Common bile duct cannulation can be achieved with various techniques, depending on factors such as ampulla anatomy, technical difficulties, and endoscopist preference. Advanced cannulation techniques (eg transpancreatic sphincterotomy/precut sphincterotomy and the double-wire technique) are mostly used in cases of difficult cannulation. Our aim was to compare advanced cannulation techniques in terms of cannulation success and adverse event rates using real-life data from the Greek ERCP registry.  

We conducted a multicenter observational study with prospectively collected data from the Greek national ERCP database. The registry was searched for ERCP cases performed January 2023 - September 2025, in patients with naïve ampulla of Vater. We performed univariate and multivariate analyses.

A total of 1693 ERCP procedures in patients with naïve ampulla of Vater were included (mean age 73 yo (SD 15.7), 69.4% with bile duct stones, 36.4% jaundice, 15.7% cholangitis/sepsis, 11.5% biliary stricture). The most frequently used cannulation technique was conventional guide-wire guided cannulation (n=1283, 80.4%), followed by transpancreatic sphincterotomy (n=140, 8.8%), double-wire (n=97, 6.1%), precut sphincterotomy (n=72, 4.5%) and "rendezvous" (n=4, 0.3%). Overall, 51.3% of the cases were performed electively, most patients had an ASA score of 2 (42.5%, 27.9% score 1, 25.7% score 3, 3.8% score 4 and 0.2% score 5) and the most common type of sedation was conscious sedation (82.9% followed be 16.4% deep sedation and 0.7% general anesthesia). The overall deep bile duct cannulation success rate was 94.1%. The cannulation success rate was higher in the double wire technique (100%) compared to transpancreatic/precut sphincterotomy (89.6%, p<0.01). The overall adverse event rate was 9.8% (post ERCP pancreatitis 6.5% and post ERCP cholangitis 5.8%). The overall adverse event rate did not differ significantly between the double-wire (6.2%) and the transpancreatic/precut sphincterotomy group (11.3%, p=0.1), and the same was true for post ERCP cholangitis, perforation, bleeding, respiratory or cardiovascular adverse events (p>0.05 for all). However, the post ERCP pancreatitis rate was higher with the double-wire technique (17.5%) compared to the transpancreatic/precut sphincterotomy group (8.5%, p=0.02). In multivariate analysis the use of transpancreatic or precut sphincterotomy vs double wire technique was not an independent predictive factor of cannulation failure (p=0.9). 

In a real-life multicenter registry study, there do not appear to be major differences in cannulation success among different advanced cannulation techniques.  Further randomized trials are warranted.