Reply to González Lama et al. Selective Biliary Cannulation Using Pancreatic Guide-Wire Placement

We are grateful to Dr. González Lama and colleagues for their interest in our article [1]. We agree that it is important to exercise caution when cannulating the bile duct using pancreatic guide-wire placement, as is also emphasized by Devière [2]. Still, we sometimes encounter difficult and demanding cases and we keep trying to improve our skills and insertion rates. Our study attempted to demonstrate the usefulness of pancreatic guide-wire placement in improving the insertion rate into the deep bile duct, and the method had no significant adverse effects or complications. Our report included some explanations, and the meaning of the figures given was clarified in it [1].

In our institution, we also use the procedure with the help of a guide wire to enter the bile duct (the single-guide technique, as González Lama describes it) when we encounter cases in which there are difficulties with the ordinary method. Nevertheless, some cases remain that these two methods - the ordinary procedure and the single guide-wire one - cannot handle, or in which it takes too long to access the deep bile duct. In these extremely difficult cases, we have previously reported that the use of isosorbide dinitrate [3] can improve the success rate. The use of pancreatic guide-wire placement [4] can also improve the success rate, as the report by Dumonceau et al. shows [5].

For the study, we defined ”difficult cases” as those in which it was not possible to access the deep bile duct using the conventional method within 10 min. This is because our institution’s guidelines instruct endoscopists to use pancreatic guide-wire placement when they cannot access the deep bile duct using the conventional method within 10 min or it is impossible to insert a cannula with the single-guided technique.

Our success rate with insertion into the deep bile duct using the conventional method within 10 min was 51 % - 54 of a total of 107 endoscopic retrograde cholangiography procedures (ERCPs) - as shown in our report [1]. However, the final success rate with the conventional method was 86 %, since in the group assigned to undergo persistent attempts with the conventional method there were 15 successful cases in 26 patients (15 + 54)/(26 + 54) = 86 %.

In addition, cholangiography succeeded in 105 cases out of a total 107 patients in this study. The success rate with cholangiography was 98 %.

In another study [3] from our institution, it was previously reported that the success rate of deep bile duct cannulation was 83 % using the conventional method and that the success rate with cholangiography was 97 %. A total of 138 ERCPs were carried out during a 6-month period in the study [1]. We believe our institution’s success rates with deep bile duct cannulation and cholangiography are hardly inferior to the worldwide level in terms of quality and quantity, and they confirm the expertise present in our institution.

As the letter and the conclusion of our study mentioned, further results from multicenter studies will be required in order to confirm current evaluations of the helpfulness of, and risks associated with, these insertion methods.

References

• 1 Maeda S, Hayashi H, Hosokawa O. et al . Prospective randomized pilot trial of selective biliary cannulation using pancreatic guide-wire placement.  Endoscopy. 2003;  35 721-724
• 2 Devière J. Using the pancreas for bile duct cannulation?.  Endoscopy. 2003;  35 750-751
• 3 Hayashi H, Hosokawa O, Ohta K. et al . Validity of isosorbide dinitrate administration in endoscopic retrograde cholangiopancreatography: a prospective study [in Japanese with English abstract].  Syoukaki Naishikyou. 1999;  11 757-762
• 4 Hayashi H, Maeda S, Hosokawa O. et al . A technique for selective cannulation of the common bile duct in endoscopic retrograde cholangiopancreatography: insertion of guide wire into the pancreatic duct [in Japanese with English abstract].  Gastroenterol Endosc. 2001;  43 828-832
• 5 Dumonceau J M, Devière J, Cremer M. A new method of achieving deep cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography.  Endoscopy. 1998;  30 80