Advanced and Salvage Techniques for Difficult Biliary Cannulation in ERCP: A Randomized Trial of Outcomes and Efficacy
In brief
All three salvage techniques reach 100% final biliary cannulation in difficult ERCP
In a randomized trial of 150 patients with difficult biliary cannulation, double-guidewire, trans-pancreatic sphincterotomy and precut fistulotomy each achieved about 70% initial success and 100% success after a second attempt using the same method. Procedure times and pancreatitis rates were similar, though precut used less contrast dye. The findings suggest any of the three can be chosen based on anatomy, expertise, and resources.
- Journal
- Gastrointestinal endoscopy (Q1)
- Published
- 15 July 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Mohamed Mahmoud Elhoseeny, Omkolsoum Alhaddad, Maha Elsabaawy, Eman Abdelsameea, Ahmed Sallam, Ahmed Khamis, et al.
- PMID
- 42456983
- DOI
- 10.1016/j.gie.2026.07.004
Why clinicians should know about it
- Picked for Anatomy (top studies of the week, 19 July 2026): High-quality evidence in a top journal
Abstract
BACKGROUND AND AIMS: Difficult biliary cannulation (DBC) complicates 5-20% of ERCP procedures. Advanced techniques, double-guidewire (DGT), trans-pancreatic sphincterotomy (TPS), and precut fistulotomy, have been introduced to improve outcomes, but their comparative effectiveness remains uncertain. This study compared their efficacy, safety, and time-related performance using robust statistical analyses. METHODS: This randomized trial was conducted from March 2019 to March 2022 at two tertiary Egyptian centers. A total of 150 patients with DBC were assigned to DGT, TPS, or precut fistulotomy (n=50 each). Patients included those with difficult biliary cannulation secondary to both malignant and benign biliary obstruction. Primary outcomes included initial and final cannulation success (final success defined as success with the same initially assigned salvage technique on a second attempt). Secondary endpoints were procedure time, contrast dye usage, adverse events, and hospital stay. Kaplan-Meier and cumulative incidence analyses assessed time-dependent success. Multivariate logistic regression identified predictors of outcomes. RESULTS: Initial success rates were 72% (DGT), 68% (TPS), and 68% (precut) (p=0.882). Final success reached 100% in all groups. Median cannulation times were 21 min (DGT), 17.5 min (TPS), and 18 min (precut) (p=0.145). Precut required less contrast dye (p<0.005). Post-ERCP pancreatitis occurred in 10% (DGT), 22% (TPS), and 24% (precut) (p=0.151). Other adverse events and outcomes showed no significant differences. CONCLUSIONS: DGT, TPS, and precut fistulotomy achieved comparable efficacy and safety in patients with DBC. The selection of salvage technique should be individualized and based on patient anatomy, operator expertise, and local resources.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.