Biliary Cannulation and Pancreatic Guide-Wire Placement

I read with interest the article by Maeda et al. on selective biliary cannulation using pancreatic guide-wire placement [1] and the accompanying editorial by Devière [2] in a recent issue of Endoscopy. I strongly support Dr. Devière’s view that we should be reluctant to accept the idea of intentionally cannulating and injecting the pancreatic duct as a method of gaining access to a difficult bile duct.

Although the study by Maeda et al. did not show an increased incidence of clinical pancreatitis following the use of this technique, the significantly higher amylase levels in the study group is a cause of concern, as Dr. Devière mentions. It may be added that unintentional visualization of the pancreatic duct is a moment of disappointment for most endoscopists, mainly due to its unequivocal association with ERCP-induced pancreatitis [3].

But should this be the end of the story? I believe there is still a place for this technique. We all know that, for anatomical reasons, unintentional cannulation of the pancreatic duct is frequent and sometimes unavoidable. In these cases, if simple changes in the direction of the catheter do not succeed and the instrument continues to advance in the wrong direction, then (and only then) the catheter can be withdrawn, leaving the guide wire in the pancreatic duct, with a repeated attempt at cannulation while the wire is in the pancreatic duct.

Whether or not this helps, it will not add to the morbidity associated with the procedure. If pancreatitis occurs, it will be attributed to an unintentional and scarcely avoidable pancreatography. In this way, the technique could be added to the wide variety of tricks that can be used for assistance in difficult cases.

Finally, I would like to congratulate Dr. Devière for the description and illustrations of common bile duct cannulation he provides. Although the technical points he raises are not new, the clear and simple way in which he presents them is impressive. I have no hesitation in recommending the editorial to all endoscopists looking to improve their cannulation skills.

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 common bile duct cannulation?.  Endoscopy. 2003;  35 750-751
• 3 Freeman M L, Di Sario J A, Nelson D B. et al . Risk factors for post-ERCP pancreatitis: prospective, multicenter study.  Gastrointest Endosc. 2001;  54 425-434