Which Cannulation Technique Is Better for Difficult ERCPs?

To date, no single advanced cannulation technique to achieve successful biliary access (after standard techniques have failed) has been identified. The so-called two-wire technique (TWT), whereby a wire is inserted into the pancreatic duct and a second wire is inserted into a sphincterotome to access the bile duct, is widely employed in this situation. Far less commonly employed is the so-called transpancreatic precut papillotomy (TPPP), which utilizes a sphincterotomy over a wire inserted into the pancreatic duct (performed towards the bile duct orifice to allow biliary access).

In a prospective, randomized study, researchers compared outcomes of TWT and TPPP at a single center in Japan. Of 2052 endoscopic retrograde cholangiopancreatograph…