Pancreatic stent insertion should not be a routine procedure after precutting in patients in whom access has failed with both ducts

I read with great interest the recent Expert Approach paper by Bourke et al. on biliary cannulation technique [1]. The content is very practical and helpful for both young and experienced biliary endoscopists since advice was given on management when varying situations are encountered.

However, I am concerned about the part of the algorithm in Fig. 4 where placement of a pancreatic duct stent is considered in patients at high risk of post-ERCP pancreatitis (PEP), with no pancreatic duct cannulation (failure of access to both ducts), who had undergone what I understand to be a freehand needle knife sphincterotomy. In my experience of this situation, finding the pancreatic orifice after precutting of the major papilla is not easy and a failed attempt at pancreatic duct cannulation may aggravate the higher chance for PEP.

In addition, some of the endoscopists who prefer to use fistulotomy precutting will agree that fistulotomy has no role with regard to pancreatic access. The only precutting that aims to identify the pancreatic orifice is that of the minor papilla in patients with pancreas divisum [2].

In my opinion, a blind attempt at pancreatic duct cannulation after precutting in patients in whom access to both ducts has failed should not be a routine procedure. I would reserve pancreatic stent insertion only for when I could see the pancreatic orifice after precutting and when deep pancreatic cannulation would not be too difficult.

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 Sahin B, Parlak E, Ciçek B. et al . Precutting of the minor papilla for pancreatic duct cannulation in pancreas divisum patients.  Endoscopy. 2005;  37 779