ERCP Topics

Pancreaticobiliary Imaging

Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for pancreaticobiliary ductal imaging. Over the last few years, the quality of imaging produced by magnetic resonance cholangiopancreatography (MRCP) has improved greatly, and indeed in some specialist centers it has supplanted ERCP as a diagnostic test. However, there is still confusion regarding the place of MRCP in the investigational algorithm of patients with suspected pancreaticobiliary disease-whether or not it avoids the need for ERCPs, and if so, whether it is cost-effective in doing so.

In two abstracts, Hellerhoff and colleagues in Munich [1] [2] report investigations on the impact of MRCP on the number of ERCPs performed and on whether MRCP aided those ERCPs that required intervention. A total of 113 patients with a “moderate” probability of pancreaticobiliary disease (bilirubin ≤ 2.4 mg/dl and common bile duct diameter ≤ 10 mm) underwent MRCP prior to diagnostic ERCP. The results were disappointing. Although MRCP was relatively accurate in identifying strictures, stones, and normal ducts (sensitivity 77 % for stones, 83 % for normal ducts), the results were inferior to published data [3] [4] [5] . MRCP had a sensitivity and specificity of 97 % and 100 % in 34 patients with normal pancreatic ducts, and a sensitivity and specificity of 100 % and 100 % in 11 patients with main pancreatic duct strictures. As all of the patients went on to undergo ERCP, the data presented are essentially a comparison between ERCP and MRCP. The overall conclusion was that MRCP rarely makes it possible to avoid ERCP in patients with a “moderate” probability of pathology. Although the small numbers of patients in the subgroups should be borne in mind, this study is in conflict with other published work, and suggests that MRCP is not yet ready to relieve ERCP of its role in the diagnosis of pancreaticobiliary diseases. Subsequently, the authors attempted to assess the value of MRCP prior to interventional ERCP. In 45 patients with obstructive jaundice or chronic pancreatitis, information obtained from MRCP was used in the planning of the subsequent intervention. The extent of hilar strictures (eight patients), the number and size of “difficult” common bile duct (CBD) stones (three patients), the extent of bilio-enteric anastomotic strictures (nine patients), and the presence of strictures or stones in the main pancreatic duct (MPD) in patients with known chronic pancreatitis (25 patients) were evaluated. Again, apart from the chronic pancreatitis group, the subgroup numbers were too small to judge the importance of the results. Also, it was not clear whether this was a retrospective or a prospective study-a fact that tempers the authors’ conclusion that MRCP can play a significant role in the planning of therapeutic ERCP. The information may well have been nice to have, but what difference did it ultimately make?

An interesting abstract by a group in Nagoya, Japan [6] introduces a further imaging modality that may be of value in the assessment of pancreatic disease. Three-dimensional transabdominal ultrasonography uses a combination of standard ultrasonography, electromagnetic sensors, and computer software reconstruction to produce three-dimensional images of intra-abdominal structures. In 34 patients, it was found that adequate “virtual” images were obtained in 30 patients when the results were compared with the resected specimens, direct pancreatoscopy, or direct cholangioscopy. The authors’ conclusion that virtual pancreatoscopy can produce adequate three-dimensional images of the main pancreatic duct, common bile duct, and pancreatic cysts, is qualified only by their acknowledgment that further hardware and software improvements are needed before accurate definition of the shape and extent of pancreatic tumors is possible. Problems with the technique are likely to be encountered due to the limitations of extracorporeal ultrasound in imaging the entire pancreas. One wonders whether it might be possible to apply principles from this technique to EUS. The cost and often limited availability of MRCP are its major disadvantages, and-provided that the cost differential is significant-this study suggests a method of achieving noninvasive pancreaticobiliary imaging at an acceptable price.

References

• 1 Hellerhoff K, Petzfold V, Born P, et al. MRCP versus ERCP in the evaluation of patients with suspected biliopancreatic disease: can ERCPs be saved [abstract]?.  Gastrointest Endosc. 2001;  53 AB97
• 2 Hellerhoff K, Petzfold V, Born P, et al. Which information can MRCP provide prior to interventional ERCP? A prospective comparative study [abstract].  Gastrointest Endosc . 2001;  53 AB87
• 3 Alcaraz M J, de la Morena E J, Polo A, et al. A comparative study of magnetic resonance cholangiography and direct cholangiography.  Rev Esp Enferm Dig. 2000;  92 427-438
• 4 Reinhold C, Taourel P, Bret P M, et al. Choledocholithiasis: evaluation of MR cholangiography for diagnosis.  Radiology. 1998;  209 435-442
• 5 Varghese J C, Liddell R P, Farrell M A, et al. Diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.  Clin Radiol. 2000;  55 25-35
• 6 Hashimoto S, Goto H, Hirooka Y, et al. Virtual pancreatoscopy using transabdominal three-dimensional ultrasound [abstract].  Gastroenterology . 2001;  118 A764
• 7 Rabenstein T, Roggenbuck S, Frampe B. Prevention of acute post-ERCP pancreatitis with heparin? Final results of a prospective study in risk factors for AP [abstract].  Gastrointest Endosc. 2000;  51 AB184
• 8 Duvnjak M, Supane V, Simicevic V N, et al. Octreotide acetate pretreatment in the prevention of post ERCP abdominal pain [abstract].  Gastroenterology. 2000;  118 A160
• 9 Sand J, Matikainen M, Nordback I. Antibiotic prophylaxis reduces post-ERCP pancreatitis [abstract].  Gastroenterology . 2000;  118 A1062
• 10 Moreto M, Zaballa M, Ramirez K, et al. Transdermal glyceryl trinitrate in the prevention of post-ERCP pancreatitis [abstract].  Gastrointest Endosc. 2000;  51 AB67
• 11 Andriulli A, Leandro G, Niro G, et al. Pharmacologic treatment can prevent pancreatic injury after ERCP: a meta-analysis.  Gastrointest Endosc. 2000;  51 1-7
• 12 Testoni P A, Bagnolo F, Andriulli A, et al. 24-hour prophylaxis with octreotide in high-risk patients for post-ERCP pancreatitis: results of a multicenter, randomized trial [abstract].  Gastrointest Endosc . 2001;  53 AB97
• 13 Prat F P, Amaris J, Ducot B, et al. Nifedipine for post-ERCP pancreatitis prophylaxis: results of a prospective, double-blind randomized study [abstract].  Gastrointest Endosc . 2001;  53 AB105
• 14 Johnston S D, McKenna A, Tham T C. Silent myocardial ischaemia during endoscopic retrograde cholangiopancreatography (ERCP) [abstract].  Gastrointest Endosc . 2001;  53 AB99
• 15 Christensen M, Rasmussen V, Schulze S, et al. Vagal withdrawal during endoscopic retrograde cholangiopancreatography.  Scand J Gastroenterol. 2000;  35 96-101
• 16 Rosenberg J, Overgaard H, Anderson M M, et al. Metoprolol prevents myocardial ischemia during endoscopic retrograde cholangiopancreatography.  Ugeskr Laeger. 1997;  159 5514-5518
• 17 Rosenberg J, Overgaard H, Andersen M, et al. Double blind randomised controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic cholangiopancreatography.  Br Med J. 1996;  313 258-261
• 18 Rosenberg J, Jorgensen L N, Rasmussen V, et al. Hypoxaemia and myocardial ischaemia during and after endoscopic cholangiopancreatography: call for further studies.  Scand J Gastroenterol. 1992;  27 717-720
• 19 Tung B Y, Kimmey M B. Biliary complications of orthotopic liver transplantation.  Dig Dis. 1999;  17 133-144
• 20 Hintze R E, Adler A, Veltzke W, et al. Endoscopic management of biliary complications after orthotopic liver transplantation.  Hepatogastroenterology. 1997;  44 258-262
• 21 Theilmann L, Kuppers B, Kadmon M, et al. Biliary tract strictures after orthotopic liver transplantation: diagnosis and management.  Endoscopy. 1994;  26 517-522
• 22 Pfau P R, Kochman M L, Lewis J D, et al. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation.  Gastrointest Endosc. 2000;  52 55-63
• 23 Sossenheimer M, Slivka A, Carr-Locke D. Management of extrahepatic biliary disease after orthotopic liver transplantation: review of the literature and results of a multicenter survey.  Endoscopy. 1996;  28 565-571
• 24 Schwartz D A, Petersen B T, Poterucha J J, et al. Endoscopic therapy of anastomotic bile duct strictures occurring after liver transplantation.  Gastrointest Endosc. 2000;  51 169-174
• 25 Raijman I, Fukami N, Lappin J, et al. The use of multiple stents (MS) in the management of liver transplantation-related biliary stricture (LTBS): long-term follow-up [abstract].  Gastrointest Endosc . 2001;  53 AB106
• 26 Minami A, Nakatsu T, Uchida N, et al. Papillary dilation vs. sphincterotomy in endoscopic removal of bile duct stones: a randomized trial with manometric function.  Dig Dis Sci. 1995;  40 2550-2554
• 27 Staritz M, Ewe K, Meyer zum Büschenfelde K H. Endoscopic papillary dilation (EPD) for the treatment of common bile duct stones and papillary stenosis.  Endoscopy. 1983;  15 (Suppl 1) 197-198
• 28 Staritz M, Ewe K, Meyer zum Büschenfelde K H. Endoscopic papillary dilatation: an alternative to papillotomy?.  Dtsch Med Wochenschr. 1982;  107 895-897
• 29 DiSario J A, Freeman M L, Bjorkman D J, et al. Endoscopic balloon dilatation vs. sphincterotomy (EDES) for bile duct stone removal [abstract].  Digestion . 1998;  59 26
• 30 Fujita N, Maguchi H, Komatsu Y. Endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilatation (EPBD) for bile duct stones: preliminary report on a randomized controlled multicenter trial [abstract].  Gastrointest Endosc . 2001;  53 AB60
• 31 Matsumoto H, Araki M, Kawanishi N, et al. Shortened duration of balloon dilatation may reduce the incidence of pancreatitis and the elevation of serum amylase after endoscopic papillary balloon dilatation for extracting bile duct stones [abstract].  Gastrointest Endosc. 2001;  53 AB100
• 32 Mutignani M, Foschia F, Pandolfi M, et al. Transnasal extraction (TNE) of residual common bile duct (CBD) stones by the Seldinger technique [abstract].  Gastrointest Endosc. 2001;  53 AB91
• 33 Hochberger J, Bayer J, May A, et al. Laser lithotripsy of difficult bile duct stones: results in 60 patients using a rhodamine 6G dye laser with optical stone tissue detection system.  Gut. 1998;  43 823-829
• 34 Zorcher T, Hochberger J, Schrott K M, et al. In vitro study concerning the efficiency of the frequency-doubled double-pulse neodymium:YAG laser (FREDDY) for lithotripsy of calculi in the urinary tract.  Lasers Surg Med. 1999;  25 38-42
• 35 Hochberger J, Maiss J, Tex S, et al. First clinical data on laser lithotripsy of common bile duct stones with a new frequency-doubled double-pulse Nd:YAG-laser (FREDDY) in 19 patients [abstract].  Gastrointest Endosc. 2001;  53 AB87
• 36 Saab S, Martin P, Soliman G Y, et al. Endoscopic management of biliary leaks after T-tube removal in liver transplant recipients: nasobiliary drainage versus biliary stenting.  Liver Transpl. 2000;  6 627-632
• 37 Mergener K, Strobel J C, Suhocki P, et al. The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy.  Gastrointest Endosc. 1999;  50 527-531
• 38 Sugiyama M, Mori T, Atomi Y. Endoscopic nasobiliary drainage for treating bile leak after laparoscopic cholecystectomy.  Hepatogastroenterology. 1999;  46 762-765
• 39 Ryan M E, Geenen J E, Lehman G A, et al. Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review.  Gastrointest Endosc. 1998;  47 261-266
• 40 Hawes R H, Matsuda K, Trus T L, et al. Cystic duct leak closure using poly-n-acetyl glucosamine (p-glc-nac) results in a swine model [abstract].  Gastrointest Endosc. 2001;  53 AB99
• 41 Brodsky J A, Marks J M, Malm J A, et al. Sphincter of Oddi injection with botulinum toxin is as effective as endobiliary stenting in resolving cystic duct leaks in a canine model [abstract].  Gastrointest Endosc. 2001;  53 AB85
• 42 Huibregtse K, Cheng J, Coene P P, et al. Endoscopic placement of expandable metal stents for biliary strictures: a preliminary report on experience with 33 patients.  Endoscopy. 1989;  21 280-282
• 43 Rossi P, Bezzi M, Salvatori F M, et al. Clinical experience with covered Wallstents for biliary malignancies: 23-month follow-up.  Cardiovasc Intervent Radiol. 1997;  20 441-447
• 44 Rossi P, Bezzi M, Rossi M, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients.  J Vasc Interv Radiol. 1994;  5 279-285
• 45 Huibregtse K, Carr-Locke D L, Cremer M, et al. Biliary stent occlusion: a problem solved with self-expanding metal stents? European Wallstent Study Group.  Endoscopy. 1992;  24 391-394
• 46 Howell D A, Shah R J, Desilets D J, et al. Multicenter randomized comparative trial of the new spiral Z-stent compared to Wallstent: final results of the ZOOM study [abstract].  Gastrointest Endosc. 2001;  53 AB60
• 47 Cunningham J T, Uflacker R, Rossi P, et al. Multi-center clinical experience with percutaneous transhepatic deployment (PTD) and endoscopic retrograde deployment (ERD) of an EPTFE-lined nitinol biliary self-expanding metal stent (SEMS) [abstract].  Gastrointest Endosc. 2001;  53 AB105
• 48 Isayama H, Komatsu Y, Tsujino T, et al. A prospective randomized study of “covered” vs. “uncovered” Diamond stent for malignant biliary obstruction [abstract].  Gastrointest Endosc. 2001;  53 AB106
• 49 Kawase Y, Hori J, Okuno T, et al. Clinical evaluation of covered metallic stents vs. bare stents for malignant biliary strictures: results of a multicenter study in Japan [abstract].  Gastrointest Endosc . 2001;  53 AB99
• 50 Yoo B M, Kim J H, Park J J, et al. Long-term follow up of covered metal stents versus uncovered metal stents for malignant extrahepatic bile duct obstruction [abstract].  Gastrointest Endosc. 2001;  53 AB91
• 51 Pahernik S A, Dellian M, Berr F, et al. Distribution and pharmacokinetics of Photofrin in human bile duct cancer.  J Photochem Photobiol B. 1998;  47 58-62
• 52 Zopf T, Riemann J F. Therapy of pancreatic and bile duct tumors: value of radiotherapy and photodynamic therapy.  Schweiz Rundsch Med Prax. 2000;  89 1293-1298
• 53 Zopf T, Riemann J F. The change in laser usage in gastroenterology: status in 1997.  Z Gastroenterol. 1997;  35 987-997
• 54 Zoepf T, Rosenbaum A, Schneider A J, et al. Conversion from percutaneous to transpapillary drainage in non-resectable bile duct cancer is possible after photodynamic therapy (PDT) [abstract].  Gastrointest Endosc. 2001;  53 AB101
• 55 Ortner M AE, Berr F, Liebetruth J, et al. Photodynamic therapy of non-resectable cholangiocarcinoma: a randomized prospective study-first results [abstract].  Gastrointest Endosc . 2001;  53 AB85
• 56 Catalano M F, Rosenblatt M L, Geenen J E, et al. Diagnosis of sphincter of Oddi dysfunction: comparison of sphincter of Oddi manometry, fatty meal sonography and hepatobiliary scintigraphy [abstract].  Gastrointest Endosc. 2001;  53 AB71
• 57 Catalano M F, Rosenblatt M L, Geenen J E, et al. Treatment of sphincter of Oddi dysfunction by endoscopic sphincterotomy: clinical response predicted by hepatobiliary scintigraphy and fatty meal sonography [abstract].  Gastrointest Endosc. 2001;  53 AB71
• 58 Silverman W B, Johlin F C, Crowe G. Does secretin-stimulated ultrasound (SSU) predict results of sphincter of Oddi manometry (SOM), basal sphincter pressure (BSP) in patients suspected of having sphincter of Oddi dysfunction (SOD)? [abstract].  Gastrointest Endosc. 2001;  53 AB100
• 59 Fogel E L, Sherman S, Bucksot T L, et al. Sphincter of Oddi manometry (SOM): effects of droperidol in the biliary and pancreatic sphincter [abstract].  Gastrointest Endosc. 2001;  53 AB89
• 60 Wilcox C M, Linder J, Price J, et al. Prospective evaluation of droperidol on sphincter of Oddi manometry [abstract].  Gastrointest Endosc. 2001;  53 AB82
• 61 Bak A W, Perini R F, Muscara M, et al. An endoscopic animal model of sphincter of Oddi dysfunction [abstract].  Gastroenterology. 2001;  120 (Suppl 1) A390
• 62 Linder J D, Klapow J C, Geels W, et al. Long-term follow-up of patients undergoing sphincter of Oddi manometry (SOM) and sphincterotomy (S): evidence for a chronic pain syndrome [abstract].  Gastrointest Endosc. 2001;  53 AB87
• 63 Catalano M F, Rosenblatt M L, Geenen J E, Hogan W J. Effectiveness in endotherapy in the treatment of chronic pancreatitis associated with SOD [abstract].  Gastrointest Endosc. 2001;  53 AB139
• 64 Saurin J C, Chavaillon A, Napoleon B, et al. Long-term outcome of patients after endoscopic treatment of duodenal benign ampullomas [abstract].  Gastrointest Endosc. 2001;  53 AB64
• 65 Catalano M F, Rosenblatt M L, Geenen J E, Hogan W J. Pancreatic endotherapy of pancreas divisum (PDV): response based on clinical presentation and results of secretin-stimulated endoscopic ultrasound (S-EUS) [abstract].  Gastrointest Endosc. 2001;  53 AB133
• 66 Fogel E L, Kwon E, Sherman S, et al. Pancreatic ductal alterations following small diameter, long length, unflanged pancreatic duct (PD) stent placement [abstract].  Gastrointest Endosc. 2001;  53 AB86
• 67 Rosenblatt M L, Catalano M F, Nawra A T, et al. The management of pancreatic duct (PD) stenting for obstructive-type pain of pancreatic cancer [abstract].  Gastrointest Endosc. 2001;  53 AB136
• 68 Altorfer J, Muller A P, Ammann R, Munch R. Endoscopic therapy of chronic pancreatitis (CP): long-term follow-up [abstract].  Gastrointest Endosc. 2001;  53 AB138
• 69 Kozarek R A, Brandabur J J, Gibbons R P, et al. ERCP and ESWL for refractory pancreatic duct stones: do we really improve pain, preclude the need for surgery? [abstract].  Gastrointest Endosc. 2001;  53 AB60
• 70 Borel I, Saurin J C, Bory R, et al. Treatment of chronic pancreatitis using “definitive” stenting of the main pancreatic duct [abstract].  Gastrointest Endosc. 2001;  53 AB139
• 71 Schmitt T, Wehrmann T, Caspary W F, et al. New endoscopic method for debridement of infected peripancreatic necrosis [abstract].  Gastrointest Endosc. 2001;  53 AB131