ERCP Group Research Articles

Management of gallstone disease in the elderly.

To determine the outcome of management of symptomatic gallstone disease (GSD) in patients aged 80 years or more. A retrospective review of the outcome of 79 patients admitted to 2 district general hospitals with symptomatic GSD over a 1-year period was undertaken. Patients were grouped according to method of management: non-operative, ERCP, and cholecystectomy. POSSUM scores for the ERCP and cholecystectomy groups were calculated and observed, and predicted outcome compared. Obstructive jaundice and biliary colic were the most common presenting symptoms. Each patient had been admitted at least once before the study period (median, 2; range, 1-3). Outcomes are detailed in Table 1. Non-operative management failed in 18 of 23 patients, with 17.4% mortality. ERCP was successful in 40 of 47 patients with 3 complications (0.24 of predicted) and no mortality. In all, 11 laparoscopic and 12 open cholecystectomies were performed with 6 complications and 1 mortality (0.95 and 0.83 of predicted, respectively): 4 complications and the only death occurring after emergency cholecystectomy. Table 1 Outcomes Management Number Mortality Morbidity Outcome Non-operative 23 4 9 5 OK, 13 re-admitted, 4 still symptomatic ERCP 47 0 3 1 PTC, 6 operated Operative 23 1 6 CONCLUSIONS: This study suggests that recurrent GSD in elderly patients managed non-operatively may have fatal outcome. Elective cholecystectomy has acceptable morbidity and mortality in this age group and there is often ample opportunity to avoid emergency surgery, but a prospective randomised study is required to improve clinical algorithms.

4671 A randomized clinical trial comparing ercp and mrcp in an effectiveness setting.

BACKGROUND: Magnetic Resonance Cholangiopancreatography (MRCP) can accurately image the pancreaticobiliary system without significant risks. Rapid and widespread diffusion of MRCP has occurred in the absence of cost-effectiveness data comparing it to the gold standard of ERCP. AIM: We performed a prospective randomized multicenter clinical trial to study the effectiveness (real-life setting) and costs of MRCP and ERCP in patients with suspected biliary obstruction. METHODS: Over 24 months, 162 patients with a clinical suspicion of obstruction and/or dilated duct on ultrasound (but without a definitive etiologic diagnosis), who were considered for either ERCP or MRCP, were randomized to either undergo MRCP or ERCP using block allocation stratified by level of obstruction on ultrasound. These patients were either at intermediate risk for obstruction or required further imaging because the next step in management was not clear. The main endpoint was the occurrence of a negative outcome attributable to the biliopancreatic disease or the procedure within 12 months of randomization. Secondary outcomes included mortality and accuracy for the detection of given pathologies. An intention to treat analysis was carried out. Standard statistical tests were performed. RESULTS: 82 patients to date have been randomized to MRCP and 80 to ERCP. Mean age in each group was 50.0±25.1 (SD) and 56.6±18.4 yrs, respectively, with 33% men in both groups. 40 (48.8%) patients randomized to MRCP required an ERCP after their MRCP for various reasons, 80% of which were therapeutic. At 12 months, in the MRCP group, 6 had died, 25 were cured, 1 was palliated, and 1 was unchanged vs 5 who had died, 19 cured, 1 palliated, and 3 unchanged in the ERCP group. Excluding one outlier in the MRCP group who suffered multiple complications and had a hospital stay of 157 days, 19 complications occurred in the MRCP group in 15 (18%) patients with a total length of stay of 79 days (0.98 d/patient randomized) vs 14 in the ERCP group in 10 (13%) patients accounting for a total of 63 days in hospital (0.79 d/patient randomized); a difference of 5% of patients (95%CI: -6,16). CONCLUSIONS: For all outcomes, no statistically or clinically significant differences between ERCP and MRCP for patients with suspected biliary obstruction exist to date. As anticipated by our preliminary sample size calculations, further accrual of patients is required to achieve adequate statistical power. Subgroup examinations are required to determine the optimal role of this new diagnostic modality.

CT before and after ERCP: detection of pancreatic pseudotumor, asymptomatic retroperitoneal perforation, and duodenal diverticulum

Background: A prospective study was done to investigate the occurrence of morphologic changes after ERCP that present as pancreatic pseudotumor on CT scan. Fifty-eight patients underwent CT before and after ERCP. In addition, post-ERCP complications and the value of routinely obtained CT before ERCP were assessed. Results: Thirty-nine patients could be fully analyzed; 12 underwent a papillotomy (group 1). Pseudotumor of the pancreatic head was demonstrated on CT after ERCP in 2 of them (17%). No changes were seen in the 27 patients who underwent diagnostic ERCP (group 2) (p = 0.048). Asymptomatic retroperitoneal perforation after papillotomy was diagnosed in 3 patients (13%). Routinely obtained CT scans before ERCP defined a specific etiology of the biliary obstruction in 12% of patients not suggested by ultrasound. Duodenal diverticulum was found in 4 patients, resulting in a sensitivity of 36% and a specificity of 100% for CT. Oral contrast (600 ml) administered a few hours before endoscopy never hampered the endoscopist. Conclusion: Pancreatic pseudotumor on CT after ERCP occurred only when papillotomy was performed. CT remains a valuable diagnostic tool after diagnostic ERCP. Asymptomatic perforation may occur following ERCP with papillotomy. Routinely obtained CT before ERCP was not profitable for the endoscopist in more than 80% of our patients. (Gastrointest Endosc 1997;45:231-5.)