We thank Dr. Hamouda and Dr. Nassar for their interest in our study and their comments. Their letter emphasizes the importance of attempting transcystic laparoscopic common bile duct (CBD) exploration in cases of CBD stones (CBDS) discovered during laparoscopic cholecystectomy by intraoperative cholangiography (IOC). Simple transcystic maneuvers allow avoidance of the expense or complications of endoscopic retrograde cholangiopancreatography (ERCP).

First, we respond to your questions. The main goal of the study was to examine the outcomes of patients who underwent any form of transcystic procedure to remove CBDS found during IOC. We excluded patients who had open CBD explorations from analysis only if they had not had a prior attempt at transcystic CBDE. We included those with open CBDE if any attempt at transcystic techniques had been attempted. In every case, the decision to proceed to open CBDE, with or without an attempt at transcystic CBDE, was indeed based on cholangiographic evidence at the time of laparoscopic cholecystectomy.

We agree that one of the reasons for attempting laparoscopic transcystic CBDE is that it is more cost effective than postoperative ERCP. The total hospital cost for treating a CBDS with postoperative ERCP are almost twice that for a successful laparoscopic CBDE [2].

Another reason for performing laparoscopic CBDE is to avoid post-ERCP complications. We had no cases of pancreatitis or complications after transcystic maneuvers performed during laparoscopic CBDE, in contrast to the 7% post-ERCP pancreatitis rate. In a recent study comparing intraoperative ERCP and postoperative ERCP for CBD stones discovered at the time of laparoscopic cholecystectomy, the authors also reported a 10% rate of ERCP-related complications, specifically papillary bleeding [1].

The increased expense for ERCP and the complications associated with the procedure should be the impetus for surgeons to provide their patients with a more favorable alternative. The transcystic maneuvers we describe are technically feasible for any surgeon performing laparoscopic cholecystectomy, and should be the initial attempt to clear the duct of CBDS discovered during laparoscopic cholecystectomy and IOC.