Response

Abstract

We thank Ozaslan for his letter in which he speculates that the vulnerability of the papilla of Vater, with the complex microscopic mucosal features of its orifice and intrapapillary ducts, may explain the difficulties of papillary cannulation, a procedural technique associated with an increased risk for post-ERCP pancreatitis (PEP). He thinks that the anatomic features of the papillary mucosa may be the reason for similar trauma to the papilla by the guidewire and sphincterotome contrast medium injection technique, as confirmed by the similar numbers of cannulation attempts and the lack of a significant difference in the rate of PEP between the 2 techniques in our study.1Mariani A. Giussani A. Di Leo M. et al.Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients.Gastrointest Endosc. 2012; 75: 339-346Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Both the guidewire and the sphincterotome could get stuck in the mucosal folds of the papilla. In particular, Ozaslan suggests that the guidewire cannulation technique would encounter an obstacle to its upstream progression in the valviform mucosal reduplications and blind pouches within the intrapapillary ducts, and in the filamentous nature of the terminal septum. This last microscopic feature could have much more impact during the sphincterotome cannulation once the tip of the device has already been pushed and advanced through the papillary orifice. The loop-tip guidewire, a device recently available for ERCP practice, designed to reduce trauma to the papilla, cannot get stuck in the mucosal folds of the papilla because it is rounded, and this might explain the easier papillary cannulation. In any case, knowledge of the complex microscopic mucosal features of the papilla only increases the need for detailing and standardizing the method of cannulation in ERCP studies. In conclusion, the remarks of Ozaslan suggest the protective role of the papilla of Vater on the biliary and pancreatic ducts against the traumatic action of any cannulation maneuver during ERCP. Difficult cannulation is the most important factor for post-ERCP pancreatitis: what is the mechanism?Gastrointestinal EndoscopyVol. 77Issue 2PreviewI read with great interest the study by Mariani et al1 describing that guidewire biliary cannulation does not reduce post-ERCP pancreatitis (PEP) compared with the contrast injection technique in low-risk and high-risk patients. PEP occurred in 35 of 678 patients (5.2%) in the guidewire biliary cannulation group and 25 of 571 patients (4.4%) in the contrast injection group (not significant). In their study, the guidewire biliary cannulation technique did not prevent the trauma to the papilla more than the contrast injection technique, as confirmed by the similar number of cannulation attempts with the two techniques, a parameter used to grade the difficulty of cannulation. Full-Text PDF