Reply to Dr. Froehlich

We are very grateful to Dr. F. Froehlich for his kind letter and for his precise and welcome comments. One of the inclusion criteria to be fulfilled in order to be included in our study was that the patient’s bile duct stones were smaller than 15 mm, but unfortunately this fact was lost from the original article during the process of translation into English, and we would like to apologize for this omission. However, we would like to stress that we did encounter a few patients with bile duct stones that were bigger than 15 mm, although they were not included in the trial. In these cases, we proceeded with the intraoperative endoscopic retrograde cholangiopancreatography (ERCP) and performed the papillotomy, and we waited until the postoperative period in order to finish the clearing the bile duct. The intraoperative procedure helped to make the postoperative ERCP easier, safer, and faster.

When it comes to the suitability of the intraoperative procedure and the number of bile stones found, we would like to stress that the idea of the intraoperative ERCP is to allow the surgeon to avoid hav„ing to perform an open cholecystectomy, without any anxiety about failure of postoperative ERCP if this should be necessary. We therefore did not spend a great amount of time trying to achieve complete cleansing of the bile duct during the intraoperative procedure.

Secondly, we agree with your comments with regard to the issue of retracting the guide wire. In fact, once you finish the pap„illotomy you have two options: either you completely retract the guide wire, introducing different devices with ease into the bile duct without using the guide „wire; or you first retract the guide wire and then move it forward into the common bile duct, making it easier to advance the Dormia catheter or the Fogarty balloon over the wire, and avoiding introduction of the balloon or the Dormia devices into the cystic duct.

Finally, the per-protocol success rate of the intraoperative approach reached 91.5 %, showing no difference from the results of the preoperative approach. In daily practice, the per-protocol analysis in this particular matter is a more realistic comparison. We should not consider this as a failure of the intraoperative approach because these patients, who were on the waiting list, had to undergo an urgent preoperative ERCP because they had developed acute complications of choledocholithiasis.

Competing interests: None