Visualized biliary cannulation during ERCP: do we really need it?

We read with great interest the article by Liu et al. [1] reporting their initial experience of visualized biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP); however, we have several questions about the study.

First, as mentioned in the article, although the ERCP technique is difficult, the success rate of cannulation is now very high for experienced endoscopists [2]. Visualized biliary cannulation does not simplify the ERCP procedure, instead it requires further learning to perform cholangioscopy on top of mastering ERCP and also increases the costs significantly. Therefore, for most situations, visualized biliary cannulation is not necessary. It is necessary only for patients with difficult cannulation or those who cannot undergo radiographic examination. The inclusion criteria for this study should have been patients in this category, and the results would have been more meaningful.

Second, our center has also performed numerous cholangioscopy procedures. For complex cholangioscopy procedures, in addition to control of the direction of the duodenoscope and the insertion and withdrawal of the cholangioscope by the operator, an experienced assistant is also required to manipulate the direction of the cholangioscope. Compared with traditional ERCP, it therefore requires more manpower. For complex procedures such as visualized biliary cannulation, we wonder how many operators your center typically requires?

Third, this study is not a controlled trial, so comparing it to the previous literature [3] alone cannot prove that the cannulation success rate is higher and the postoperative complications fewer. Moreover, the operators chosen to perform this study were experienced endoscopists with extensive traditional ERCP experience but even they, at the learning stage, still had some limitations, demonstrating that this technique is more difficult than traditional ERCP.

Overall, cholangioscopy is a revolutionary technology that helps us address some areas where traditional ERCP is lacking, particularly in the diagnosis and treatment of bile duct strictures and refractory stones; however, it requires higher operator expertise and there should be some selectivity in its application. It cannot be blindly expanded for new indications and cannot completely replace traditional ERCP.

Publication History

Article published online:
27 June 2024

• References

• 1 Liu WH, Huang XY, Hu X. et al. Initial experience in visualized biliary cannulation during ERCP. Endoscopy 2023; 55: 1037-1042
• 2 Testoni PA, Mariani A, Aabakken L. et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 657-683 DOI: 10.1055/s-0042-108641. (PMID: 27299638)
• 3 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 DOI: 10.1016/j.gie.2020.06.064. (PMID: 32615179)