Stepwise Algorithm for Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography in the Era of Endoscopic Ultrasound-Guided Biliary Drainage - A Single-Center Retrospective Cohort Study

Q: What was the main objective of this study?

To evaluate the status of biliary cannulation and associated adverse events using a stepwise cannulation algorithm in patients with a naïve papilla undergoing ERCP.

Q: How was the stepwise biliary cannulation algorithm implemented?

Biliary cannulation was attempted sequentially, starting with wire-loaded cannulation, then progressing to double-guidewire technique, precut techniques, and endoscopic ultrasound-guided rendezvous (EUS-RV) as needed.

Q: What were the key outcomes for success and adverse events?

Initial wire-loaded cannulation achieved 69.2% selective cannulation, while salvage techniques showed high success rates, leading to an overall final success of 97.8%. The overall adverse event rate was 7.5%, with post-ERCP pancreatitis as the most common at 6.1%.

Q: Which factors increased the risk of post-ERCP pancreatitis?

Multivariate analysis identified advanced cannulation techniques, pancreatography, and metallic stent placement as independent risk factors for post-ERCP pancreatitis.

Sep 29, 2026

Uploaded by Kurz

Endoscopic retrograde cholangiopancreatography (ERCP) relies on successful biliary cannulation as the first critical step in managing biliary diseases. This single-center retrospective cohort study evaluated a stepwise cannulation algorithm in 1,000 consecutive patients with a naïve papilla between 2012 and 2022. The algorithm progressed from wire-loaded cannulation to double-guidewire, precut techniques, and endoscopic ultrasound-guided rendezvous. Overall technical success reached 97.8% with an adverse event rate of 7.5%, mainly post-ERCP pancreatitis (6.1%).

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Introduction

Aims

Methods

Results

Conclusion

Background

Abbreviations

DEN Open ORIGINAL ARTICLE Stepwise Algorithm for Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatographyin the Era of Endoscopic Ultrasound-Guided Biliary Drainage: A Single-Center Retrospective Cohort Study Akihiko Senju1, 2 Takuji Iwashita1, 3 Takuya Koizumi1 Yosuke Ohashi1 Shota Iwata1 Akinori Maruta1 Shinya Uemura1 Masahito Shimizu1 1 First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan 2 Department of Gastroenterology, Seino Kosei Hospital, Gifu, Japan 3 Department of Gastroenterology, Shiga University of Medical Science, Shiga, Japan Correspondence: Takuji Iwashita ([takuji@w7.dion.ne.jp](takuji@w7.dion.ne.jp)) Received: 19 November 2025 Revised: 16 December 2025 Accepted: 21 December 2025 Keywords: difficult biliary cannulation | double-guidewire technique | endoscopic ultrasound-guided rendezvous technique (EUS-RV) | precut technique | post-ERCP pancreatitis ABSTRACT Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management ofbiliary diseases. Successful biliary cannulation is the first step. Advanced cannulation techniques, such as the double-guidewire technique (DGW), precut techniques, and endoscopic ultrasound (EUS)-guided rendezvous (RV), have been developed to improve cannulation success. However, comprehensive evaluations of a structured cannulation algorithm remain limited. Aims: To evaluate the status ofbiliary cannulation and associated adverse events (AEs) using a stepwise cannulation algorithm. Methods: A retrospective evaluation of 1,000 consecutive patients with a naïve papilla who underwent ERCP for biliary disease was performed between 2012 and 2022. Biliary cannulation was attempted using a stepwise algorithm, beginning with wire-loaded cannulation (WLC), followed by DGW, precut techniques, and EUS-RV. The primary endpoint was overall technical success; secondary endpoints included AEs, incidence of post-ERCP pancreatitis (PEP), and risk factor analysis. Results: Initial WLC achieved selective biliary cannulationin 69.2% of cases. Salvage techniques achieved high success rates: DGW (74.9%), precut techniques (77.6%), and EUS-RV (97.0%) . Overall, the final cannulation success rate was 97.8% . The overall AE rate was 7.5%, with PEP being the most common (6.1%) . AEs were significantly more frequent in advanced cannulation techniques than WLC (13.3% vs. 5.2%, p < 0.001) . Multivariate analysis identified advanced cannulation techniques, pancreatography, and metallic stent placement as independent factors increasing the risk of PEP. Conclusion: A structured stepwise approach achieves very high biliary cannulation success in patients with a naïve papilla, though advanced cannulation techniques increase AE risk. Appropriate timing and positioning of EUS-RV may further optimize safety and efficacy in biliary cannulation. | Abbreviations: AE, adverse event; CI, confidence interval; DGW, double-guidewire technique; ERCP, endoscopic retrograde cholangiopancreatography; EUS-BD, endoscopic ultrasound-guided biliary drainage; EUS-RV, endoscopic ultrasound-guided rendezvous technique; NKP, needle-knife precutting; OR, odds ratios; PEP, post-ERCP pancreatitis; PTBD, percutaneous transhepatic biliary drainage; TPS, transpancreatic precut sphincterotomy; WLC, wire-loaded cannulation..
| | --- | | This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
© 2026 The Author(s). DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society. | DEN Open, 2026; 6:e70272 [https://doi.org/10.1002/deo2.70272](https://doi.org/10.1002/deo2.70272) 1 of 7 1 Background Endoscopic retrograde cholangiopancreatography (ERCP) plays a pivotal role in both the diagnosis and treatment ofbiliary diseas

FAQs

What was the main objective of this study?

To evaluate the status of biliary cannulation and associated adverse events using a stepwise cannulation algorithm in patients with a naïve papilla undergoing ERCP.

How was the stepwise biliary cannulation algorithm implemented?

Biliary cannulation was attempted sequentially, starting with wire-loaded cannulation, then progressing to double-guidewire technique, precut techniques, and endoscopic ultrasound-guided rendezvous (EUS-RV) as needed.

What were the key outcomes for success and adverse events?

Initial wire-loaded cannulation achieved 69.2% selective cannulation, while salvage techniques showed high success rates, leading to an overall final success of 97.8%. The overall adverse event rate was 7.5%, with post-ERCP pancreatitis as the most common at 6.1%.

Which factors increased the risk of post-ERCP pancreatitis?

Multivariate analysis identified advanced cannulation techniques, pancreatography, and metallic stent placement as independent risk factors for post-ERCP pancreatitis.

Sep 29, 2026

Uploaded by Kurz