Endoscopic retrograde cholangiopancreatography (ERCP) has a significant mortality, morbidity, and failed cannulation rate. Magnetic resonance cholangiopancreatography (MRCP) is a safer, noninvasive method of imaging the pancreaticobiliary tree.
A substantial number of patients are referred for ERCP because of abdominal pain, a high proportion of whom have normal ducts or pathology not requiring interventional ERCP.
Two teams in Dublin, Ireland, and Boston, Massachusetts, USA, conducted the study. They assessed the potential impact of MRCP on overall ERCP workload and patient outcome, if MRCP were the primary investigation in patients referred for ERCP because of abdominal pain.
The survey involved 1758 consecutive ERCPs performed in 1148 patients. These were conducted over a 3-year period in a single tertiary referral center in the pre-MRCP era.
|Initial MRCP could significantly reduce patient mortality.|
Cannulation failure, ERCP findings, need for follow-up ERCP, and all 30-day major complication rates were analyzed, with regard to clinical indications.
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 choledocholithiasis, and 246 (22%) had strictures.
If MRCP had been used as the primary imaging investigation in the 451 patients (39%) referred for ERCP because of abdominal pain, the research group predicted that 197 patients (44%) would have avoided ERCP. In addition, the overall ERCP workload would have been reduced by 13%.
Initial MRCP in suspected gallstone pancreatitis and certain miscellaneous groups, it was estimated, would have further decreased ERCP workload by 9%.
Furthermore, 4 of 40 major ERCP-related complications and 1 of 4 ERCP-related deaths would potentially have been avoided.
The research group concluded that the relatively small reduction in ERCP workload among these patients reflects the fact that over half of them had probable sphincter dysfunction. A significant proportion of these might have benefited from biliary manometry and/or endoscopic intervention despite a normal MRCP.
Moreover, a small number of patients with calculi and subtle biliary and pancreatic strictures would be missed by this approach.