Letter to the Editor Open Access
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jul 16, 2022; 14(7): 467-470
Published online Jul 16, 2022. doi: 10.4253/wjge.v14.i7.467
Multimodal treatments of “gallstone cholangiopancreatitis”
Serafino Vanella, Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
Mario Baiamonte, General and Emergency Surgery Unit, Civico Benfratelli Di Cristina Hospital, Palermo 90121, Italy
Francesco Crafa, Oncological and General Surgery Unit, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
ORCID number: Serafino Vanella (0000-0002-6599-8225); Mario Baiamonte (0000-0001-8323-8118); Francesco Crafa (0000-0002-2038-625X).
Author contributions: Vanella S wrote and edited the manuscript and collected the clinical data; Crafa F reviewed the discussion section of the manuscript; Baiamonte M revised the manuscript and provided recommendations for the manuscript.
Conflict-of-interest statement: All authors have no conflicts of interest to declare.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Serafino Vanella, PhD, Doctor, Surgeon, Surgical Oncologist, Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, C/da Amoretta, Avellino 83100, Italy. nekroma@yahoo.it
Received: January 20, 2022
Peer-review started: January 20, 2022
First decision: March 25, 2022
Revised: April 11, 2022
Accepted: June 3, 2022
Article in press: June 3, 2022
Published online: July 16, 2022


Gallstone cholangiopancreatitis is a potentially life-threatening pathology which requires quick intervention involving endoscopists, interventional radiologists, anesthesiologists and surgeons in relation to clinical conditions. Treatment possibilities are varied, especially with current progress in advanced endoscopy, interventional radiology, and minimally invasive surgery. The following treatments are available: endoscopic sphincterotomy (ES) with stone extraction followed by laparoscopic cholecystectomy; simultaneous endoscopic stone extraction with laparoscopic cholecystectomy (rendezvous technique); combined laparoscopic cholecystectomy and common bile duct (CBD) exploration; open CBD exploration; ES post-cholecystectomy; percutaneous placement of biliary drains for unstable patients, followed by percutaneous cholangioscopy; and lithotripsy with different approaches, including a laser and balloon dilation of the sphincter of Oddi. Each technique has its strengths and weaknesses, and there is great discussion in the literature on choosing the ideal approach based on the patient’s clinical conditions.

Key Words: Cholangiopancreatitis, Common bile duct stones, Endoscopic retrograde cholangiopancreatography, Endoscopic sphincterotomy, Laparoscopic common bile duct exploration, Percutaneous

Core Tip: Urgent biliary decompression represents the treatment of gallstone pancreatitis associated with cholangitis. There are different techniques for common bile duct (CBD) clearance. Endoscopic retrograde cholangiopancreatography is not always feasible, as in the case of poor clinical conditions, large stones, or biliodigestive derivations. We analyzed the different approaches for decompression of the CBD in the case of “cholangiopancreatitis”.


We read with interest the article by Isogai[1] about the definition of “gallstone cholangiopancreatitis,” and the assessments regarding the aetiology and prognosis. Although the study is very well worded, we would like to add a few comments.

We think that it is complex to distinguish, with the only dosage of alanine aminotransferase, between a liver disease or the onset of multi-organ failure and cholangitis associated with pancreatitis[2]. However, the reflections expressed in the document stimulate the research activity to realize diagnostic methods that allow distinguishing “cholangiopancreatitis” from other adverse events that can worsen the clinical course of acute pancreatitis.

Moreover, we would like to integrate the different CBD obstruction management techniques even if this was not the main focus of the article.

Acute pancreatitis complicated by cholangitis due to CBD obstruction must be approached with an urgent decompression of the biliary tract to improve the pathology course. There are different approaches to decompress CBD, such as endoscopic retrograde cholangiopancreatography (ERCP), concerning the clinical conditions, the diameter of the stones, and any previous biliodigestive derivation. Urgent ERCP is recommended in patients with gallstone pancreatitis and concomitant cholangitis. The guidelines suggest that ERCP can improve the course in patients with CBD obstruction even in the absence of cholangitis[3-5].

In the study by Schepers et al[6], it appears that urgent ERCP associated with sphincterotomy may help in cholangitis complicating acute pancreatitis or in persistent obstruction of CBD. ERCP results in excellent clearance of CBD; nevertheless, in a certain proportion of patients, it may be necessary to resort to multiple procedures. ERCP associated with sphincterotomy is an aggressive approach which can lead to complications in up to 10% of patients[7,8], including bleeding, cholangitis, pancreatitis, duodenal perforation, and CBD lesions. A previous study showed that ERCP could lead to an increase in respiratory complications[9-13]. Sedation and possible aspiration can lead to respiratory complications in clinically critically ill patients. In the study of Schepers et al[6], in the urgent ERCP group there were more intensive care unit admissions.

Our clinical approach to patients with severe clinical conditions, unable to withstand general anesthesia or deep sedation is to subject these patients to percutaneous decompression of the CBD with a drain placed under local anesthesia and possible subsequent clearance of the CBD with the use of percutaneous cholangioscopy and laser.

Percutaneous biliary drainage can also have complications such as infections, and it can become blocked or displaced. However, it allows performing cholangiographies that can evaluate the possible presence of residual stones or the complete clearance of the biliary tract throughout their entire course. Once the patient's clinical condition has been improved, surgery and rendezvous ERCP can be carried out; if endoscopic treatment is not feasible, a laparoscopic exploration of CBD (LCBDE) could be performed.

In the study of Aawsaj et al[14] the LCBDE has been used in both elective and emergency contexts. A transcystic approach is preferable whenever possible. It is preferable to perform cholecystectomy during the same hospitalization to avoid recurrent gallstone pancreatitis.

A previous review by Dasari et al[15] showed no difference in clearance, morbidity, and mortality between open surgery and ERCP. In the ERCP group there were significantly more retained stones than in the open surgery group (16% vs 6%; P = 0.0002).

Laparoscopic cholecystectomy (LC) + LCBDE had fewer retained stones (8%) than two-staged pre-operative ERCP plus LC or LC plus post-operative ERCP (14%) (P = not significant). In the study by Ding et al[16], there were more recurrent CBD stones in the two-stage group at longer-term follow-up (9.5% vs 2.1%; P = 0.037). In the endoscopic group, there were more procedures per patient (P < 0.001) and most costly espenses (P = 0.002).

The study of Bansal et al[17] showed a shorter hospital stay in the single-stage group but no differences in major complications between the two groups.

Percutaneous or endoscopic balloon dilation represents a valid alternative to ES. It is simpler, has fewer complications in terms of bleeding and sphincter of Oddi lesions but has a lower performance in CBD clearance than ES[18,19]. In the current era, endoscopic approaches guarantee excellent results in the management of the biliary tract. Surgical management of CBD can be a viable option for patients in good condition with large diameter stones, previous biliodigestive derivations, and in case of failure of the endoscopic approach[20-22]. In addition, laparoscopic treatment can be performed with single anesthesia. Exploration of CBD by intraoperative choledochoscopy and simultaneous biliary clearance in a single time is not very aggressive and safe, with excellent results for treating "gallstone cholangiopancreatitis" and should only be performed in high volume centres with surgeons with proven experience. The laparoscopic management of CBD stones also reduces the average hospital stay, the anesthetic risks associated with two different procedures, and the cost of multiple hospitalizations.


We thank the members of the Department of Surgery at San Giuseppe Moscati Hospital for carefully reading of and examining the manuscript.


Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: Italy

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C, C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Akaraviputh T, Thailand; Isogai M, Japan A-Editor: Liu X, United States S-Editor: Wang LL L-Editor: A P-Editor: Wang LL

1.  Isogai M. Proposal of the term "gallstone cholangiopancreatitis" to specify gallstone pancreatitis that needs urgent endoscopic retrograde cholangiopancreatography. World J Gastrointest Endosc. 2021;13:451-459.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 1]  [Cited by in F6Publishing: 1]  [Article Influence: 0.5]  [Reference Citation Analysis (2)]
2.  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;23:541-551.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 35]  [Article Influence: 2.9]  [Reference Citation Analysis (0)]
3.  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;108:1400-15; 1416.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1232]  [Cited by in F6Publishing: 1230]  [Article Influence: 123.0]  [Reference Citation Analysis (3)]
4.  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;50:524-546.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 221]  [Cited by in F6Publishing: 226]  [Article Influence: 45.2]  [Reference Citation Analysis (0)]
5.  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;154:1096-1101.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 405]  [Cited by in F6Publishing: 415]  [Article Influence: 83.0]  [Reference Citation Analysis (0)]
6.  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 vs conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet. 2020;396:167-176.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 56]  [Cited by in F6Publishing: 25]  [Article Influence: 8.3]  [Reference Citation Analysis (0)]
7.  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;102:1781-1788.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 669]  [Cited by in F6Publishing: 683]  [Article Influence: 42.7]  [Reference Citation Analysis (0)]
8.  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;335:909-918.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1716]  [Cited by in F6Publishing: 1811]  [Article Influence: 67.1]  [Reference Citation Analysis (2)]
9.  Travis AC, Pievsky D, Saltzman JR. Endoscopy in the elderly. Am J Gastroenterol. 2012;107:1495-501; quiz 1494, 1502.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 58]  [Cited by in F6Publishing: 58]  [Article Influence: 5.3]  [Reference Citation Analysis (0)]
10.  Clarke GA, Jacobson BC, Hammett RJ, Carr-Locke DL. The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort. Endoscopy. 2001;33:580-584.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 104]  [Cited by in F6Publishing: 114]  [Article Influence: 5.2]  [Reference Citation Analysis (0)]
11.  Freeman ML. Sedation and monitoring for gastrointestinal endoscopy. Gastrointest Endosc Clin N Am. 1994;4:475-499.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Faigel DO, Baron TH, Goldstein JL, Hirota WK, Jacobson BC, Johanson JF, Leighton JA, Mallery JS, Peterson KA, Waring JP, Fanelli RD, Wheeler-Harbaugh J; Standards Practice Committe, American Society for Gastrointestinal Endoscopy. Guidelines for the use of deep sedation and anesthesia for GI endoscopy. Gastrointest Endosc. 2002;56:613-617.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 142]  [Cited by in F6Publishing: 156]  [Article Influence: 7.4]  [Reference Citation Analysis (0)]
13.  Perel A. Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 European National Societies of Anaesthesia. Eur J Anaesthesiol. 2011;28:580-584.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 114]  [Cited by in F6Publishing: 128]  [Article Influence: 10.7]  [Reference Citation Analysis (0)]
14.  Aawsaj Y, Light D, Horgan L. Laparoscopic common bile duct exploration: 15-year experience in a district general hospital. Surg Endosc. 2016;30:2563-2566.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 35]  [Cited by in F6Publishing: 36]  [Article Influence: 4.5]  [Reference Citation Analysis (0)]
15.  Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA. Surgical vs endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;CD003327.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 72]  [Article Influence: 7.2]  [Reference Citation Analysis (0)]
16.  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;18:947-951.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 72]  [Cited by in F6Publishing: 74]  [Article Influence: 8.2]  [Reference Citation Analysis (0)]
17.  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 vs 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;28:875-885.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 128]  [Cited by in F6Publishing: 142]  [Article Influence: 14.2]  [Reference Citation Analysis (0)]
18.  Kim MU, Lee Y, Lee JH, Cho SB, Lee MS, So YH, Choi YH. Predictive factors affecting percutaneous drainage duration in the percutaneous treatment of common bile duct stones. PLoS One. 2021;16:e0248003.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1]  [Cited by in F6Publishing: 1]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
19.  Han JY, Jeong S, Lee DH. Percutaneous papillary large balloon dilation during percutaneous cholangioscopic lithotripsy for the treatment of large bile-duct stones: a feasibility study. J Korean Med Sci. 2015;30:278-282.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 7]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
20.  Sharma A, Dahiya P, Khullar R, Soni V, Baijal M, Chowbey PK. Management of common bile duct stones in the laparoscopic era. Indian J Surg. 2012;74:264-269.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 17]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
21.  Singh AN, Kilambi R. Single-stage laparoscopic common bile duct exploration and cholecystectomy vs two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis. Surg Endosc. 2018;32:3763-3776.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 67]  [Cited by in F6Publishing: 45]  [Article Influence: 9.0]  [Reference Citation Analysis (0)]
22.  Prete FP, Baiamonte M, Ruotolo F, Bavetta F, Crafa F.   Surgical Technique and Difficult Situations from Francesco Crafa In: Korenkov M, Germer CT, Lang H. Gastrointestinal Operations and Technical Variations. Springer, Berlin, Heidelberg. [cited 20 January 2022]. Available from: https://doi.org/10.1007/978-3-662-49878-1_23.  [PubMed]  [DOI]  [Cited in This Article: ]