ERCP / endo sphincterotomy question

[dodobird]

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I'm reviewing a journal article comparing outcomes of ES vs cholecystectomy. In the group that is selected for ES, an ERCP is performed first. The study states, "ES was performed irrespective of the presence or absence of bileduct stones as revealed by ERCP" Isn't this fixing something that isn't broken?

This sounds unethical to me (an MSI btw) so I wanted to ask those in the know what you think.

Thanks!

 

[FliteSurgn]

If I understand your question...I assume that the study was trying to compare treatments for gallstone pancreatitis. In that case, the gastroenterologist is trying to make a bigger hole for any future gallstones to traverse without getting lodged and causing pancreatitis again. If they are going to try using ERCP as sole treatment for stones (ie. not perform a cholecystectomy after the pancreatitis resolves), then they need a sphincterotomy.

That being said, I think that it's ludicrous to use it in this manner except in those that will not tolerate a cholecystectomy. I think that ERCP is a great adjunct when needed, but most ducts can be cleared at the time of cholecystectomy. In the trials that I have seen, there is a clear trend towards more complications in the ERCP only group (with short follow-up too).

There are numerous articles on the clearance of common duct stones comparing lap chole with common duct exploration (LCBDE) vs. lap chole with ERCP. There is an equal rate of ductal clearance between the groups with a slightly higher rate of complications in the LC w/ ERCP group. Of course, this all assumes that the surgeon can perform LCBDE with the same success of the published series.

Here's a decent review article for anyone interested.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=12445057

 

[Idiopathic]

Isnt there a ridiculous mortality rate associated with gallstone pancreatitis? It seems that any Rx would be helpful.

 

[FliteSurgn]

The mortality rate associated with gallstone pancreatitis is <5%.

 

[dodobird]

Thanks for the replies. I'm too green to follow a lot of this, but it seemed that the ES was performed solely to avoid an experimental failure. But if doing the procedure was prophylactic, it sounds reasonable. 😳

Again, thank you for replying.