Endoscopy 2017; 49(10): 1014
DOI: 10.1055/s-0043-117409
Letter to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Reply to Goetz et al.

Rakesh Kalapala
Gastroenterology, Asian institute of Gastroenterology, Hyderabad, India
,
Radhika Chavan
,
Zaheer Nabi
,
Sundeep Lakhtakia
,
D. Nageshwar Reddy
› Author Affiliations
Further Information

Publication History

Publication Date:
27 September 2017 (online)

We thank Martin Goetz for his insightful comments on our case report entitled “Reverse sphincterotomy of the minor papilla via the major papilla for chronic pancreatitis with incomplete pancreas divisum.”

In his letter, Goetz described a new technique of cannulating the major papilla in a difficult case. We appreciate his effort in this difficult and elegant technique.

There are noticeable differences in the case as well as the technique described by us. We had a patient with chronic pancreatitis with incomplete pancreas divisum. In our case, the cannulation of the minor papilla was not successful. Although cannulation of the major papilla was successful, the guidewire repeatedly followed the path of the accessory duct and could be seen crossing the minor papilla. For cannulation of the minor papilla we used the “reverse sphincterotomy” technique. In this technique, we negotiated the guidewire through the minor papilla via major papilla cannulation (“reverse cannulation”), railroaded the cannulotome, and performed a small sphincterotomy. We want to emphasize here that the purpose of the reverse sphincterotomy technique in our case was only to facilitate cannulation of the minor papilla.

In contrast, the case described by Goetz had acute on chronic pancreatitis with incomplete pancreas divisum. This case had a stenosed major papilla leading to unsuccessful cannulation. The minor papilla could be cannulated, after which reverse bougienage of the major papilla was performed.

The technique described by the author is appealing as it avoids the application of sphincterotomy and associated adverse events. However, we would like to highlight certain important points. First, the need to cannulate the major papilla after successful cannulation of the minor papilla should be elaborated by the author. Did the author find it difficult to negotiate the guidewire deep into the pancreatic duct via the minor papilla? Was double stenting via the major and minor papillae intended for trans-papillary drainage of pancreatic fluid collection?

Both the aforementioned techniques should be used only as a “last-ditch effort” after balancing the risks and benefits. The techniques have not been studied well, and may not be successful in all cases. We believe that more studies are required to demonstrate the true utility of such novel techniques of pancreatic duct cannulation. As of now, these techniques should only be used as a last resort by experienced hands.