Precut sphincterotomy is an essential access technique for selective biliary cannulation in difficult endoscopic retrograde cholangiopancreatography (ERCP). It requires advanced endoscopic expertise and is usually reserved for experienced centers. Although its effectiveness is established, its use varies according to practice patterns and operator experience. The aim of this study was to evaluate the technical approach, success rate, and safety of precut sphincterotomy in our center.

We conducted a retrospective single-center study including all patients who underwent precut sphincterotomy between January 2019 and December 2025. Difficult cannulation was defined according to ESGE criteria (≥5 minutes, ≥5 attempts, or repeated pancreatic cannulation). Demographic, clinical, anatomical, and procedural data were analyzed. Cannulation time was not systematically recorded.

Among 825 ERCPs performed during the study period, 48 required precut sphincterotomy (5.8%). The mean age was 68.1 years, and 58.3% were female. Indications included malignant obstruction in 52% (25/48) and choledocholithiasis in 43.7% (21/48). The papilla was normal in 91.7% and diverticular in ~8%.

Techniques used included papillotomy (68.8%), infundibulotomy (29.2%), and transpancreatic precut (2.1%). Additional sphincterotomy to extend the precut was required in 43.8%.

Selective biliary cannulation was achieved using guidewire-assisted technique in 89.6% and double-wire technique in 6.3%. Two patients (4.1%) had cannulation failure, resulting in an overall success rate of 93.8%. Precut success was similar for lithiasis and malignant indications (100% vs 92%, p=0.49), suggesting that the indication did not influence procedural success.

Post-ERCP pancreatitis occurred in 8.3%. Three mild intraprocedural bleeding events (6.25%) were controlled endoscopically, and one severe hemorrhage (2.1%) corresponded to a post-ERCP episode of moderate hematemesis. The patient developed aspiration-induced respiratory distress during endoscopy, requiring ICU admission.One Stapfer type II perforation (2.1%) was managed conservatively with antibiotics, monitoring, and CT evaluation. No patient required surgical intervention.

In our experience, precut sphincterotomy was required in 5.8% of ERCPs and achieved a high success rate of 93.8%, with an acceptable safety profile consistent with published data. This study supports the feasibility and effectiveness of precut sphincterotomy in difficult biliary access cases in an intermediate-volume center, highlighting the importance of technical expertise and close post-procedural monitoring.