Response| Volume 54, ISSUE 5, P675, November 2001

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      We thank Dr. Mosca for his interest in our recent article on the single-step treatment of gallbladder and bile duct stones with a combined endoscopic-laparoscopic technique. We agree that our approach might prove difficult to reproduce in a large, overcrowded hospital. At our small institution a collaborative feeling between all specialists involved in the care of patients with biliary stone disease allows the combined treatment to be quickly arranged in the operating room. Undoubtedly, these are the advantages of being “small.”
      As to our changing selection criteria over time, it should be stressed that at the beginning of our experience the single-step technique was often not planned before surgery because bile duct stones were found incidentally at intraoperative cholangiography. These patients account for the smallest group of subjects included in the study (group IV). Afterward, we tried to optimize selection criteria by placing greater emphasis on ultrasonographic, clinical, and laboratory findings. Presently, all patients who are candidates for laparoscopic surgery for cholecystolithiasis undergo 3D ct cholangiography and wideband second harmonic tissue US of the bile duct to improve preoperative diagnosis of choledocolithiasis (MRCP is not yet available).
      As clearly stated in the discussion section of our paper, our current policy is to perform preoperative ERCP in patients with stones requiring urgent bile duct decompression and those in whom a neoplasm is suspected, whereas postoperative ERCP is performed in the few cases in which the combined technique is unsuccessful.