S15 A Protocolized Approach to Difficult Cannulation in ERCP: Experience From a High-Volume Practice

Introduction: Successful cannulation during index endoscopic retrograde cholangiopancreatography (ERCP) is achieved in approximately 75%–85% of cases. When initial biliary access is unsuccessful, salvage techniques such as Goff septotomy, needle-knife precut sphincterotomy, or the double guidewire technique are employed. This study evaluates the efficacy of a standardized short-guidewire cannulation protocol on cannulation success and patient outcomes. Methods: In this retrospective single-center study, a standardized short-guidewire-assisted cannulation protocol was utilized in patients undergoing ERCP between March 2023 and October 2024. Data collected included ERCP indications, target duct, use of disposable scopes, and cannulation difficulty. Difficult cannulation was defined as failure to access the duct of interest within 5 minutes or unintentional pancreatic duct (PD) cannulation. If PD cannulation occurred, a modified Goff septotomy (Goff septotomy followed by double guidewire-assisted cannulation) was performed. If PD cannulation did not occur, needle-knife precut sphincterotomy was used. Cannulation success and post-procedural outcomes—including pancreatitis, cholangitis, bleeding, and perforation—were recorded. Results: Over the past 3 years, more than 1,000 ERCPs were performed in a hybrid academic–community practice using this standardized protocol. A total of 237 patients with native papilla were identified within the study period. The most common indication for ERCP was choledocholithiasis (60%, 143/237), followed by malignant biliary strictures (14%, 32/237) and cholangitis (7%, 17/237). Standard biliary cannulation was successful in 65% of cases. Difficult cannulation occurred in 83 patients (35%), with 59 patients (25%) undergoing modified Goff septotomy and 24 (10%) undergoing needle-knife precut sphincterotomy. Prophylactic PD stents were placed in 35 patients. Overall, biliary cannulation was successful in 92% of patients (218/237) during the index procedure. The overall complication rate was 5.1% (12/237), including pancreatitis (1.7%), post-sphincterotomy bleeding (1.7%), and cholangitis (1.7%). Among patients with pancreatitis, 2 had mild and 2 had moderate severity, requiring 3–5 days of hospitalization. Conclusion: This study highlights the effectiveness of a standardized short-guidewire cannulation protocol for difficult biliary access with a low overall complication rate, underscoring its utility and safety in real-world practice.