Response

Abstract

We would like to express our appreciation for the comments and observations made by Drs Hew, Bechara, and Hookey.1Hew S. Bechara R. Hookey L. Papillary morphology influences biliary cannulation: beware the small papilla!.Gastrointest Endosc. 2020; 91: 959Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Likewise, we appreciate the editorial comments by Dr Adler2Adler D.G. ERCP biliary cannulation difficulty as a function of papillary subtypes: a tale of shapes and Shar-Pei dogs.Gastrointest Endosc. 2019; 90: 964-965Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar concerning our article related to the influence of the major duodenal papilla appearance on bile duct cannulation.3Haraldsson E. Kylänpää L. Grönroos J. et al.The macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy study group for ERCP.Gastrointest Endosc. 2019; 90: 957-963Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar The primary conclusion of our study is that certain types of endoscopic appearances of the major duodenal papilla present an increased frequency of difficult cannulation, without specifying the technique used. Dr Adler’s concern is this: What do we do with these findings, and how does this information guide the endoscopist in what to do when faced with a certain type of papilla? Undoubtedly, this is the key issue that at present and in several aspects has no definite answer. However, our study clearly shows that the macroscopic appearance does influence bile duct cannulation and suggests that an inexperienced endoscopist should refrain from cannulating a type 2, the small papilla, and a type 3, the protruding or pendulous papilla, leaving them to more experienced endoscopists so as not to jeopardize a succesful cannulation. In addition, by creating a validated and easy-to-use classification,4Haraldsson E. Lundell L. Swahn F. et al.Endoscopic classification of the papilla of Vater: results of an inter- and intraobserver agreement study.United European Gastroenterol J. 2017; 5: 504-510Crossref PubMed Scopus (28) Google Scholar our study sets the stage for further studies, such as the one presented in the letter by Hew et al.1Hew S. Bechara R. Hookey L. Papillary morphology influences biliary cannulation: beware the small papilla!.Gastrointest Endosc. 2020; 91: 959Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Previous studies concerning the papillary appearance and the choice of cannulation technique have used neither any validated classification for endoscopic appearance nor a universal definition for difficult cannulation, making the results difficult to interpret.5Horiuchi A. Nakayama Y. Kajiyama M. et al.Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla.Clin Gastroenterol Hepatol. 2007; 5: 1113-1118Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 6Katsinelos P. Gkagkalis S. Chatzimavroudis G. et al.Comparison of three types of precut technique to achieve common bile duct cannulation: a retrospective analysis of 274 cases.Dig Dis Sci. 2012; 57: 3286-3292Crossref PubMed Scopus (61) Google Scholar, 7Lee T. Hwang S. Choi H. et al.Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study.BMC Gastroenterol. 2014; 14: 30Crossref PubMed Scopus (26) Google Scholar, 8Pan Y. Zhao L. Leung J. et al.Appropriate time for selective biliary cannulation by trainees during ERCP: a randomized trial.Endoscopy. 2015; 47: 688-695Crossref PubMed Scopus (28) Google Scholar Therefore, we eagerly look forward to future studies using our suggested classification, with reference to Dr Adler, ie, “The appearance of the major papilla can affect outcomes during ERCP.” All authors disclosed no financial relationships. Papillary morphology influences biliary cannulation: beware the small papilla!Gastrointestinal EndoscopyVol. 91Issue 4PreviewWe read with interest the article by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP1 and the accompanying editorial by Dr Adler2 regarding the endoscopic appearance of the major papilla and its effect on biliary cannulation. The present study does not detect a difference in success between different cannulation techniques and papillary morphology, and given these results, Dr Adler suggests that time and effort identifying the type of papilla may be wasted. However, this may not be true for needle-knife fistulotomy (NKF), where a controlled incision is made directly into the intraduodenal portion of the bile duct away from the native orifice. Full-Text PDF