04093402

January 22, 2025, 16:22

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This study presents an evaluation of a novel contrast-enhanced catheter with a chamfered tip. Achieving selective biliary cannulation is one of the most challenging endoscopic maneuver. We congratulate the authors on demonstrating in this paper that a novel device granted higher rates of biliary cannulation when retrospectively compared to a standard sphincterotome. However, a few points warrant further discussion: 1. Generalizability: As a single-center retrospective study, the external validity of these findings could be enhanced with multicenter randomized trials. Variations in patient populations, procedural techniques, and institutional expertise might influence outcomes. 2. Non-expert outcomes: The results indicate a lack of significant improvement in outcomes among non-experts or trainees using the novel catheter. This suggests the device's utility may be contingent on the operator's skill. We also noticed that the expert performed procedure percentage was slightly higher (57% vs 50%) in the novel cathether group, and, although not statistically significant, this could explain the lower use of advanced or rescue cannulation techniques. 3. Adverse Events (AEs): While the overall AE rates were low and comparable between groups, the trend toward fewer cases of PEP with the novel catheter merits closer scrutiny in larger cohorts as this could be an advantage in patients at risk for PEP. On the other hand, the non-statistically significant difference between the two groups in PEP incidence suggests us that the device used to achieve initial selective cannulation maybe isn’t that relevant in increasing PEP risk or incidence, but this should be confirmed in larger studies. 4. Cost-effectiveness: Although not discussed, evaluating the cost implications of adopting this catheter, including potential savings from reduced reliance on rescue techniques and decreased procedural times, would be beneficial for broader clinical adoption. We should also think of the negative aspects: for example, like stone clearance, achieving cannulation with a catheter would require a subsequent switch to a sphincterotome, increasing procedure length and costs, as you would be using two devices instead of one to achieve cannulation. 5. Papilla characteristics: we noticed that in the baseline characteristics intradiverticular papillas and oral oriented papillas were less represented in the catheter group. These types of papilla could benefit of the angling capabilities of a sphincterotome, so this could be a bias that needs to be furthermore cleared. In our experience the angling capabilities of a sphincterotome are crucial in achieving bile duct cannulation in difficult situations. 6. Malignant disease: we do know that malignant diseases (e.g. pancreatic cancer) affecting the ampullar area negatively affect rates of cannulation and increase the need for rescue or advanced techniques of cannulation. This point could have been furthermore discussed by making a distinction between cannulation failures in the setting of benign vs. malignant disease in both groups. In conclusion, this study gives us valuable insights into advancing ERCP outcomes through innovative device design. We must experiment with more designs to compare results and finally choose the best device for cannulation in unexpected and difficult anatomies.

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