Dear Sir, We read the article by Artifon et al. [1] entitled ‘‘Management of common bile duct stones in cirrhotic patients with coagulopathy: a comparison of suprapapillary puncture and standard cannulation technique.’’ The authors applied this novel technique of suprapapillary puncture in 42 patients, which resulted in biliary access in 95% of cases, which was not significantly better than the rate of biliary access (85%) with the standard cannulation method. The overall rate of complications, including bleeding, pancreatitis, and perforation, was also statistically comparable in both groups of cases (15.8 vs. 11.9%, with standard cannulation and suprapapillary puncture techniques, respectively). The important issue in this report is the unacceptably high rate of perforation with suprapapillary puncture technique to obtain biliary access. The patients within the standard cannulation and suprapapillary puncture groups had 3.2 and 7.1% rates of perforation, respectively. Perforation has been reported to be less than 1% of ERCP and sphincterotomies [2]. In a previous report [3] published by the same author group, there was a consistently high rate of perforation in their series of patients (two of 28 patients, 7%). Although the authors indicated that all the patients with this complication were treated conservatively without any mortality, we believe that this high rate of perforation casts doubt regarding the use of this technique. As the authors [1] indicated in the text, the lower rate of pancreatitis is an expectable finding since during suprapapillary puncture, the puncture site is far away from the pancreatic channel orifice, and that there is no cauterization is another factor preventing the development of pancreatitis. However, we believe that biliary access by fistulotomy has the same philosophy, which provides us lesser rates of pancreatitis than standard sphincterotomy. Nevertheless, we also know that biliary access with a fistulotomy had much lower rates of perforation than the authors indicated in their patients who underwent biliary access via suprapapillary puncture method. We understand that this study carries important limitations due to its retrospective design. For example, the groups of patients who underwent standard cannulation had longer prothrombin time than the other group, and the group of patients who underwent suprapapillary puncture had larger and a higher number of bile duct stones than the other group. However, we do not know if these differences between both groups had any statistical significance since the authors did not provide any statistical data in this subanalysis. Indeed, the aim of this study was to compare bleeding complications in association with both techniques in patients with coagulopathy in the setting of cirrhosis. The rate of bleeding was reported to be the same in both cannulation methods in this study. We think that this is an attractive finding since this shows us that the suprapapillary puncture and balloon dilatation did not cause more severe bleeding than that which occurred with biliary sphincterotomy after standard cannulation. However, the authors did not mention the severity of bleeding episodes in these cases. We need to know if there was any significant U. Saritas Clinics of Gastroenterology, Medicana International Hospital, Ankara, Turkey