Potential impact of magnetic resonance cholangiopancreatography on endoscopic retrograde cholangiopancreatography workload and complication rate in patients referred because of abdominal pain
Rj. Farrell et al., Potential impact of magnetic resonance cholangiopancreatography on endoscopic retrograde cholangiopancreatography workload and complication rate in patients referred because of abdominal pain, ENDOSCOPY, 33(8), 2001, pp. 668-675
Background and Study Aims: Endoscopic retrograde cholangiopancreatography (
ERCP) has a significant mortality, morbidity, and failed cannulation rate.
Magnetic resonance cholanglopancreatography (MRCP) is a safer, noninvasive
method of imaging the pancreaticobiliary tree. A substantial number of pati
ents are referred for ERCP because of abdominal pain, a high proportion of
whom have normal ducts or pathology not requiring interventional ERCP. The
aim was to assess the potential impact of MRCP on overall ERCP workload and
patient outcome if MRCP were the primary,investigation in patients referre
d for ERCP because of abdominal pain.
Patients and Methods: 1758 consecutive ERCPs performed in 1148 patients ove
r a 3-year period in a single tertiary referral center in the pre-MRCP era
were reviewed. Cannulation failure, ERCP findings, need for follow-up ERCP
and all 30-day major complication rates were analyzed with regard to clinic
al indications.
Results: The overall workload comprised 1108 (63%) successful initial ERCPs
, 188 (11 %) failed cannulation attempts and 462 (26%) follow-up ERCPs. Of
the patients, 299 (27%) had normal ERCP findings, 331 (30 %) had choledocho
lithiasis and 246 (22 %) had strictures. If MRCP had been used as the prima
ry imaging investigation in the 451 patients (39 %) referred for ERCP becau
se of abdominal pain, we estimate that 197 patients (44 %) would have avoid
ed ERCP, and the overall ERCP workload would have been reduced by 13 %. Ini
tial MRCP in suspected gallstone pancreatitis and certain miscellaneous gro
ups, it was estimated, would have further decreased ERCP workload by 9 %. F
our of 40 major ERCP-related complications (3.5 %) and one of four ERCP-rel
ated deaths (0.35 %) would potentially have been avoided.
Conclusions: Initial MRCP in patients referred with abdominal pain would po
tentially have avoided ERCP in 44 % of cases, reduced ERCP workload by, 13
% and significantly reduced patient morbidity, and mortality. The relativel
y small reduction in ERCP workload among these patients reflects the fact t
hat over half of them had probable sphincter dysfunction, a significant pro
portion of whom might have benefited from biliary manometry and/or endoscop
ic intervention despite a normal MRCP. Furthermore, a small number of patie
nts with calculi and subtle biliary and pancreatic strictures would be miss
ed by this approach.