Re: Kelly, MD. Results of laparoscopic bile duct exploration via choledochotomy (ANZ J. Surg. 2010; 80: 694–8)
I wish to congratulate Michael Kelly for an excellent article on the management of common bile duct (CBD) stones. However, I wish to draw the author to some comments.
First, what is the author's practice on patients who are not unwell but jaundiced (due to CBD stones)? A preoperative endoscopic retrograde cholangiopancreatography (ERCP) is not without risks; and at our institution, we would organize cholecystectomy and usually place a transcystic stent (antegrade stent). A post-operative ERCP would then ensue.
Second, a failure rate of 25% for ERCP seems high. Could the author explain this rate?
Third, if there is a suspicion for CBD stones with known gallstones, why bother with a magnetic retrograde cholangiopancreato-graphy; and not plan for surgery?
Fourth, what size of bile duct (diameter) would preclude a choledochotomy?
And finally, why place T-tubes and not consider placing an antegrade stent? T-tubes do carry their own morbidity.
Sulman Ahmed, MB BS (Syd), FRACS
Department of Surgery, Nepean Hospital, Sydney, New South Wales, Australia
