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Mesenteric ischaemia: A multidisciplinary approach

( 2 ) It is not clear why the six asymptomatic patients in the group undergoing endoscopic sphincterotomy were subjected to cholecystectomy. (3) The authors’ suggestion that operation prevented heartrelated mortality (presumably myocardial infarction) because of subclinical biliary infection is highly speculative. The hypothesis would suggest that biliary surgery could prevent myocardial infarction. Their second suggestion that ‘the diagnosis of cholangitis or cholecystitis was missed, and death erroneously attributed to a cardiac cause’ appears more logical. It is also probable that patients undergoing operation were screened and followed more carefully for heart disease than those undergoing endoscopic sphincterotomy. (4) The median hospital stay of 13 days in the group undergoing endoscopic sphincterotomy appears to be high. (5) The authors have included complications such as postoperative gastric retention secondary to duodenal ulcer and accidental injury to the duodenum at elective cholecystectomy in the endoscopic sphincterotomy group. These complications are unrelated to endoscopic sphincterotomy and may occur in any patient. (6) In Patients and methods, it was stated that patients’ death certificates and/or post-mortem examination reports were reviewed. Were post-mortem reports available in the 16 patients who died from non-biliary diseases? Had they been available, there would not have been any speculation as to the cause of death in those presumed to have heart disease. The authors set up a trial to study the two treatment modalities of managing patients with common bile duct stones, but they actually enumerated the advantages of cholecystectomy. One aspect of the study appears clear: patients with gallbladder in situ and choledocholithiasis may either be managed surgically or, if endoscopic sphincterotomy is performed and the common bile duct is cleared of calculi, then these patients should undergo cholecystectomy as early as possible. Such an approach will prevent biliary complications, acute pancreatitis, the occasional case of gallbladder cancer and, if the authors’ contention about heart disease is correct, myocardial infarction also.