Multimodal treatments of “gallstone cholangiopancreatitis”

TO THE EDlTOR

We read with interest the article by Isogai[1] about the definition of “gallstone cholangiopancreatitis,”and the assessments regarding the aetiology and prognosis.Although the study is very well worded,we would like to add a few comments.

We think that it is complex to distinguish,with the only dosage of alanine aminotransferase,between a liver disease or the onset of multi-organ failure and cholangitis associated with pancreatitis[2].However,the reflections expressed in the document stimulate the research activity to realize diagnostic methods that allow distinguishing “cholangiopancreatitis” from other adverse events that can worsen the clinical course of acute pancreatitis.

Moreover,we would like to integrate the different CBD obstruction management techniques even if this was not the main focus of the article.

Acute pancreatitis complicated by cholangitis due to CBD obstruction must be approached with an urgent decompression of the biliary tract to improve the pathology course.There are different approaches to decompress CBD,such as endoscopic retrograde cholangiopancreatography (ERCP),concerning the clinical conditions,the diameter of the stones,and any previous biliodigestive derivation.Urgent ERCP is recommended in patients with gallstone pancreatitis and concomitant cholangitis.The guidelines suggest that ERCP can improve the course in patients with CBD obstruction even in the absence of cholangitis[3-5].

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In the study by Schepers

[6],it appears that urgent ERCP associated with sphincterotomy may help in cholangitis complicating acute pancreatitis or in persistent obstruction of CBD.ERCP results in excellent clearance of CBD;nevertheless,in a certain proportion of patients,it may be necessary to resort to multiple procedures.ERCP associated with sphincterotomy is an aggressive approach which can lead to complications in up to 10% of patients[7,8],including bleeding,cholangitis,pancreatitis,duodenal perforation,and CBD lesions.A previous study showed that ERCP could lead to an increase in respiratory complications[9-13].Sedation and possible aspiration can lead to respiratory complications in clinically critically ill patients.In the study of Schepers

[6],in the urgent ERCP group there were more intensive care unit admissions.

Percutaneous or endoscopic balloon dilation represents a valid alternative to ES.It is simpler,has fewer complications in terms of bleeding and sphincter of Oddi lesions but has a lower performance in CBD clearance than ES[18,19].In the current era,endoscopic approaches guarantee excellent results in the management of the biliary tract.Surgical management of CBD can be a viable option for patients in good condition with large diameter stones,previous biliodigestive derivations,and in case of failure of the endoscopic approach[20-22].In addition,laparoscopic treatment can be performed with single anesthesia.Exploration of CBD by intraoperative choledochoscopy and simultaneous biliary clearance in a single time is not very aggressive and safe,with excellent results for treating "gallstone cholangiopancreatitis" and should only be performed in high volume centres with surgeons with proven experience.The laparoscopic management of CBD stones also reduces the average hospital stay,the anesthetic risks associated with two different procedures,and the cost of multiple hospitalizations.

The study of Bansal

[17] showed a shorter hospital stay in the single-stage group but no differences in major complications between the two groups.

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We thank the members of the Department of Surgery at San Giuseppe Moscati Hospital for carefully reading of and examining the manuscript.

Vanella S wrote and edited the manuscript and collected the clinical data;Crafa F reviewed the discussion section of the manuscript;Baiamonte M revised the manuscript and provided recommendations for the manuscript.

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Laparoscopic cholecystectomy (LC) + LCBDE had fewer retained stones (8%) than two-staged preoperative ERCP plus LC or LC plus post-operative ERCP (14%) (

= not significant).In the study by Ding

[16],there were more recurrent CBD stones in the two-stage group at longer-term follow-up(9.5%

2.1%;

= 0.037).In the endoscopic group,there were more procedures per patient (P ＜ 0.001)and most costly espenses (P = 0.002).

Percutaneous biliary drainage can also have complications such as infections,and it can become blocked or displaced.However,it allows performing cholangiographies that can evaluate the possible presence of residual stones or the complete clearance of the biliary tract throughout their entire course.Once the patient's clinical condition has been improved,surgery and rendezvous ERCP can be carried out;if endoscopic treatment is not feasible,a laparoscopic exploration of CBD (LCBDE) could be performed.

In a few minutes the toad stood in front of him and asked, What s the matter with you now, my dear Prince? Oh, Puddocky, this time you can t help me, for the task is beyond even your power, replied the Prince

Our clinical approach to patients with severe clinical conditions,unable to withstand general anesthesia or deep sedation is to subject these patients to percutaneous decompression of the CBD with a drain placed under local anesthesia and possible subsequent clearance of the CBD with the use of percutaneous cholangioscopy and laser.

In the study of Aawsaj

[14] the LCBDE has been used in both elective and emergency contexts.A transcystic approach is preferable whenever possible.It is preferable to perform cholecystectomy during the same hospitalization to avoid recurrent gallstone pancreatitis.

A previous review by Dasari

[15] showed no difference in clearance,morbidity,and mortality between open surgery and ERCP.In the ERCP group there were significantly more retained stones than in the open surgery group (16%

6%;

= 0.0002).

All authors have no conflicts of interest to declare.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

Italy

Serafino Vanella 0000-0002-6599-8225;Mario Baiamonte 0000-0001-8323-8118;Francesco Crafa 0000-0002-2038-625X.

Wang LL

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Wang LL

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