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Abstract

We thank Saritas et al for their interest in our article. In case-control studies, the traditional rendezvous (RV) cannulation results in a lower risk of post-ERCP pancreatitis (PEP) in comparison with cannulation without RV.1Swahn F. Nilsson M. Arnelo U. et al.Rendezvous cannulation technique reduces post-ERCP pancreatitis: a prospective nationwide study of 12,718 ERCP procedures.Am J Gastroenterol. 2013; 108: 552-559Crossref PubMed Scopus (43) Google Scholar In this view, the advantages of traditional RV could be secondary to limitation of repeated cannulations of the papillary orifice and prevention of inadvertent cannulation or injection of contrast medium into the pancreatic ducts. In previous studies involving patients referred for cholecystectomy2La Greca G. Barbagallo F. Sofia M. et al.Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis.Surg Endosc. 2010; 24: 769-780Crossref Scopus (44) Google Scholar and in our series of patients with biliary adverse events after liver transplantation,3Cantù P. Parzanese I. Melada E. et al.A new duodenal rendezvous technique for biliary cannulation in patients with T-tube after orthotopic liver transplantation (with video).Gastrointest Endosc. 2016; 83: 229-233Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar mild PEP also occurred after traditional RV had been performed with great caution. The mechanisms leading to PEP during traditional RV are unknown, but instrumentation with the guidewire to pass into the duodenum and retrieval of the wire into the endoscope are probably major factors leading to trauma at the level of the papilla. To minimize as much as possible the risk of PEP in patients after liver transplantation, we have proposed direct duodenal cannulation over the wire during RV procedures. During nonrandomized consecutive cases, we have recorded no PEP after our duodenal RVs, possibly related to reduction of cannulation time compared with traditional RV. We agree with Saritas et al that a large randomized study is needed to confirm our preliminary data. However, the large number of patients with biliary adverse events after liver transplantation needed for such a study (>200 per arm) makes it difficult to perform in centers with a high workload of liver transplantations, considering that approximately 10% to 15% of biliary adverse events occur yearly. Waiting for the best evidence in this field, we now routinely use duodenal RV as a first step to cannulate when a T tube is present, to avoid the unnecessary risk of pancreatitis in patients who have undergone liver transplantation, and we are glad to share this approach with Saritas et al. All authors disclosed no financial relationships relevant to this publication. Post-ERCP pancreatitis after biliary cannulation with traditional rendezvous in patients with T-tubeGastrointestinal EndoscopyVol. 83Issue 6PreviewWe read with interest the article by Cantù et al1 about a new technique of duodenal rendezvous for successful biliary cannulation in patients with a T-tube after orthotopic liver transplantation. Although the sample of the study group in this report was very small (10 duodenal, 10 traditional), the authors reported that this technique is relatively safe with regard to the risk of post-ERCP pancreatitis (PEP), and the procedure time is shorter in duodenal rendezvous than in traditional rendezvous. Full-Text PDF