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. 2025 Sep 16;17(9):108420.
doi: 10.4253/wjge.v17.i9.108420.

Early precut is useful for difficult bile duct cannulation, particularly in cases with long oral protrusion

Toru Kaneko  1   2 , Mitsuhiro Kida  1   3 , Takahiro Kurosu  1   3 , Gen Kitahara  1   3 , Tomohiro Betto  1   3 , Yutaro Saito  1   3 , Shiori Koyama  1   3 , Nao Nomura  1   3 , Chika Kusano  3
Affiliations

Early precut is useful for difficult bile duct cannulation, particularly in cases with long oral protrusion

Toru Kaneko et al. World J Gastrointest Endosc. .

Abstract

Background: Endoscopic retrograde cholangiopancreatography involves selective bile duct cannulation, which is often challenging and associated with complications. In difficult cannulation cases, early precutting is frequently used. However, its efficacy and optimal indications require further evaluation.

Aim: To evaluate the efficacy and safety of early precut (EP) in difficult bile duct cannulation.

Methods: This retrospective analysis of endoscopic retrograde cholangiopancreatography procedures was performed for bile duct cannulation in patients with naive papillae who required advanced cannulation techniques (ACTs). These patients were admitted between April 2020 and March 2024 and were analyzed for risk factors, success rates, and complications. Outcomes were compared between the EP group and the conventional other ACTs group, with a focus on cases with oral protrusion large (oral protrusion-L).

Results: The need for ACTs was identified as an independent risk factor for complications [odds ratio (OR) = 5.4; 95% confidence interval: 1.887-15.53]. Malignant biliary strictures (OR = 2.58) and oral protrusion-L (OR = 2.77) were also identified as independent risk factors for requiring ACTs. The EP group had a significantly higher second-line cannulation success rate (97.9% vs 73.2%, P = 0.001) and lower complication rate (8.3% vs 39.0%, P = 0.001) than the other ACTs group. Additionally, similar benefits were observed in the oral protrusion-L cases.

Conclusion: This study provides compelling evidence that EP is a viable alternative and a superior strategy in cases requiring ACTs, particularly oral protrusion-L.

Keywords: Biliary cannulation; Early precut; Endoscopic retrograde cholangiopancreatography; Needle knife fistulotomy; Oral protrusion; Post-endoscopic retrograde cholangiopancreatography pancreatitis; Precut sphincterotomy.

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Conflict of interest statement

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

Figures

Figure 1
Figure 1
Flow chart of the inclusion process. ERCP: Endoscopic retrograde cholangiopancreatography; B-I: Billroth I reconstruction.
Figure 2
Figure 2
Flow chart of biliary cannulation. ACT: Advanced cannulation technique; SCT: Standard cannulation techniques; ERCP: Endoscopic retrograde cholangiopancreatography; EUS-HGS: Endoscopic ultrasonography-guided hepaticogastrostomy; EUS-rendezvous: Endoscopic ultrasound-guided rendezvous technique; PTBD: Percutaneous transhepatic biliary drainage.
Figure 3
Figure 3
Stepwise endoscopic images of early precut needle knife fistulotomy in a case with a large oral protrusion. A: Papilla with a long oral protrusion (oral protrusion-L); the incision line is marked at the apex of the protrusion prior to precutting; B: The initial incision is made using a needle knife, limited to the oral protrusion only, avoiding the papillary orifice characteristic of needle knife fistulotomy; C: Exposure of the sphincter of the Oddi muscle layer (highlighted with a blue circle). The extended oral protrusion allows for a wide incision plane, facilitating clear visualization of the muscle layer; D: Identification of the artificially created bile duct opening after further dissection (blue arrow); E: Successful bile duct cannulation with a guidewire through the exposed opening.
See this image and copyright information in PMC

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