Effect of type of alcoholic beverage in causing acute pancreatitis (Br J Surg 2011; 98: 1609-1616).


Sir We read with great interest the metaanalysis of intraoperative (IOES) versus preoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones by Gurusamy and colleagues. We trialled this approach in the early 1990s with the advent of laparoscopic cholecystectomy, and our initial experience was published1. Our conclusions were similar but we have a few additional comments to make. As pointed out in the paper, IOES is performed in the supine rather than the usual prone position making the procedure more challenging. The availability of resources is important and our conclusion was that IOES would be feasible only in centres where the surgeon is also the endoscopist. It is not feasible in centres where it takes a significant amount of time to gather the expertise in the operating theatre with the patient already anaesthetized. In view of these difficulties it is no surprise that IOES has not gained popularity amongst surgeons. There is no doubt an advantage to the patient. Whether performed before or after operation endoscopic retrograde cholangiopancreatography (ERCP) can be an unpleasant experience, and having it under a general anaesthetic can be advantageous for the patient. Another advantage is a shorter hospital stay as the bile duct can be cleared during the same operating session. The common practice in the UK is either preoperative ERCP for patients who are symptomatic or found to have stones at magnetic resonance cholangiopancreatography, or postoperative ERCP in patients in whom a ‘silent stone’ or stones are found on routine cholangiography. There is no doubt that, with the establishment of more integrated operating theatres with endoscopy facilities available at short notice, this technique merits a revisit. IOES shortens hospital stay and reduces the patient’s anxiety and discomfort after cholecystectomy. When we initially reported our experience, laparoscopic exploration of the common bile duct (CBD) was not routine practice. Currently most upper gastrointestinal surgeons have the expertise to undertake at least a transcystic exploration of theCBDwith stone extraction. There is no doubt that this should be the preferred management of CBD stones and IOES may have a very limited role because of the logistics of undertaking it, often at short notice, However, if facilities exist it provides cost-effective management for patients in whom a laparoscopic approach has failed. This comparison may merit future study. On a technical point, we agree that a cholecystectomy following IOES can become more challenging with insufflation of the bowel. Therefore, as a matter of routine we advocated leaving a peroperative cholangiogram catheter in situ via the cystic duct and completing the cholecystectomy first. ERCP was then performed and, following endoscopic sphincterotomy, the stones were extracted using a combination of basket and balloon catheter techniques. With the peroperative cholangiogram catheter in situ it was possible to flush the duct to aid clearance of the bile duct. Following successful CBD clearance the peroperative cholangiogram catheter was removed, the cystic duct was clipped and the gallbladder extracted. M. N. Siddiqui and Z. A. Siddiqui Queen Elizabeth Hospital, London UK (e-mail: midhatsiddiqui@aol.com) DOI: 10.1002/bjs.7826

DOI: 10.1002/bjs.7830

Cite this paper

@article{Barreto2012EffectOT, title={Effect of type of alcoholic beverage in causing acute pancreatitis (Br J Surg 2011; 98: 1609-1616).}, author={Savio George Barreto and Tom Paxton and Mike Whitlaw}, journal={The British journal of surgery}, year={2012}, volume={99 1}, pages={146; author reply 146} }