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We thank Bronswijk et al1Bronswikj M. Voiosu A.M. Van der Merwe S. et al.Bringing down the hammer on difficult biliary cannulation.Gastrointest Endosc. 2022; 95: 813-814Google Scholar for their comments on our article.2Facciorusso A. Ramai D. Gkolfakis P. et al.Comparative efficacy of different methods for difficult biliary cannulation in ERCP: a systematic review and network meta-analysis.Gastrointest Endosc. 2022; 95: 60-71Google Scholar Indeed, the concept of difficult biliary cannulation remains a topic of great interest. We agree that persistence with standard cannulation techniques is not always ideal for managing difficult cannulation, although this remains a highly specialized field that relies heavily on individual experience and expertise. The authors are correct in stating there are variations in needle-knife technique, and it is difficult to identify a true “best” technique. However, we noted in the limitations section that a significant number of studies did not specify which variant of the needle-knife technique was used.2Facciorusso A. Ramai D. Gkolfakis P. et al.Comparative efficacy of different methods for difficult biliary cannulation in ERCP: a systematic review and network meta-analysis.Gastrointest Endosc. 2022; 95: 60-71Google Scholar Hence, the authors of some studies may have elected to pool variations of the early needle-knife technique. Although this holds the possibility of affecting outcomes, we believe this effect to be small. Our study concluded that endoscopists should consider transpancreatic sphincterotomy in cases of difficult cannulation. We understand that there are risks associated with transpancreatic sphincterotomy, and some endoscopists are unwilling to perform this technique. Alternatively, some endoscopists may be very successful at other methods, such as the pancreatic guidewire-assisted approaches, a.k.a. the “2-wire technique,” and they are not wrong to proceed in that direction. Although we acknowledge that there are limited randomized trials comparing difficult cannulation techniques, our network analysis used the GRADE criteria, which provides the most up-to-date evaluation for endoscopists.3Puhan M.A. Schünemann H.J. Murad M.H. et al.A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis [published correction appears in BMJ 2015;350:h3326].BMJ. 2014; 349: g5630Google Scholar It should be emphasized that both novice and experienced biliary endoscopists occasionally encounter cases of difficult cannulation, and many options can be be considered in these situations to achieve technical and clinical success. Dr Adler is a consultant for Boston Scientific. The other authors disclosed no financial relationships. Bringing down the hammer on difficult biliary cannulationGastrointestinal EndoscopyVol. 95Issue 4PreviewThe outcomes of ERCP are known to depend highly on endoscopists’ skill and expertise.1,2 Mastering difficult biliary cannulation, one of the pivotal skills within ERCP, has remained a hot topic throughout the decades.1-7 The recent systematic review and network meta-analysis by Facciorusso et al8 compared 4 separate techniques for difficult biliary cannulation by analyzing 17 randomized controlled trials with a total of 2015 patients. Although their results may support the use of transpancreatic sphincterotomy above other approaches in a theoretic comparative setting, we believe several important points need to be addressed before we can incorporate these data into clinical practice. Full-Text PDF