Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy

Abstract

1. Table 1 has only two studies comparing recurrent acute biliary pancreatitis (RABP) after cholecystectomy and endoscopic sphinctrotomy (ES).The total number of these patients was 81. Accordingly, the power of the conclusion from these two studies would be low. 2. One of the important points is the time from the acute cholecystitis to the cholecystectomy. A number of patients will experience RABP while they are awaiting cholecystectomy. This study had no time specification, so these vital data have not been explored in the literature, as the authors mentioned. 3. In the fourth paragraph on page 953, the authors said ‘‘an additional cholecystectomy resulted in a lower death rate (7.9 vs. 14.1%).’’ Although there is no doubt about this, we were nevertheless surprised at the high mortality rate of 7.9%. In our experience, the number of patients who experienced RABP after ES and cholecystectomy was negligible, and we reported only one death over the last 10 years with a work load exceeding 2,000 laparoscopic cholecystectomies. 4. The number of patients in each group shows constant variation. The study compares different numbers of patients. For example Hammarstrom et al. [2] compared 49 patients with RABP after ES and 16 patients who had RABP after cholecystectomy. Consequently, it would be difficult to have a sound conclusion from such nonmatched data. 5. Our practice is to perform laparoscopic cholecystectomy at the same admission whether the attack of pancreatitis was mild or severe provided there is no radiologic stigmata of common bile duct stone and the liver function test results are normal. However, for patients who have a recurrent attack of biliary pancreatitis, we certainly perform ES before proceeding with cholecystectomy. If the cholecystectomy was performed previously, the postoperative ES is our choice even if there is no radiologic evidence of common bile duct stones.