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Recent studies have revealed that deep pancreatic duct wire passage, even in the absence of contrast injection, is a major technique-related culprit in post-ERCP pancreatitis, unless followed by placement of a pancreatic stent. As guidewire cannulation becomes increasingly widespread, precise control of the guidewire is thus critical. The first randomized trial to compare endoscopist-controlled wire guided vs. assistant-controlled bile duct cannulation has shown a significant reduction in post ERCP pancreatitis when the physician manipulates the wire. Though there is no single universal solution to post-ERCP pancreatitis, careful attention to wire contol is emerging as an important aspect of safety in ERCP.

To evaluate if using a soft-tipped guidewire to cannulate the common bile duct may ameliorate development of post-ERCP pancreatitis and facilitate cannulation of the CBD.A single-center, blinded, randomized trial of conventional cannulation technique using sphinctertome and contrast injection versus guidewire cannulation technique.We prospectively randomized 300 patients to conventional cannulation (group I) or guidewire cannulation (group II) technique.Primary outcome measure was incidence of acute pancreatitis and secondary outcome measures were ease of cannulation of common bile duct (assessed by attempts required for common bile duct cannulationrates of precut sphincterotomy) and overall complication rates.Guidewire cannulation was associated with significantly lower likelihood of post-ERCP pancreatitis (adjusted OR 0.43, 95% CI 0.21-0.89, P= 0.02). Twenty-five patients (16.6%) in group I and thirteen patients (8.6%) in group II developed acute pancreatitis, P= 0.037. All instances of pancreatitis were mild. There were more women in group II; 41 in group I and 59 in group II, P= 0.028. Otherwise the two groups were comparable for age, age under 35 yr, indication for ERCP, diagnosis, and number of patients with SOD. The number of patients requiring 0-3, 4-6, and 7-10 attempts for successful cannulation of the common bile duct were 87, 48, and 15 in group I and 117, 24, and 9 in group II, respectively, P= 0.001. A total of 33 patients in group I and 13 patients in group II required precut sphincterotomy, P= 0.007. Rates of accidental pancreatic duct cannulation were 21 in group I and 27 in group II, P= 0.34. Rates of overall complication were not significantly different in the two groups.Guidewire technique for bile duct cannulation lowers likelihood of post-ERCP pancreatitis by facilitating cannulation and reducing need for precut sphincterotomy.

To the Editor: Sotoudehmanesh et al. (1) report an interesting randomized controlled trial showing a reduction in the incidence of post-ERCP pancreatitis (PEP) when sublingual nitroglycerine was given along with rectal indomethacin 30 min before ERCP compared with giving indomethacin alone. An absolute risk reduction of 8.6% and a number needed to treat of 12 patients were reported. Pancreatic duct (PD) stents were placed only in 5.7% or 17 patients (8 in the combined group, and 7 in the indomethacin alone group). These results seem promising in the world of PEP prevention and may even question the role of placing PD stents. So, should we abandon the use of PD stents?

Acute pancreatitis continues to be the most dreaded complication after ERCP. Various risk factors for post-ERCP pancreatitis have now been recognized including patient-related, procedure-related, and operator-related factors. Numerous attempts at finding the ideal pharmacological agent for prevention of this complication have been made but nearly all drugs evaluated have failed to demonstrate clinical efficacy. Predictably, these agents have shown promise in early single-center studies but met with disappointing results when tested in larger multicenter randomized controlled trials. As the quest for the "magic bullet" continues, selecting patients with appropriate indications for ERCP and prophylactic pancreatic duct stenting in high-risk cases appears to be the best approach to averting this complication.

The aim of this study was to investigate if intraoperative rendezvous cannulation reduces the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) because there is no universal consensus on the optimal treatment of common bile duct stones.We performed a nationwide case-control study, nested within the cohort of ERCP procedures reported to the Swedish Registry for Gallstone Surgery and ERCP (GallRiks), between 2007 and 2009. Data were collected prospectively from a web-based registry of ERCP procedures that includes variables such as patient characteristics, indication, cannulation technique, diagnostic findings, therapeutic measures, and complications. The primary outcome was PEP.The registry included 12,718 ERCP procedures performed on patients without a history of previous ERCP. The risk of PEP when using the rendezvous technique compared with those who were cannulated by conventional means was reduced from 3.6 to 2.2% (odds ratio (OR) 0.5, 95% confidence interval 0.2-0.9, P=0.02). Although a significant reduction there are overall relatively few cases with PEP and the calculated numbers needed to treat to avoid one case of PEP is as high as 71. Other factors associated with increased risk of PEP were young age, prolonged procedure time, and elective ERCP.Rendezvous bile duct cannulation during ERCP reduces the risk of PEP from 3.6 to 2.2% compared with conventional biliary cannulation.

Hypocalcemia

TO THE EDITOR: We read with interest the results of the randomized trial carried out by Li et al. on the prophylactic benefit of octreotide administration in reducing pancreatic damage after ERCP (1). In this study, the drug was able to reduce the incidence of postprocedural pancreatitis to one half that of the control group. Unfortunately, the authors did provide any explanation for the discrepancy between positive results of the present study and negative data of a previous meta-analysis (2) and recent trials on this topic (3,4). Furthermore, they used a per-protocol analysis of their data, instead of the more appropriate intention-to-treat analysis. Indeed, they mention that of the 479 patients randomized to octreotide, 65 patients were excluded without providing reasons for such an action. Although this also happened in controls (482 patients randomized and 64 evaluated), one wonders how this exclusion might have affected the final results.