Letter to the Editor—Early ERCP for Gallstone Pancreatitis: For Whom and When?

Excerpt

I read with interest the article recently published in the Journal of Gastrointestinal Surgery in which Behrns et al. reported the result of an evidence-based review of the outcomes of early endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. The study adds to the slow-growing knowledge of evidence supporting advantages and disadvantages from the use of this procedure, but not much. The study does not provide a careful evidence-based analysis of the data in relation to duration of ampullary obstruction provided in the trials analyzed. In fact, excepting the time of ERCP calculated from admission and, more recently, from the onset of symptoms, no other data have been reported in most publications about this point. Apparently, there is no doubt at present that the time of the onset of symptoms is the time of stone impaction, and consequently, it is also the time of the onset of obstruction. Likewise, the time of ERCP + endoscopic sphincterotomy (ES) is considered the time of the end of obstruction. However, the fact that 80–90% of the patients with obstructive gallstone pancreatitis pass the stone spontaneously within 48 h from the onset of symptoms makes necessary to find other indicators than ERCP since it is not completely innocuous, and moreover, it is irrelevant once the stone has passed. Our study—one of the studies analyzed by Behrns et al.—reports a non-invasive and accurate method for measuring the duration of ampullary obstruction in that important group of patients who disobstructs spontaneously. It also permits to evaluate the relationship between patient outcome and duration of obstruction regardless of whether the last is due to ES or to the natural history of the disease. The authors stated that our method can be “subjective and open to interpretation.” As the authors noted, our diagnostic test consists of three variables: severe unremitting epigastric pain, bile-free gastric aspirate, and persistent or increasing serum bilirubin level serially determined every 6 h from admission to normalization. Excepting pain, the other two variables are very objective and permit to omit ERCP + ES when they are unnecessary. It has been employed for our group for many years, and its accuracy has been validated in a previous publication (Acosta et al., Am J Gastroenterol 2000;95:122–127). The following unpublished data is part of our study and may illustrate on the calculation used to define the accuracy of our method. …