Reply to Sundaram and Jagtap

We thank Drs. Sundaram and Jagtap for their comments concerning our article “Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial,” which was recently published in Endoscopy [1]. In our multicenter study, transpancreatic biliary sphincterotomy (TPBS) was performed when the guidewire was inside the pancreatic duct (PD) and access to the common bile duct (CBD) was gained by cutting the septum between the PD and CBD with the sphincterotome toward the 11 o’clock position. Additional needle-knife cut was included in the technique when necessary and performed toward the 10 o’clock position, starting from the upper end of the TPBS cut. TPBS ( + needle-knife) succeeded more often than the double-guidewire technique (DGW). In difficult cannulation, we have previously compared TPBS with precut sphincterotomy, and TPBS was more successful (97.3 % vs. 71.3 %; P < 0.001) [2].

In our opinion, TPBS only after failed DGW unnecessarily leads to continuous papillary manipulation, thus increasing the risk of PEP [3]. We suggest endoscopists choose the cannulation method for each patient individually, weighing up the methods especially in difficult situations.

Previously, pancreatic sphincterotomy was used to gain access to the PD. In TPBS, the CBD access is the aim. Difficult CBD cannulation requires advanced methods, TPBS being one option but only for experienced endoscopists. In our recent case–control study, 143 TPBS patients and 140 control patients were followed for 4–10 years after index ERCP. No difference in long-term complications occurred between the groups [4].

Sundaram and Jagtap, as well as guidelines from the European Society of Gastrointestinal Endoscopy [3], suggest that in difficult cannulation situations, a prophylactic pancreatic stent should be placed and rectal nonsteroidal anti-inflammatory drugs (NSAIDs) administered to prevent PEP. Unfortunately, no hard data exist concerning the role of prophylactic pancreatic stents in the era of rectal NSAIDs. Thus, we have started a randomized multicenter study (NCT04408482) to determine whether such stents are useful with NSAIDs in difficult cannulation after TPBS.

Publication History

Article published online:
26 August 2021

• References

• 1 Leena Kylänpää, Vilja Koskensalo, Arto Saarela. et al. Transpancreatic biliary sphincterotomy versus double guidewire in difficult biliary cannulation: a randomized controlled trial. Endoscopy 2021;
• 2 Halttunen J, Keranen I, Udd M. et al. Pancreatic sphincterotomy versus needle knife precut in difficult biliary cannulation. Surg Endosc 2009; 23: 745-749
• 3 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149
• 4 Koskensalo V, Udd M, Rainio M. et al. Transpancreatic biliary sphincterotomy for biliary access is safe also on a long-term scale. Surg Endosc 2021; 35: 104-112