medical Academy, Haydarpasa Teaching Hospital, Istanbul, Turkey.
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Hallal AH, Amortegui JD, Jeroukhimov IM, Casillas J, Schulman CI, Manning RJ, Habib FA, Lopez PP, Cohn SM, Sleeman D. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis. J Am Coll Surg 2005; 200:869-75. [PMID: 15922197 DOI: 10.1016/j.jamcollsurg.2005.02.028] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Revised: 02/08/2005] [Accepted: 02/08/2005] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is controversy about the optimal method to detect common bile duct (CBD) stones in patients with mild resolving gallstone pancreatitis. The aim of this study was to evaluate magnetic resonance cholangiopancreatography (MRCP) in detecting choledocholithiasis in this group of patients. STUDY DESIGN A prospective randomized trial was conducted. Patients randomized to group 1 (n = 34) underwent laparoscopic cholecystectomy (LC) and intraoperative cholangiography (IOC). Those randomized to group 2 (n = 29) had preoperative MRCP, of these, patients with negative MRCP underwent LC and IOC, patients with positive MRCP had preoperative ERCP followed by LC. RESULTS Sixty-three patients were randomized (34 to group 1 and 29 to group 2). CBD stones were found in 5 patients in group 1. CBD exploration was performed in 2 patients, preoperative ERCP in 1, and postoperative ERCP in the other 2. MRCP showed CBD stones in 4 patients in group 2. There were two false-positive MRCPs. Four patients with a negative MRCP did not have IOC or ERCP, the remaining 21 patients with a negative MRCP had a negative IOC. The MRCP sensitivity was 100% (95% CI, 16-100%), specificity 91% (95% CI, 72-99%), positive predictive value 50% (95% CI, 7-93%), negative predictive value 100% (95% CI, 84-100%), and accuracy 92% (95% CI, 74-99%). CONCLUSIONS Patients with resolving gallstone pancreatitis and a negative MRCP do not need preoperative ERCP or IOC. Only patients with a positive MRCP will require preoperative ERCP.
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Affiliation(s)
- Ali H Hallal
- Dewitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, Ryder Trauma Center, University of Miami School of Medicine, Miami, FL 33101, USA
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20
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Kim YJ, Kim MJ, Kim KW, Chung JB, Lee WJ, Kim JH, Oh YT, Lim JS, Choi JY. Preoperative evaluation of common bile duct stones in patients with gallstone disease. AJR Am J Roentgenol 2005; 184:1854-9. [PMID: 15908542 DOI: 10.2214/ajr.184.6.01841854] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Young-Jin Kim
- Department of Diagnostic Radiology and Research Institute of Radiological Science, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, South Korea
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21
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Millat B. The author replies. Surg Endosc 2004. [DOI: 10.1007/s00464-003-9306-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Metcalfe MS, Ong T, Bruening MH, Iswariah H, Wemyss-Holden SA, Maddern GJ. Is laparoscopic intraoperative cholangiogram a matter of routine? Am J Surg 2004; 187:475-81. [PMID: 15041494 DOI: 10.1016/j.amjsurg.2003.12.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2003] [Revised: 08/11/2003] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Matthew S Metcalfe
- Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Woodville Rd., Woodville, SA 5011, Australia
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Patel AP, Lokey JS, Harris JB, Sticca RP, McGill ES, Arrillaga A, Miller RS, Kopelman TR. Current Management of Common Bile Duct Stones in a Teaching Community Hospital. Am Surg 2003. [DOI: 10.1177/000313480306900702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.
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Affiliation(s)
- Ajay P. Patel
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Jonathan S. Lokey
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - James B. Harris
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Robert P. Sticca
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Eric S. McGill
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Abenamar Arrillaga
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Richard S. Miller
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
| | - Tammy R. Kopelman
- From the Academic Department of Surgery, Greenville Hospital System, Greenville, South Carolina
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Boraschi P, Gigoni R, Braccini G, Lamacchia M, Rossi M, Falaschi F. Detection of common bile duct stones before laparoscopic cholecystectomy. Evaluation with MR cholangiography. Acta Radiol 2002. [PMID: 12485257 DOI: 10.1034/j.1600-0455.2002.430610.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To assess the diagnostic value of MR cholangiography (MRC) for detecting common bile duct (CBD) stones in candidates for laparoscopic cholecystectomy (LC). MATERIAL AND METHODS A series of 95 selected patients with gallstones and suspected CBD lithiasis (abnormal serum liver tests and/or CBD size > or = 6.5 mm at US) were referred to our institution for MRC, before LC. MRC was performed on a 0.5 T magnet through a non-breath-hold, respiratory-triggered, fat-suppressed, thin-slab, heavily T2-weighted fast spin-echo sequence and through a breath-hold, thick-slab, single-shot T2-weighted sequence in the coronal plane. Axial T1- and T2-weighted sequences were first obtained. Two observers in conference reviewed source images and maximum intensity projections to determine the presence or absence of choledocholithiasis. MR findings were compared with endoscopic retrograde cholangiography and intraoperative cholangiography (IOC); IOC was always performed during LC. RESULTS CBD calculi (single or multiple) were identified in 41 out of 95 patients (43%). Two false-positive and 4 false-negative cases were found on MRC. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of MRC for choledocholithiasis were 90%, 96%, 94%, 95%, and 93%, respectively. CONCLUSION MRC is a highly effective diagnostic modality for evaluation of patients with risk factors for CBD stones prior to LC.
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Affiliation(s)
- P Boraschi
- Second Department of Radiology, Pisa University Hospital, Pisa, Italy
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Kim JH, Kim MJ, Park SI, Chung JJ, Song SY, Kim KS, Yoo HS, Lee JT, Kim KW. MR cholangiography in symptomatic gallstones: diagnostic accuracy according to clinical risk group. Radiology 2002; 224:410-6. [PMID: 12147836 DOI: 10.1148/radiol.2241011223] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Joo Hee Kim
- Department of Diagnostic Radiology, Yonsei University College of Medicine, Seodaemun-ku Shinchon-dong 134, Seoul 120-752, Korea
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Arguedas MR, Dupont AW, Wilcox CM. Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model. Am J Gastroenterol 2001; 96:2892-9. [PMID: 11693323 DOI: 10.1111/j.1572-0241.2001.04244.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP. METHODS A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented. RESULTS At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15-58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7-45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option. CONCLUSIONS Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.
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Affiliation(s)
- M R Arguedas
- Department of Medicine, University of Alabama at Birmingham, 35294-0007, USA
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27
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Management of choledocholithiasis during pregnancy by magnetic resonance cholangiography and laparoscopic common bile duct stone extraction. Surg Laparosc Endosc Percutan Tech 2001. [PMID: 11083218 DOI: 10.1097/00129689-200010000-00013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Management of common bile duct (CBD) stones during pregnancy is a difficult problem. The authors reported the case of a patient who was 22 weeks' pregnant who had a symptomatic CBD stone successfully treated by the association of magnetic resonance cholangiography and laparoscopic CBD stone removal. The patient delivered a healthy baby boy at 39 weeks. Magnetic resonance cholangiography and laparoscopic CBD exploration is a viable option in the management of CBD stones in pregnant patients that carries a low risk for the fetus while preserving the advantages of minimally invasive surgery for the mother.
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28
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Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL. Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc 2001; 15:4-13. [PMID: 11178753 DOI: 10.1007/s004640000322] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND There are a variety of approaches to the diagnosis and treatment of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC). METHODS Decision modeling was used to evaluate the cost-effectiveness of four strategies for managing CBD stones around the time of LC: (a) routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) (preoperative ERCP), (b) LC with intraoperative cholangiography (IOC), followed by laparoscopic common bile duct exploration (LCDE), (c) LC with IOC, followed by ERCP (postoperative ERCP), and (d) expectant management (LC without any tests for CBD stones). Local hospital data were used to estimate costs. Cost-effectiveness was expressed in terms of the cost per case of residual CBD stones prevented (in excess of the cost of LC alone). Diagnostic test characteristics, procedure success rates, and adverse event probabilities were derived from a systematic review of the literature. Sensitivity analysis was used to explore the effect of uncertainty on the results of the model. RESULTS LC alone was the least costly strategy, but it was also the least effective. Of the more aggressive strategies, LCDE and preoperative ERCP were associated with marginal costs of $5993.60 and $299,259.35, respectively, per case of residual CBD stones prevented. Postoperative ERCP was more costly and less effective than LCDE, but it had a lower cost-effectiveness ratio than preoperative ERCP when the prevalence of CBD stones was <80%. CONCLUSIONS Compared to other common approaches, laparoscopic CBD exploration is a cost-effective method of managing CBD stones in patients who undergo LC. If expertise in LCDE is unavailable, selective postoperative ERCP is preferred over routine preoperative ERCP, unless the probability of CBD stones is very high (>80%).
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Affiliation(s)
- D R Urbach
- Department of Minimally Invasive Surgery and Surgical Research, Legacy Health Systems, Portland, OR 97227, USA
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Ishikawa M, Tagami Y, Toyota T, Nishioka M, Hanaki N, Sasaki K, Yagi Y, Kashiwagi Y, Miki H, Uemura N, Inoue S, Komatsu Y. Surg Laparosc Endosc Percutan Tech 2000; 10:351-356. [DOI: 10.1097/00019509-200012000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Can Three-Dimensional Helical CT Cholangiography Before Laparoscopic Cholecystectomy Be a Substitute Study for Endoscopic Retrograde Cholangiography? Surg Laparosc Endosc Percutan Tech 2000. [DOI: 10.1097/00129689-200012000-00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tuech J, Binelli C, Aube C, Pessaux P, Fauvet R, Descamps P, Arnaud J. Surg Laparosc Endosc Percutan Tech 2000; 10:323-325. [DOI: 10.1097/00019509-200010000-00013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Macdonald GA, Peduto AJ. Magnetic resonance imaging and diseases of the liver and biliary tract. Part 2. Magnetic resonance cholangiography and angiography and conclusions. J Gastroenterol Hepatol 2000; 15:992-9. [PMID: 11059927 DOI: 10.1046/j.1440-1746.2000.02277.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Magnetic resonance cholangiography (MRC) relies on the strong T2 signal from stationary liquids, in this case bile, to generate images. No contrast agents are required, and the failure rate and risk of serious complications is lower than with endoscopic retrograde cholangiopancreatography (ERCP). Data from MRC can be summated to produce an image much like the cholangiogram obtained by using ERCP. In addition, MRC and conventional MRI can provide information about the biliary and other anatomy above and below a biliary obstruction. This provides information for therapeutic intervention that is probably most useful for hilar and intrahepatic biliary obstruction. Magnetic resonance cholangiography appears to be similar to ERCP with respect to sensitivity and specificity in detecting lesions causing biliary obstruction, and in the diagnosis of choledocholithiasis. It is also suited to the assessment of biliary anatomy (including the assessment of surgical bile-duct injuries) and intrahepatic biliary pathology. However, ERCP can be therapeutic as well as diagnostic, and MRC should be limited to situations where intervention is unlikely, where intrahepatic or hilar pathology is suspected, to delineate the biliary anatomy prior to other interventions, or after failed or inadequate ERCP. Magnetic resonance angiography (MRA) relies on the properties of flowing liquids to generate images. It is particularly suited to assessment of the hepatic vasculature and appears as good as conventional angiography. It has been shown to be useful in delineating vascular anatomy prior to liver transplantation or insertion of a transjugular intrahepatic portasystemic shunt. Magnetic resonance angiography may also be useful in predicting subsequent variceal haemorrhage in patients with oesophageal varices.
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Affiliation(s)
- G A Macdonald
- Department of Medicine, The University of Queensland and The Queensland Institute of Medical Research, Brisbane, Australia.
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Affiliation(s)
- David J Lomas
- University Department of Radiology, Addenbrooke's Hospital Cambridge CB2 2QQ and University of Cambridge,
| | - Alex Gimson
- Department of Medicine, Addenbrooke's Hospital, Cambridge
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Liu TH, Consorti ET, Kawashima A, Ernst RD, Black CT, Greger PH, Fischer RP, Mercer DW. The efficacy of magnetic resonance cholangiography for the evaluation of patients with suspected choledocholithiasis before laparoscopic cholecystectomy. Am J Surg 1999; 178:480-4. [PMID: 10670857 DOI: 10.1016/s0002-9610(99)00224-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiography is the most commonly utilized tool for the identification of common bile duct stones (CBDS) before laparoscopic cholecystectomy, whereas the role of magnetic resonance cholangiography (MRC) for patient evaluation before laparoscopic cholecystectomy is currently undefined. METHODS We prospectively evaluated the efficacy of MRC for the identification of CBDS among patients with high risk for choledocholithiasis. Patient selection was based on clinical, sonographic, and laboratory criteria. Standard cholangiograms were obtained when possible for verification of MRC results. RESULTS Ninety-nine patients underwent evaluation with preoperative MRC. CBDS was visualized in 30% of patients. MRC sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 85%, 90%, 77%, 94%, and 89%, respectively. CONCLUSIONS MRC is useful for the evaluation of patients with suspected choledocholithiasis. Advantages of MRC include its noninvasive nature, ease of application, and accuracy in identifying and estimating the size of CBDS. Application of MRC in this setting reduces the need for diagnostic endoscopic retrograde cholangiography. Future investigations should be directed at the development of cost-effective utilization strategies for MRC application.
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Affiliation(s)
- T H Liu
- Department of Surgery, The University of Texas, Houston Health Science Center at Lyndon B. Johnson General Hospital, 77026-1967, USA
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Bibliography. J Laparoendosc Adv Surg Tech A 1999. [DOI: 10.1089/lap.1999.9.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Johnson CD. BJS Digest October–December, 1998. Surg Today 1999. [DOI: 10.1007/bf02483050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Comparaison de l'échoendoscopie avec les nouvelles méthodes d'imagerie médicale. ACTA ACUST UNITED AC 1999. [DOI: 10.1007/bf03020859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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