Farrell R J, Noonan N, Mahmud N, Morrin M M, Kelleher D, Keeling P W
Dept. of Clinical Medicine, St James' Hospital, Trinity College, Dublin, Ireland.
Endoscopy. 2001 Aug;33(8):668-75. doi: 10.1055/s-2001-16218.
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. 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 referred for ERCP because of abdominal pain.
1758 consecutive ERCPs performed in 1148 patients over 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 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. lf MRCP had been used as the primary imaging investigation in the 451 patients (39 %) referred for ERCP because of abdominal pain, we estimate that 197 patients (44 %) would have avoided ERCP, and 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 %. Four of 40 major ERCP-related complications (3.5 %) and one of four ERCP-related deaths (0.35 %) would potentially have been avoided.
Initial MRCP in patients referred with abdominal pain would potentially have avoided ERCP in 44 % of cases, reduced ERCP workload by 13 % and significantly reduced patient morbidity and mortality. 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 whom might have benefited from biliary manometry and/or endoscopic intervention despite a normal MRCP. Furthermore, a small number of patients with calculi and subtle biliary and pancreatic strictures would be missed by this approach.
内镜逆行胰胆管造影术（ERCP）具有显著的死亡率、发病率及插管失败率。磁共振胰胆管造影（MRCP）是一种更安全的、用于胰胆管成像的非侵入性方法。大量因腹痛转诊行ERCP的患者中，很大一部分患者的胆管正常或其病变不需要进行介入性ERCP。本研究旨在评估若将MRCP作为因腹痛转诊行ERCP患者的首要检查手段，其对ERCP总体工作量及患者预后的潜在影响。
回顾了在MRCP应用前的3年时间里，在一家三级转诊中心对1148例患者连续进行的1758例ERCP的情况。分析了插管失败情况、ERCP检查结果、后续ERCP需求以及所有30天内的主要并发症发生率，并与临床指征进行对照分析。
总体工作量包括1108例（63%）首次ERCP成功、188例（11%）插管尝试失败以及462例（26%）后续ERCP。患者中，299例（27%）ERCP检查结果正常，331例（30%）有胆总管结石，246例（22%）有狭窄。如果将MRCP用作因腹痛转诊行ERCP的451例患者（39%）的首要影像检查手段，我们估计197例患者（44%）可避免行ERCP，ERCP总体工作量将减少13%。据估计，对疑似胆石性胰腺炎患者及某些其他特定患者群体先行MRCP检查，可使ERCP工作量进一步减少9%。40例与ERCP相关的主要并发症中有4例（3.5%）以及4例ERCP相关死亡病例中有1例（0.35%）可能得以避免。
对因腹痛转诊的患者先行MRCP检查，有可能使44%的病例避免行ERCP，减少13%的ERCP工作量，并显著降低患者的发病率和死亡率。这些患者中ERCP工作量减少幅度相对较小，这反映出超过半数患者可能存在括约肌功能障碍，其中很大一部分患者即便MRCP检查结果正常，也可能从胆管测压和/或内镜干预中获益。此外，这种方法会遗漏少数有结石以及轻微胆管和胰腺狭窄的患者。
