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In the past 3½ decades we have witnessed the introduction of multiple new imaging techniques: endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography, transcutaneous ultrasonography, computed tomography (CT), and, most recently, endoscopic ultrasonography and magnetic resonance cholangiopancreatography (MRCP). All techniques have their proponents, and each has inherent advantages and limitations. Currently, there seems to be no universally accepted consensus on the imaging procedure-of-choice in patients with presumed or suspected mechanical biliary obstruction, as either a diagnostic or a staging procedure.
Georgopoulos and colleagues from Memorial Sloan-Kettering Cancer Center, New York, NY, suggest that MRCP might be the optimal diagnostic test (ie, the safest test, with high sensitivity, specificity, and positive predictive value) and should replace ERCP—and I believe they are correct, although this study does not prove it. Results of their preliminary study (only 18 patients) suggest that the noninvasive MRCP is as accurate as the invasive ERCP. This study, however, has several limitations that I am certain the authors would acknowledge. First, small numbers and a wide spectrum of sites of extrahepatic biliary obstruction limit definitive conclusions. Second, there is no comparison with CT (as a diagnostic procedure), which begs the question of whether MRCP was even necessary (if the CT showed a mass and the proximal [hepatic] extent of resection).
These criticisms aside, this study and several recent others1 - 2 address the use of MRCP for diagnosis of various pancreatobiliary disorders. What should we conclude? MRCP may well replace diagnostic (but not therapeutic) ERCP in patients with suspected mechanical disorders of the pancreatobiliary ductal systems—the driving forces are both accuracy (roughly equivalent) and safety (noninvasiveness). Cost and availability are other aspects that will need to be addressed.
Results of this study also attempt to suggest (indirectly) that MRCP adds data important for "staging" local vascular involvement, etc. However, this study, rightfully so with so few patients, does not and cannot pursue this topic. A better study addressing staging is that by Trede and colleagues,3 who believe that MR is superior to CT in staging pancreatobiliary neoplasms. Further studies with a direct comparison of MR and MRCP with CT (the current gold standard) will be necessary to answer this challenge.
Concerning diagnosis and staging, we as surgeons need to maintain both an open mind and a malleable approach to the evaluation of patients with jaundice; CT, MRCP, staging laparoscopy,4 and peritoneal cytology5 all have potential benefits that may change as new procedures become available.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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