Additionally, high quality comparison trials suggest that the sphincterotome is superior to the cannulatome for initial access. Schwacha et al prospectively randomized patients to bile duct cannulation with the standard cannulatome versus the sphincterotome.2 After five attempts bile duct access was achieved in 62% of those in the standard catheter group compared to 84% in the sphincterotome group. Cortus et al randomized patients to <15 attempts to access with bile duct with the cannulatome versus the sphincterotome and found that initial biliary access was obtained in 67% in the former versus 97% in the latter groups.3 In addition the mean number of cannulation attempts and time to achieve selective biliary cannulation was also less in the sphincterotome group. Given these considerations most American endoscopists use sphincterotomes for initial biliary cannulation.4