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We appreciate the commentary by Dr Cote in response to our article.1Akbar A. et al.Clin Gastroenterol Hepatol. 2013; 11: 778-783Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar We agree there are many factors that contribute to post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP). The post hoc analysis of the randomized controlled trial (RCT) performed by Elmunzer et al2Elmunzer B.J. et al.Am J Gastroenterol. 2013; 108: 410-415Crossref PubMed Scopus (76) Google Scholar adjusted for risk of PEP by using logistic regression models and still found nonsteroidal anti-inflammatory drugs (NSAIDs) to be superior to prophylactic pancreatic duct (PD) stent placement. However, the definitive RCT required to determine whether it is safe to forego prophylactic PD stent placement in favor of NSAIDs will be difficult to perform. Community practitioners are precisely the providers who would benefit the most from such a study, especially from a medical-legal perspective. Although community physicians should be comfortable with PD stent placement, attempted but failed stent placement is associated with an increased risk of pancreatitis.3Freeman M.L. et al.Gastrointest Endosc. 2004; 59: 8-14Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar In addition, PD stents are not so innocuous as ductal injury, and other adverse events may occur as a result of their placement.4Bakman Y.G. et al.Endoscopy. 2009; 41: 1095-1098Crossref PubMed Scopus (48) Google Scholar, 5Price L.H. et al.Gastrointest Endosc. 2009; 70: 174-179Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar One could envision it would be relatively easy to enroll patients in an RCT of PD stent alone to NSAIDs alone in those undergoing endoscopic papillectomy and those with difficult biliary cannulation (including access sphincterotomy) in whom there is lack of pancreatic wire placement (whether attempted or not). In addition, well-done prospective and retrospective studies that can identify outcomes of patients in whom an intent/attempt at PD stent placement failed and who then received NSAIDs as salvage therapy could provide useful data to be extrapolated to patients at high risk for PEP. Finally, exclusion of sphincter of Oddi dysfunction patients, the least applicable population to community physicians and most physicians worldwide, is easier to swallow but would require participation of a large number of centers to enroll a sufficient number of high-risk non–sphincter of Oddi patients. Dr Baron is currently affiliated with the Division of Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina. The End of Prophylactic Pancreatic Duct Stents? Proceed With Caution and CourageClinical Gastroenterology and HepatologyVol. 12Issue 3PreviewThe network meta-analysis by Akbar et al1 builds on the recent momentum in the United States advocating the use of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) in the prevention of post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).2,3 The authors conclude that not only is pharmacotherapy (NSAIDs) superior to placebo, but that NSAIDs may obviate the need for prophylactic pancreatic duct stent placement. The authors appropriately recommend that a randomized clinical trial is needed to confirm this finding, but I would like to caution the readers of several important caveats. Full-Text PDF