CARTAS AL EDITOR

 

Diagnosis and management of patients with an intermediate probability of choledocholithiasis

 

 

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Key words: Choledocholithiasis. Common bile duct. Endoscopic retrograde cholangiopancreatography. Endoscopic ultrasonography. Magnetic resonance cholangiopancreatography. Cholecystectomy. Intraoperative cholangiography.

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Dear Editor,

We thank Dr. Dib for his interest in our prospective study, in which we assessed the accuracy of the American Society for Gastrointestinal Endoscopy guidelines for the prediction of choledocholithiasis (CL) (1).

The guidelines suggest the option of using a less-invasive initial test including endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) in patients with intermediate probability of CL (2). However, there is a paucity of published literature supporting this recommendation. Furthermore, in the study by Adams et al. (3) such a recommendation is not supported by their data. Additionally, because the prevalence of CL varies among ethnic groups, we did not consider performing pre-ERCP (endoscopic retrograde cholangiopancreatography) imaging studies in our study.

We speculate that if we had performed pre-ERCP imaging (EUS or MRCP), the accuracy of the guidelines would have improved from 41% to ~60% in this intermediate-probability subgroup. This was implied by analyzing those patients in our database with an intermediate and high probability of CL, the latter based solely on the presence of a common bile duct (CBD) stone on abdominal ultrasound (Table I). These patients with the presence of a CBD stone on ultrasound that did not fulfill any of the other high-probability criteria had a 61% probability of CL. Thus, even if we had used pre-ERCP imaging studies in the intermediate-probability subgroup, the rate of unnecessary ERCPs would probably continue to be unacceptably high (~40%) and even at a higher cost.

 

 

In this subgroup of patients, the cholecystectomy and intraoperative cholangiography (IOC) is a better diagnostic and therapeutic approach (4). Therefore, based on ERCP expertise the performance of cholecystectomy and IOC is a reasonable approach, so ERCP is performed postoperatively when the IOC is positive for CL or if needed for other complications (e.g., bile leak, duct injury) (5).

 

José A. González-González and Roberto Monreal-Robles
Gastroenterology Department. Hospital Universitario "Dr. José E. González".
Universidad Autónoma de Nuevo León. Monterrey, México

 

References

1. Narváez Rivera RM, González González JA, Monreal Robles R, et al. Accuracy of ASGE criteria for the prediction of choledocholithiasis. Rev Esp Enferm Dig 2016;108:309-14. DOI: 10.17235/reed.2016.4212/2016.         [ Links ]

2. Committee ASoP, Maple JT, Ben-Menachem T, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010;71:1-9. DOI: 10.1016/j.gie.2009.09.041.         [ Links ]

3. Adams MA, Hosmer AE, Wamsteker EJ, et al. Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: Accuracy of existing guidelines and the impact of laboratory trends. Gastrointest Endosc 2015;82:88-93. DOI: 10.1016/j.gie.2014.12.023.         [ Links ]

4. Iranmanesh P, Frossard JL, Mugnier-Konrad B, et al. Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: A randomized clinical trial. JAMA 2014;312:137-44. DOI: 10.1001/jama.2014.7587.         [ Links ]

5. Tarnasky P, Kedia P. Regarding: Validation and improvement of a proposed scoring system to detect retained common bile duct stones in gallstone pancreatitis. Surgery 2016;159:985-6. DOI: 10.1016/j.surg.2015.08.020.         [ Links ]