05223826

November 17, 2021, 08:23

Reader’s expertise on the topic of the manuscript

Does the reader have a conflict of interest?

The overall quality of the manuscript, based on the above-listed criteria, should be evaluated and classified according to the following five categories

Language quality (style, grammar, and spelling) should be evaluated and classified according to the following five categories.

Multimodal treatments of “gallstone cholangiopancreatitis” Vanella S., MD¹; Baiamonte F., MD², Crafa F., MD ¹ 1. General and Oncological Surgery Unit, Hospital of National Relevance and High Specialty “St. Giuseppe Moscati”, Avellino – Italy 2. General and Emergency Surgery 1 Unit, Civico Hospital, Palermo, Italy We have read your article with great attention and interest. Congratulations on the article, the definition of “gallstone cholangiopancreatitis”, the etiological and prognostic hypotheses. However, it seems appropriate to report some comments. It is difficult to distinguish with alanine aminotransferase alone whether it is cholangitis associated with gallstone pancreatitis or an onset of multiorgan failure or other concomitant liver disease. [1] Anyhow, your reflections pave the way for future studies to find methods to better define cholangiopancreatitis from other liver diseases that can compromise the course of this pathology. Furthermore, even if your article was not intended to deal with all management strategies, it seems appropriate to make some clarifications here too. Gallstone pancreatitis associated with cholangitis requires urgent biliary decompression to ameliorate the disease course. The possibilities of biliary decompression are many, not only endoscopic retrograde cholangiopancreatography (ERCP), and depend on the clinical status of the patient, on the size of the stones, on any previous bilio-digestive derivations. Guidelines recommend urgent ERCP in patients with gallstone pancreatitis with concomitant cholangitis and suggest that ERCP might be beneficial in patients with cholestasis but without cholangitis.[2-4] Schepers et al showed that the urgent ERCP + endoscopic sphynterotomy (ES) is indicated in patients with acute pancreatitis and cholangitis or persistent cholestasis. [5] The execution of an ERCP ensures excellent clearance of the VBP where, however, a certain percentage of patients require two or more treatments with ERCP. ERCP with sphincterotomy is an invasive procedure that is associated with complications in up to 10% of patients. [6,7] Local complications of ERCP include bleeding, duodenal perforation, cholangitis, pancreatitis, VBP lesions. Furthermore, in some cases the ERCP is not practicable. Previous trial suggested that ERCP was associated with increased respiratory complications.19 In severely ill patients these respiratory complications might be triggered by conscious sedation and potential aspiration or by temporarily reduced oxygenation associated with sedation. Schepers et al observed more intensive care admissions in the urgent ERCP group. [5] In our clinical practice we subject critically ill patients, who may not tolerate general anesthesia or deep sedation, to percutaneous placement of biliary drains as a first step with a possible attempt to clear the common bile duct also with the use of percutaneous cholangioscopy and laser. it is also clear that the postoperative management of a VBP drainage can present some complications such as displacement, obstruction, bacterial superinfection. At the same time, it offers the advantage of an easy cholangiographic check in the follow-up, useful for documenting the absence of residual stones and the patency of the biliary tract in its entirety. After stabilization of the clinical picture we proceed to surgery and ERCP with rendez-vous or if it is not possible to perform ERCP + ES, with laparoscopic CBD exploration (LCBDE). Aawsaj showed that laparoscopic bile duct exploration can be performed successfully in both the emergency and elective settings. A transcystic approach should be favoured where possible. [8] Cholecystectomy within the same admission might prevent recurrent gallstone pancreatitis. A previous Review showed no difference between open surgery versus ERCP in clearance, morbidity and mortality. In the open surgery group had significantly fewer retained stones compared with the ERCP group (6% vs 16%, p= 0.0002). Comparing LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP There were fewer retained stones in the single-stage group (8%) compared with the two-stage group (14%) (p=ns). [9] In the study of Ding et al, at longer-term follow-up, recurrent CBD stones were seen more often in the two-stage group (9.5 vs. 2.1%, p = 0.037). [10] Endoscopic group had a significantly greater number of procedures per patient (p < 0.001) and a higher cost (p = 0.002). The two groups did not differ significantly in terms of major complications. [11] Balloon dilation is a valid alternative to endoscopic sphincterotomy, it can be performed both percutaneously and endoscopically, and compared to sphincterotomy it is simpler to perform, it is burdened by a lower percentage of bleeding and lesions of the sphincter of Oddi, but compared to sphincterotomy it is less effective in guaranteeing a correct clearance of VBP. In the era of multimodal treatments where endoscopic techniques offer significant diagnostic and therapeutic advantages for the treatment of common bile duct obstruction, laparoscopic treatment may represent the technique of choice in clinically stable patients with larger CBD, in patients with a history of previous bariatric surgery or other bilio-digestive derivations, and in patients in whom the endoscopic route has proved unsuccessful. In addition, the laparoscopic approach guarantees the possibility of performing only one anesthesia. The exploration by means of choledochoscopy of the main biliary tract and the simultaneous removal of the stones from the choledochus in a single stage (single-stage procedure), is an effective, safe and minimally invasive method in the treatment of gallstone cholangiopancreatitis, provided that it is performed in reference centers. and by operators with adequate experience. It also reduces the anesthetic risks associated with two subsequent procedures, reduces the average hospital stay and the costs of multiple hospitalizations. References 1. Brisinda G, Vanella S, Crocco A, Mazzari A, Tomaiuolo P, Santullo F, Grossi U, Crucitti A. Severe acute pancreatitis: advances and insights in assessment of severity and management. Eur J Gastroenterol Hepatol. 2011 Jul;23(7):541-51. doi: 10.1097/MEG.0b013e328346e21e. 2. Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013 Sep;108(9):1400-15; 1416. doi: 10.1038/ajg.2013.218. Epub 2013 Jul 30. Erratum in: Am J Gastroenterol. 2014 Feb;109(2):302. 3. Arvanitakis M, Dumonceau JM, Albert J, Badaoui A, Bali MA, Barthet M, Besselink M, Deviere J, Oliveira Ferreira A, Gyökeres T, Hritz I, Hucl T, Milashka M, Papanikolaou IS, Poley JW, Seewald S, Vanbiervliet G, van Lienden K, van Santvoort H, Voermans R, Delhaye M, van Hooft J. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy. 2018 May;50(5):524-546. doi: 10.1055/a-0588-5365. Epub 2018 Apr 9. 4. Crockett SD, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis. Gastroenterology. 2018 Mar;154(4):1096-1101. doi: 10.1053/j.gastro.2018.01.032. Epub 2018 Feb 3. 5. Schepers NJ, Hallensleben NDL, Besselink MG, Anten MGF, Bollen TL, da Costa DW, van Delft F, van Dijk SM, van Dullemen HM, Dijkgraaf MGW, van Eijck CHJ, Erkelens GW, Erler NS, Fockens P, van Geenen EJM, van Grinsven J, Hollemans RA, van Hooft JE, van der Hulst RWM, Jansen JM, Kubben FJGM, Kuiken SD, Laheij RJF, Quispel R, de Ridder RJJ, Rijk MCM, Römkens TEH, Ruigrok CHM, Schoon EJ, Schwartz MP, Smeets XJNM, Spanier BWM, Tan ACITL, Thijs WJ, Timmer R, Venneman NG, Verdonk RC, Vleggaar FP, van de Vrie W, Witteman BJ, van Santvoort HC, Bakker OJ, Bruno MJ; Dutch Pancreatitis Study Group. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet. 2020 Jul 18;396(10245):167-176. doi: 10.1016/S0140-6736(20)30539-0. 6. Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, Pilotto A, Forlano R. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007 Aug;102(8):1781-8. doi: 10.1111/j.1572-0241.2007.01279.x. Epub 2007 May 17. PMID: 17509029. 7. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996 Sep 26;335(13):909-18. doi: 10.1056/NEJM199609263351301. 8. Aawsaj Y, Light D, Horgan L. Laparoscopic common bile duct exploration: 15-year experience in a district general hospital. Surg Endosc. 2016 Jun;30(6):2563-6. doi: 10.1007/s00464-015-4523-0. Epub 2015 Aug 26. PMID: 26307600. 9. Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013 Dec 12;2013(12):CD003327. doi: 10.1002/14651858.CD003327.pub4. PMID: 24338858; PMCID: PMC6464772. 10. Ding G, Cai W, Qin M. Single-stage vs. two-stage management for concomitant gallstones and common bile duct stones: a prospective randomized trial with long-term follow-up. J Gastrointest Surg. 2014 May;18(5):947-51. doi: 10.1007/s11605-014-2467-7. Epub 2014 Feb 4. PMID: 24493296. 11. Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A, Kumar A, Pandav CS, Subramaniam R, Arora MK, Garg PK. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc. 2014 Mar;28(3):875-85. doi: 10.1007/s00464-013-3237-4. Epub 2013 Oct 26. PMID: 24162138.

First, thank you very much for your professional comments on the article published in World Journal of Gastrointestinal Endoscopy. Second, we read your comments with great interest. You are welcome to format your valuable comments into a Letter to the Editor and submit it online to World Journal of Gastrointestinal Endoscopy at https://www.f6publishing.com. There are no restrictions on the number of words, figures (color, B/W) or authors for a Letter to the Editor. In addition, the article processing charge will be exempted for this Letter to the Editor. As with all articles published by the Baishideng Publishing Group, the Letter to the Editor will be published online after completing peer review. The guidelines for a Letter to the Editor can be found at: https://www.wjgnet.com/bpg/GerInfo/219. Finally, we look forward to receiving your high-quality Letter to the Editor, which will promote academic communication and lead the development of this discipline.

Replied on November 23, 2021, 13:08

I thank you for your interest and comments regarding my article. As you mentioned, my article was not intended to deal with all management strategies for patients with gallstone cholangiopancreatitis (CP) who need urgent biliary decompression to ameliorate the disease course, which was beyond the scope of the opinion review. However, your detailed clarifications on the issue, referring from endoscopic retrograde cholangiopancreatography with sphincterotomy or balloon dilatation to percutaneous placement of biliary drains, depending on the clinical status of patients, the size of stones, or any previous bilio-digestive derivations, together with multimodal treatments to prevent recurrence of gallstone pancreatitis, that are informative and appropriate for readers, are greatly appreciated. Here, I would like to make one comment. I agree with you in that it is difficult to distinguish between gallstone CP and other diseases that can compromise the disease course. In the diagnosis and treatment of gallstone pancreatitis, which I proposed to call gallstone hepatopancreatitis in the article, the challenge for clinicians is to predict patients with gallstone CP. One of the distinct guidelines for the prediction of gallstone CP may be the cholangitis score[1], which consists of a combination of the following clinical parameters detected shortly after admission: (1) pyrexia (body temperature ≧38°C; (2) biochemical data (serum bilirubin level ≧2.2 mg/dL) and ultrasound findings; (3) bile duct diameter ≧11 mm; and (4) presence of bile duct stones. Patients with three or four predictors are likely to have impacted ampullary stones or persistent stones and pus in the bile duct, and may be candidate for urgent biliary decompression. Furthermore, after ruling out gallstone CP, serial determination of the lactate dehydrogenase (LDH) to aspartate aminotransferase (AST) ratio may help predicting gallstone necrotizing pancreatitis (NP)[2]. The LDH/AST ratio serially evaluated during the first seven days after admission might predict gallstone NP; in gallstone NP patients, the LDH/AST ratios on postadmission days 3, 5, and 7 were significantly higher than those in non-NP patients, and an elevated LDH/AST ratio helped in diagnosing gallstone NP faster than its diagnosis using contrast-enhanced compute tomography. REFERENCES 1 Isogai M, Yamaguchi A, Harada T, Kaneoka Y, Suzuki M. Cholangitis score: a scoring system to predict sever cholangitis in gallstone pancreatitis. J Hepatobiliary Panreat Surg 2002; 9: 98-104 [PMID: 12021903 DOI: 10.1007/s005340200010.] 2 Isogai M, Yamaguchi A, Hori A, Keneoka Y. LDH to AST Ratio in Biliary Pancreatitis – A Possible Indicator of Pancreatic Necrosis: Preliminary Results. Am J Gastroenterol 1998; 93: 363-367 [PMID: 9517641 DOI: 10.1111/j.1572-0241.1998.00363.x]