Wire-guided biliary cannulation should be considered to be standard practice

We read with great interest the recent Expert approach paper by Bourke and co-workers [1] on biliary cannulation technique during endoscopic retrograde cholangiopancreatography (ERCP). The authors suggest that the wire-guided cannulation technique should be preferred to the contrast-assisted method because of several theoretical advantages. Indeed, deep biliary cannulation may easily be achieved using a soft-tipped, hydrophilic guide wire and fluoroscopically confirmed, avoiding potentially damaging pancreatic duct opacification.

Their suggestion has been recently strengthened by our meta-analysis of five randomized controlled trials involving a total of 1762 individuals, comparing the wire-guided method with the contrast-assisted cannulation technique with regard to rates of primary biliary cannulation and post-ERCP pancreatitis [2]. The wire-guided technique does indeed result in a significantly higher primary cannulation rate (odds ratio [OR] 2.05, 95 % confidence interval [CI] 1.27 – 3.31). Furthermore, use of the precut technique to achieve deep biliary cannulation and the number of cannulations judged ”difficult” by endoscopists were substantially reduced in the wire-guided technique groups compared with the contrast-assisted method groups. These latter findings could help to explain why the use of the guide wire to achieve deep biliary cannulation also significantly reduces the risk of post-ERCP pancreatitis (OR 0.23, 95 %CI 0.13 – 0.41).

Therefore, we completely agree with Bourke and colleagues that the wire-guided technique should be considered the standard practice for biliary cannulation during ERCP and contrast injection should be used to define the anatomy only after several attempts with the guide wire have failed.

Competing interests: None

References

• 1 Bourke M J, Costamagna G, Freeman M L. Biliary cannulation during endoscopic retrograde cholangiopancreatography: core technique and recent innovations.  Endoscopy. 2009;  41 612-617
• 2 Cennamo V, Fuccio L, Zagari R M. et al . Can a wire-guided cannulation technique increase bile duct cannulation rate and prevent post-ERCP pancreatitis? A meta-analysis of randomized controlled trials.  Am J Gastroenterol. 2009;  104 2343-2350