Selective Biliary Cannulation Using Pancreatic Guide-Wire Placement: Reply to Dr. Saad

We are grateful to Dr. Saad [1] for his interest in our article [2]. We agree that it is important to be cautious during bile duct cannulation, as was also mentioned in the editorial by Dr. Devière [3]. However, as Dr. Saad also points out, there are certainly clinical situations that cannot be managed with the conventional method without great difficulty and danger for patients. Our main reason for conducting the study was that prior insertion of a pancreatic guide wire might be a sensible option in these difficult cases.

As Dr. Saad points out, the group in which the preinsertion method was used showed significantly higher serum amylase levels than the group patients who received the conventional method. However, no cases of clinical pancreatitis defined as more severe than moderate in the Cotton classification were observed. In addition, the mean serum amylase level in the group in which deep bile duct cannulation succeeded within 25 min was 163 IU/l, while that in the group in which more than 25 min was required was 626 IU/l, as shown in Table 3 in our article [2]. This implies that the longer the time required for the cannulation, the higher the serum amylase level - no matter which method was used.

Endoscopists often encounter situations in which the cannula is unintentionally inserted into the pancreatic duct instead of the bile duct. We consider that there is a greater danger of ERCP-induced pancreatitis if the physician attempts insertion several times and takes too long, rather than trying cannulation with a guide wire in the pancreatic duct in the first place. The main argument of our study is that the preinsertion method would be a useful option for avoiding ERCP-induced pancreatitis in difficult cases in which bile duct cannulation would take too long with the conventional method.

No cases of clinical pancreatitis were observed in our randomized trial, while the group in which the preinsertion method was used showed higher amylase levels. We have no intention of recommending that the preinsertion method should be used in any situation. Instead, our intention was to make it clear that the advantages of the preinsertion method may outweigh the implicitly increased danger of pancreatitis when there is a guide wire in the pancreatic duct (in difficult cases). Since the study was a pilot trial aiming to arouse interest in improved endoscopic methods, we are grateful for Dr. Saad’s active response and hope that a more thorough study of the issue including larger numbers of patients may be conducted in the future.

References

• 1 Saad M. Biliary cannulation and pancreatic guide-wire placement.  Endoscopy. 2004;  36 743
• 2 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
• 3 Devière J. Using the pancreas for common bile duct cannulation?.  Endoscopy. 2003;  35 750-751