Early endoscopic sphincterotomy in acute cholecystitis in elderly patients with high surgical risk

We read with interest the article published in your journal (August 2006 issue) in which Vracko et al. [1] report improved outcomes in elderly patients admitted with acute cholecystitis who underwent early endoscopic sphincterotomy (ES).

However there are several issues that we would like to comment on. First, the diagnostic criteria for acute cholecystitis are not defined. Secondly, 63 % of patients in the conservative group and 73 % in the ES group had evidence of either pancreatitis or biliary obstruction (jaundice, elevated bilirubin, elevated alkaline phosphatase). We presume that some patients had both but cannot tell this from the data presented. Current British Society of Gastroenterology guidelines advocate urgent ES for all patients with biliary pancreatitis and jaundice, suggesting conservative treatment in this group of patients was inappropriate [2]. Thirdly, those patients with jaundice would be expected to have a high probability of common bile duct (CBD) stones, but the authors do not report the findings at endoscopic retrograde cholangiopancreatography (ERCP) and the incidence of CBD stones. Current evidence suggests that patient with cholangitis, but no stones in the CBD at ERCP, do not benefit from ES [3].

In addition, more patients in the conservative treatment (C) group had a higher American Society of Anesthesiologists (ASA) classification, which would have influenced the less favorable outcome with conservative treatment and need for subsequent cholecystectomy. Hence the findings on postoperative complications, shown in Table 4 of the paper, must be interpreted with caution.

The question remains to be answered as to whether the clinical course of patients with acute cholecystitis but without common channel obstruction or biliary pancreatitis is improved by early ES.

Competing interests: None

References

• 1 Vracko J, Markovic S, Wiechel K L. Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk.  Endoscopy. 2006;  38 773-778
• 2 UK Working Party on Acute Pancreatitis . UK guidelines for the management of acute pancreatitis.  Gut. 2005;  54 (Suppl III) iii1-iii9
• 3 Hui C K, Lai K C, Wong W M. et al . A randomised controlled trial of endoscopic sphincterotomy in acute cholangitis without common bile duct stones.  Gut. 2002;  51 245-247