In difficult biliary cannulation, how quickly should we be reaching for the second wire?

We read with interest the study by Laquière et al. [1] on early double-guidewire vs. repeated single-guidewire techniques to facilitate selective bile duct cannulation. The results favored early double-guidewire cannulation for increasing the chance of successful bile duct cannulation with no increased risk of complications. We thank the authors for addressing this important issue.

A recent article by Maharshi and Sharma compared early and primary precut sphincterotomy. The main aim was to clarify which modality reduced the pancreatitis risk. However, the secondary outcome showed that primary precut was as successful as early precut for biliary cannulation (92.7 % vs. 92.7 %) [2].

The overall cannulation rate at first endoscopic retrograde cholangiopancreatography (ERCP) procedure was 99.3 % in the Laquière et al. study and 92.7 %. in the Maharshi and Sharma study. These both comfortably exceed the European Society of Gastrointestinal Endoscopy key performance indictor of successful bile duct cannulation of more than 90 % [3]. However, a paper by Ekkelenkamp et al. looked at procedural success rate for ERCP on a national level. Analysis of approximately 50 % of all ERCPs performed in Holland during a 1-year period found a procedural success rate at first ERCP of 83.4 % [4]. A data verification exercise suggested that success rate was likely to be significantly lower than this had this study included all the procedures performed nationally. An interesting and surprising finding in the Maharshi and Sharma study was that success at first attempt at cannulation of the common bile duct with no inadvertent pancreatic duct cannulation was achieved in only 30.9 % (47/152) of cases [2]. This may suggest that adjunctive techniques to achieve successful cannulation may be frequently required.

While in the hands of experts primary precut or early use of double-guidewire technique provide high levels of success, it is unclear which of these should be preferred and whether these would achieve comparable success and safety profiles in broad clinical ERCP practice.

Publication History

Article published online:
28 June 2022

• References

• 1 Laquière A, Privat J, Jacques J. et al. Early double-guidewire versus repeated single-guidewire technique to facilitate selective bile duct cannulation: a randomized controlled trial. Endoscopy 2022; 54: 120-127 DOI: 10.1055/a-1395-7485.
• 2 Maharshi S, Sharma SS. Early precut versus primary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos). Gastrointest Endosc 2021; 93: 586-593
• 3 Johnson G, Webster G, Boškoski I. et al. Curriculum for ERCP and endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2021; 53: 1071-1087
• 4 Ekkelenkamp VE, de Man RA, Ter Borg F. et al. Prospective evaluation of ERCP performance: results of a nationwide quality registry. Endoscopy 2015; 47: 503-507