Author Affiliations: Department of Surgery, University of California, San Francisco.
I read with interest the April 2011 “Image of the Month” article1 and congratulate Dr Dawwas and colleagues for their successful care in this challenging case. However, I do have questions regarding the exclusive use of the endoscopic approach to manage gallstones impacted at the distal end of the common bile duct (CBD) and regarding the indications for performing another endoscopic retrograde cholangiopancreatography (ERCP) and concurrent stent placement rather than a surgical intervention. First, in the setting of persistent cholangitis after placement of the initial plastic stent, was consideration given to definitive open CBD exploration, which might have rendered unnecessary the second and third ERCPs? Second, did concomitant intra-abdominal infection preclude CBD exploration during the laparotomy to retrieve the stent and perform a jejunal resection? Finally, placement of the metal stent during the third ERCP (rather than CBD exploration and possible biliary reconstruction) may prove to be only a temporary fix if the stent becomes occluded in the future.
Maa J. Emerging Trends in Endoscopic Retrograde Cholangiopancreatography and Common Bile Duct Exploration. Arch Surg. 2011;146(11):1336-1337. doi:10.1001/archsurg.2011.303