We found the article by Venneman and coworkers1 of great interest. In the effort to identify the potential risk factors for patients with gallbladder stones (GBSs) to develop pancreatitis, they consider several clinical, histopathological, biochemical, and ultrasonographic parameters, finding only three (GBS size, gallbladder motility, and rapidity of cholesterol crystallization) to be related to pancreatitis.
The results of Venneman and colleagues confirm the evidence of biliary pancreatitis as the final stage of a sequence of events starting with cholelithiasis, continuing with the migration of stones, and finally leading to pancreatitis. According to this model, the smaller the stones, the faster the emptying of the gallbladder and the greater the risk of developing pancreatitis. On the basis of their findings, the authors propose that patients with asymptomatic small GBSs and/or preserved motility of the gallbladder undergo prophylactic cholecystectomy. However, in our opinion, there are some clinical issues that must be addressed.
The authors compare patients who already had pancreatitis and patients having symptomatic GBSs. In our opinion, the finding of parameters significantly related to pancreatitis has no impact on the therapeutic strategy, because all of these patients are candidates per se for prophylactic cholecystectomy. Significantly, the authors propose, despite Gracie and Ransohoff's recommendations for asymptomatic patients,2 to select patients for cholecystectomy in the absence of symptoms, yet this category of patients was not included in the study.
In this perspective, because biliary symptoms are also generally accepted as increasing the risk of complications, it may be argued that the contemporary presence of Venneman and colleagues' criteria (small gallstones and/or preserved gallbladder motility) and biliary symptoms defines a class of patients at even higher risk of developing pancreatitis, for which an urgent (or early) rather than elective scheduling of cholecystectomy could be recommended. Obviously, only prospective, randomized studies may confirm these hypotheses and define the lines of treatment.
We, too, believe that the most interesting question is: Is it possible to select for surgery asymptomatic patients who would otherwise not be cholecystectomized and who will finally develop complications? Recently, we3 and other authors4–7 elaborated scoring systems to quantify the risk of GBSs migrating to the common bile duct. In our opinion, these scoring systems could be useful in selecting patients at risk for complication.
Venneman and colleagues propose two criteria (gallbladder motility, GBS size) for the selection of patients to undergo cholecystectomy. Whereas the assessment of gallbladder motility is accomplished via ultrasonography, it is unclear how to preoperatively assess the size of GBSs, which are accurately measured after washing, drying and counting, obviously after gallbladder extirpation.
We found that (1) the risk of migration of GBSs is greater when they are small and numerous and (2) ultrasound can preoperatively assess the number and size of GBSs.8 The implications of our and Venneman and coworkers' conclusions are interesting: ultrasound can adequately assess both gallbladder motility and size of GBS, thus allowing for the recognition of patients at risk for pancreatitis as potential candidates for prophylactic cholecystectomy, even in the absence of symptoms.