Endoscopic ultrasound versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a randomized trial comparing two management strategies

Endoscopic ultrasound in pancreatic disease--its influence on surgical decision-making. An update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bile duct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace other techniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.

Does endoscopic retrograde cholangiopancreatography reduce the risk of local pancreatic complications in acute pancreatitis? A systematic review and metaanalysis

BACKGROUND

Recent studies have added to the controversy regarding the role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis. This debate is due in part to a marked difference between the trials regarding the definition of "complication" as an outcome. This study sought to determine the effect of early ERCP versus conservative treatment on local pancreatic complications (defined by the current classification) experienced by patients with acute biliary pancreatitis.

METHODS

Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Science Citation Index) and conference proceedings were searched for relevant randomized controlled trials up to December 2007. The effect of both treatment strategies on local pancreatic complications was calculated with random-effects models.

RESULTS

Five trials involving 717 patients were included in this systematic review. Pooled analysis of all the patients with acute pancreatitis did not demonstrate a statistically significant difference between the two treatment strategies (relative risk [RR], 0.94; 95% confidence interval [CI], 0.63-1.40; p = 0.62). Similar results were observed after subgroup analysis based on the severity of disease as follows: mild acute pancreatitis (RR, 0.79; 95% CI, 0.26-2.47; p = 0.69); severe acute pancreatitis (RR, 0.77; 95% CI, 0.30-1.98; p = 0.59).

CONCLUSION

The early use of ERCP did not result in a significantly reduced risk of local pancreatic complications for either patients with mild acute pancreatitis or those with severe form of the disease.

EUS accurately predicts the need for therapeutic ERCP in patients with a low probability of biliary obstruction

BACKGROUND

Because of its inherent risks, ERCP should only be performed for purposes of treatment. EUS and MRCP have emerged as diagnostic alternatives before therapeutic ERCP.

OBJECTIVE

Our purpose was to test the accuracy of EUS in predicting the need for therapeutic ERCP in low-risk patients.

DESIGN

Prospective, unblinded, single-center study.

SETTING

Academic center of the University of Witten/Herdecke.

PATIENTS

Fifty patients with clinical, laboratory, or transabdominal US findings suggestive of biliary obstruction were included.

INTERVENTIONS

After clinical assessment and US, all patients underwent EUS. If EUS was conclusive, either ERCP with sphincterotomy (EST) was performed or the patients were followed up for 1 year. If EUS was inconclusive, MRCP was performed, followed by ERCP or a 1-year follow-up. After each diagnostic step, the examiner decided whether any biliary conditon was present and whether therapeutic ERCP was necessary. The decicions were compared with the results of ERCP with EST or the outcome after the 1-year follow-up.

MAIN OUTCOME MEASUREMENTS

Accuracy of EUS in predicting the need for therapeutic ERCP.

RESULTS

Nine patients had ERCP with EST. The final assessment classified 2 of these interventions as having been unnecessary. EUS was conclusive in 49 cases. After EUS, the accuracy of the decision on the presence of a biliary condition increased from 82% to 96% and on the need for therapeutic ERCP from 86% to 96%.

LIMITATION

Single-center experience.

CONCLUSION

EUS accurately predicts the need for therapeutic ERCP in patients at low risk for biliary obstruction.

Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study

BACKGROUND

EUS may be used to reduce the need of diagnostic ERCP.

OBJECTIVE

Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic.

DESIGN

A randomized study.

SETTING

A university medical unit.

PATIENTS

Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction.

INTERVENTIONS

In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist.

MAIN OUTCOME MEASUREMENTS

The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year.

RESULTS

Thirty-three patients were randomized to EUS and 32 to ERCP. Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP. In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients.

CONCLUSIONS

In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP.