Christina J Sperna Weiland1,2, Evelien C Verschoor3, Alexander C Poen4, Xavier J M N Smeets5, Niels G Venneman6, Abha Bhalla7, Ben J M Witteman8, Hester C Timmerhuis3,9, Devica S Umans3,10, Jeanin E van Hooft11, Marco J Bruno12, P Fockens10, Robert C Verdonk13, Joost P H Drenth14, Erwin J M van Geenen14. 1. Department of Gastroenterology and Hepatology, Radboudumc, Postbus 9101, 6500 HB, Nijmegen, The Netherlands. christa.spernaweiland@radboudumc.nl. 2. Department of Research and Development, St. Antonius ziekenhuis, Nieuwegein, The Netherlands. christa.spernaweiland@radboudumc.nl. 3. Department of Research and Development, St. Antonius ziekenhuis, Nieuwegein, The Netherlands. 4. Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands. 5. Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands. 6. Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands. 7. Department of Gastroenterology and Hepatology, Hagaziekenhuis, The Hague, The Netherlands. 8. Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands. 9. Department of Surgery, St. Antonius ziekenhuis, Nieuwegein, The Netherlands. 10. Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, Amsterdam, The Netherlands. 11. Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands. 12. Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands. 13. Department of Gastroenterology and Hepatology, St. Antonius ziekenhuis, Nieuwegein, The Netherlands. 14. Department of Gastroenterology and Hepatology, Radboudumc, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.
Abstract
BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome. METHODS: We established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP. RESULTS: We established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25-4.44; P = 0.008; number needed to harm 7.7). CONCLUSIONS: Even in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP.
BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice to remove sludge/stones from the common bile duct (CBD). In a small but clinically important proportion of patients with suspected choledocholithiasis ERCP is negative. This is undesirable because of ERCP associated morbidity. We aimed to map the diagnostic pathway leading up to ERCP and evaluate ERCP outcome. METHODS: We established a prospective multicenter cohort of patients with suspected CBD stones. We assessed the determinants that were associated with CBD sludge or stone detection upon ERCP. RESULTS: We established a cohort of 707 patients with suspected CBD sludge or stones (62% female, median age 59 years). ERCP was negative for CBD sludge or stones in 155 patients (22%). Patients with positive ERCPs frequently had pre-procedural endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) imaging (44% vs. 35%; P = 0.045). The likelihood of ERCP sludge and stones detection was higher when the time interval between EUS or MRCP and ERCP was less than 2 days (odds ratio 2.35; 95% CI 1.25-4.44; P = 0.008; number needed to harm 7.7). CONCLUSIONS: Even in the current era of society guidelines and use of advanced imaging CBD sludge or stones are absent in one out of five ERCPs performed for suspected CBD stones. The proportion of unnecessary ERCPs is lower in case of pre-procedural EUS or MRCP. A shorter time interval between EUS or MRCP increases the yield of ERCP for suspected CBD stones and should, therefore, preferably be performed within 2 days before ERCP.
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