Gallstones

We enjoyed the article by Sanders and Kingsnorth on managing
gallstones but were truly alarmed that no mention of the role of
therapeutic ERCP (Endoscopic Cholangiopancreatography)in removing common
bile duct stones was included in the treatment section. Like many
interventional endoscopists, whether physicians, surgeons or radiologists,
we devote considerable time during our working week to removing common
duct stones during ERCP in non-anaesthetised sedated patients. Whilst we
acknowledge the advances in surgical techniques enabling exploration of
the duct on the operating table are now commonplace, the reality remains
that this expertise is not universally available. A significant number of
patients, particularly the elderly, presenting with common duct
cholelithiasis related pathology will end up getting an ERCP,
sphincterotomy and duct clearance regardless of their route of admission.
Not only do these patients do very well in the long term, the majority
escape cholecystectomy.

The article also fails to mention those patients who present with
biliary sepsis or obstruction as a result of residual (secondary) or de
novo (primary) common duct stones after cholecystectomy. A number of these
patients may present years after their original surgery, a fact that every
vigilant GP should be made aware of and ideally trigger a direct referral
for ERCP.

Finally, please let us not forget the useful role of ERCP and
temporary biliary stenting in sealing a post cholecystectomy bile leak,
which will often save the patient a trip back to theatre. Although this
complication is on the decline, we have little doubt that it will keep us
ERCP'ists in business for many years to come!

Competing interests:
None declared