Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis

Published:September 16, 2021DOI:

      Background and Aims

      Several methods with variable efficacy have been proposed for difficult biliary cannulation in ERCP. We assessed the comparative efficacy of different strategies for difficult biliary cannulation through a network meta-analysis combining direct and indirect treatment comparisons.


      We identified 17 randomized controlled trials (2015 patients) that compared the efficacy of different adjunctive methods for difficult biliary cannulation (needle-knife techniques, pancreatic guidewire-assisted technique, pancreatic-assisted technique, and transpancreatic sphincterotomy) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the outcomes of interest. We performed pairwise and network meta-analysis for all treatments and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence.


      Low-quality evidence supported the use of transpancreatic sphincterotomy over persistence with standard cannulation techniques (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.05-1.59) and over any other adjunctive intervention (RR, 1.21 [95% CI, 1.01-1.44] vs pancreatic guidewire-assisted technique, RR, 1.19 [95% CI, 1.01-1.43] vs early needle-knife techniques, RR, 1.47 [95% CI, 1.03-2.10] vs pancreatic stent-assisted technique) for increasing the success rate of biliary cannulation. No other significant results were observed in any other comparisons. Based on the network model, transpancreatic sphincterotomy (P-score, .97) followed by early needle-knife techniques (P-score, .62) were ranked highest in terms of increasing the success rate of biliary cannulation. Early needle-knife techniques outperformed persistence with standard cannulation techniques in terms of decreasing PEP rate (RR, .61; 95% CI, .37-1.00), whereas both early needle-knife techniques and transpancreatic sphincterotomy led to lower PEP rates as compared with pancreatic guidewire-assisted technique (RR, .49 [95% CI, .23-.99] and .53 [95% CI, .30-.92], respectively).


      Transpancreatic sphincterotomy increases the success rate of biliary cannulation as compared with persistence with the standard cannulation techniques. Early needle-knife techniques and transpancreatic sphincterotomy are superior to other interventions in decreasing PEP rates and should be considered in patients with difficult cannulation.

      Graphical abstract


      CI (confidence interval), GRADE (Grading of Recommendations Assessment, Development and Evaluation), PEP (post-ERCP pancreatitis), RCT (randomized controlled trial), RR (risk ratio), SUCRA (surface under the cumulative ranking curve)
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      Linked Article

      • Bringing down the hammer on difficult biliary cannulation
        Gastrointestinal EndoscopyVol. 95Issue 4
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          The outcomes of ERCP are known to depend highly on endoscopists’ skill and expertise.1,2 Mastering difficult biliary cannulation, one of the pivotal skills within ERCP, has remained a hot topic throughout the decades.1-7 The recent systematic review and network meta-analysis by Facciorusso et al8 compared 4 separate techniques for difficult biliary cannulation by analyzing 17 randomized controlled trials with a total of 2015 patients. Although their results may support the use of transpancreatic sphincterotomy above other approaches in a theoretic comparative setting, we believe several important points need to be addressed before we can incorporate these data into clinical practice.
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