Biliary Cannulation Research Articles

Primary needle-knife fistulotomy versus standard transpapillary technique for cannulation of long-size papilla: a randomized clinical trial

Background: The morphology of the major papilla plays a crucial role in the selection of the cannulation method for the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP). Nevertheless, there is limited evidence available that compares the efficacy and safety of cannulation approaches in certain papilla morphologies. This study aims to assess the safety and effectiveness of two cannulation methods, including primary needle-knife fistulotomy (pNKF) and standard transpapillary (STP), in patients with long-size papilla. Methods: A total of 260 patients with intact long-size papilla were enrolled, and were randomly assigned to the pNKF or STP groups (n=130 in each group). The primary endpoint was the rate of post-ERCP pancreatitis (PEP). Biliary cannulation success rates, the duration of cannulation and the overall procedure, and the incidence of adverse events were also compared between the groups. All of the patients were hospitalized for at least 24 hours after the procedure. Results: 125 (96.2%) patients in the pNKF and 114 (87.7%) patients in the STP groups had successful primary biliary cannulation (p=0.01) and were included in the final analysis. PEP occurred in 11 patients in the STP group and 3 patients in the pNKF group (9.6% vs 2.4%, p=0.02; number needed to treat (95% confidence interval) =13.9 (7.5-83.2)). Moreover, compared to the pNKF, STP was associated with more cannulation attempts (3.4 versus 2.5, p<0.001) and longer cannulation time (258 versus 187 seconds, p<0.001). Conclusions: In patients with long-size papilla, pNKF is a safer, easier, and more efficient approach to gain primary biliary access than the STP technique.

Prediction of Difficult Biliary Cannulation During ERCP for Common Bile Duct Stones

Prediction of Difficult Biliary Cannulation During ERCP for Common Bile Duct Stones

Endoscopic ultrasound-guided biliary rendezvous after failed cannulation, and comparison between benign vs malignant biliopancreatic disorders: outcomes at a single tertiary-care centre

Background Endoscopic ultrasound (EUS)-guided biliary rendezvous (RV) is an EUS-assisted technique described as a rescue method in cases of failed biliary cannulation via endoscopic retrograde cholangiography (ERC). Current literature remains unclear regarding its current role. The study aim was to evaluate the effectiveness for biliary EUS-RV, and comparison between benign vs malignant biliopancreatic disorders. Methods Retrospective observational study with prospective consecutive inclusion in a specific database from a tertiary-center. All patients with biliopancreatic diseases that underwent a EUS-assisted ERC between October-2010 and November-2022 for failed ERC were included. Main outcomes were technical/overall success. Secondary outcomes were safety, potential factors related to failure/success or safety; and a comparative analysis between EUS-RV and EUS-guided transmural drainage (TMD) in malignant cases. Results A total of 69 patients who underwent EUS-RV procedures, with benign and malignant pathologies (n = 40 vs n = 29), were included. Technical / overall success and related-adverse events (AEs) were 79.7% (95%CI, 68.3-88.4) / 74% (95%CI, 61-83.7) and 24% (95%CI, 15.1-36.5), respectively. Failed cases were mainly related with guidewire manipulation. Seven failed RV were successfully rescued by EUS-TMD. On multivariable analysis, EUS-RV and malignant pathology was associated with a greater failure rate (technical success: OR,0.21; 95%CI,0.05-0.72; p = 0.017), and higher AEs rate (OR,3.46; 95%CI,1.13-11.5; p = 0.034). Also, the EUS-TMD group had greater technical success (OR,16.96; 95%CI,4.69-81.62; p < 0.001) and overall success (OR, 3.09; 95%CI,1.18-8-16; p < 0.026) with a lower AEs rate (OR,0.30; 95%CI,0.11-0.78; p = 0.014) than EUS-RV in malignant disorders. Conclusions EUS-RV is a demanding technique with better outcomes in benign than in malignant biliopancreatic diseases. Comparison of the EUS-TMD group on malignant disorders showed worse outcomes with EUS-RV. Given these findings, maybe EUS-RV is not the best option for malignant biliopancreatic disorders.

The Impact of Difficult Biliary Cannulation on Post-ERCP Pancreatitis: A Secondary Analysis of the Stent versus Indomethacin Trial Dataset

Background and AimsDifficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors. MethodsThis was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: 1) DBC with high pre-procedure risk for PEP, 2) DBC without high pre-procedure risk, and 3) non-DBC at high pre-procedure risk. ResultsIn all, 1601 (84.1%) participants experienced DBC, which required a mean of 12 (SD 10) cannulation attempts and mean duration of 14.7 minutes (SD 14.9). PEP rate was highest (20.7%) in DBC with high pre-procedure risk, followed by non-DBC with high pre-procedure risk (13.5%) and then DBC without high pre-procedure risk (8.8%). Increasing number of PD-wire passages (aOR:1.97, 95% CI:1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stenting lowered PEP risk (aOR:0.61, 95% CI:0.44-0.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages. ConclusionsDBC confers higher PEP risk in additive fashion to pre-procedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stenting reduces this risk, even with increasing PD wire passages.

Real-world evidence comparing early and late pancreatic stent placement to prevent post-ERCP pancreatitis

Abstract Background and study aims Pancreatic stenting effectively lowers the occurrence of post-ERCP pancreatitis (PEP) and reduces its severity. However, limited research has been conducted to determine the optimal timing for pancreatic stent placement. Our objective was to evaluate whether early pancreatic stent placement (EPSP) is more effective than late pancreatic stent placement (LPSP) in preventing PEP among patients with naive papilla. Patients and methods We conducted a retrospective cohort study that analyzed 590 patients with difficult biliary cannulation using the pancreatic guidewire technique, who were divided into EPSP and LPSP groups. In the EPSP group, a pancreatic stent was placed immediately before/after endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (EST). Conversely, in the LPSP group, a pancreatic stent was placed after partial/all completion of major endoscopic procedures. Results From November 2017 to May 2023, 385 patients were in the EPSP group and 205 in the LPSP group. EPSP was associated with a decreased PEP occurrence compared with LPSP (2.9% vs. 7.3%; P = 0.012). Similarly, hyperamylasemia was lower in the EPSP group (19.7% vs. 27.8%; P = 0.026). Furthermore, sensitivity analysis using multivariable analysis and propensity score–matched (PSM) analysis also validated these findings. Conclusions Early pancreatic stent placement reduced the incidence of PEP and hyperamylasemia compared with late pancreatic stent placement. Our findings favor pancreatic stenting immediately before/after ERC or EST.

Risk factors for acute pancreatitis after endoscopic retrograde cholangiopancreatography: a retrospective single-center study

Background. Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure in the diagnosis and management of pancreaticobiliary diseases. Post-ERCP pancreatitis (PEP) is the most common and serious adverse event after ERCP. Purpose – to evaluate retrospectively PEP incidence and to identify independent risk factors of PEP. Materials and Methods. The analysis of 578 ERCP cases was done. A number of potential risk factors for PEP were taken into uni- and multivariate analisys: age, gender, common bile duct (CBD) size, bilirubin level, presence of cholangitis, Sphincter of Oddi dysfunction (SOD), malignant biliary obstruction, chronic pancreatitis, biliary obstruction, history of cholecystectomy, history of endoscopic papillosphincterotomy (EPST), initial ERCP success, therapeutic success, selective biliary cannulation, pancreatic cannulation/injection, Precut and EPST. Results. PEP was in 29 (5%) cases. Six factors with р &lt; 0,05 by univariate analysis (CBD ≤ 10 mm, normal bilirubin level, SOD, history of cholecystectomy, pancreatic cannulation/injection, precut) were included into multivariate logistic regression model. The independent risk factor for PEP were CBD ≤ 10 mm (OR 2,416; 95% ДІ, 1,037–5,629; p = 0,041), SOD (OR 4,107; 95% ДІ, 1,726–9,771; p = 0,001) та pancreatic cannulation/injection (OR 3,447; 95% ДІ, 1,455–8,166; p = 0,005); and precut was an independent protective factor for PEP (OR 0,129; 95% ДІ, 0,047–0,354; p = 0,014). Conclusions. The incidence of PEP was 5%. Small CBD and SOD are independent PEP risk factors as well as pancreatic cannulation/injection. Early precut technique is an independent factor preventing PEP.

Can early precut reduce post-endoscopic retrograde cholangiopancreatography pancreatitis in patients with difficult bile duct cannulation?

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a variety of adverse events (AEs). One of the most important AEs is post-ERCP pancreatitis (PEP), which is most common in cases of difficult biliary cannulation. Although the precut technique has been reported as a PEP risk factor, recent studies indicate that early precut could reduce PEP, and that precut itself is not a risk factor. To evaluate the safety of the precut technique, especially in terms of PEP. We conducted a retrospective study, spanning the period from November 2011 through December 2021. It included 1556 patients, aged ≥ 20 years, who underwent their initial ERCP attempt for biliary disease with a naïve papilla at the Kawasaki University General Medical Center. We compared the PEP risk between the early precut and the delayed precut group. The PEP incidence rate did not significantly differ between the precut and non-precut groups. However, the PEP incidence was significantly lower in the early precut group than the delayed precut group (3.5% vs 10.5%; P = 0.02). The PEP incidence in the delayed precut group without pancreatic stent insertion (17.3%) was significantly higher compared to other cases (P < 0.01). Our findings indicate that early precut may reduce PEP incidence. If the precut decision is delayed, a pancreatic stent should be inserted to prevent PEP.

Development of a Scoring System for Predicting the Difficulty of Bile Duct Cannulation and Selecting the Appropriate Cannulation Method.

Selective biliary cannulation in endoscopic retrograde cholangiopancreatography can be challenging due to factors like papillary morphology. Various patterns indicate cannulation difficulty, but the combinations causing difficulty and the optimal cannulation method for each scenario are unclear. This study aimed to identify cannulation difficulty patterns and develop a predictive scoring system for selecting the appropriate cannulation method. We retrospectively compared 776 patients with naïve papilla, dividing them into conventional contrast cannulation (N = 510) and salvage technique (N = 266) groups. The salvage group included patients using pancreatic duct guidewire placement and/or wire-guided cannulation due to difficulties with the contrast method. Papillary morphology (Haraldsson's classification), periampullary diverticulum (PAD), and scope operability were analyzed using multiple regression to identify risk factors for cannulation difficulties. Factors were scored based on hazard ratios to access combinations causing difficulties. The salvage group had more older patients and higher frequencies of type 2 (small), type 3 (protruding or pendulous), type 4 (creased or ridged) papillae, PAD, and poor scope operability. Significant risk factors in the multivariate analysis included type 2 [odds ratio (OR) 6.88], type 3 (OR 7.74), type 4 (OR 4.06) papillae, PAD (OR 2.26), and poor scope operability (OR 4.03). Pattern recognition scores were significantly higher in the salvage group (1.31 vs. 3.43, P < 0.0001). Type 2-4 papillae, PAD, and poor scope operability are significant risk factors for cannulation difficulty. Pattern recognition scores based on these factors can predict cannulation difficulty and aid in selecting between conventional and salvage methods.

Same versus separate sessions of endoscopic ultrasound-guided fine-needle biopsy and endoscopic retrograde cholangiopancreatography for distal malignant biliary obstruction: a propensity score-matched study

ABSTRACT Background Same-session endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) is an attractive policy for patients with distal malignant biliary obstruction (DMBO) requiring fine-needle biopsy (FNB) and biliary drainage. However, scanty and conflicting data exists regarding safety and efficacy when comparing these two procedures performed in same versus separate sessions. Methods Single-center, retrospective, propensity score-matched study including patients with DMBO who underwent EUS-FNB followed by ERCP during the same or separate sessions. The primary outcome was the safety of the procedure [number of patients experiencing adverse events (AEs), overall AEs, its severity, post-ERCP pancreatitis (PEP)]. Secondary outcomes were successful ERCP, use of advanced cannulation techniques, EUS-FNB adequacy, length of hospital stay, overall procedure time, and time to recurrent biliary obstruction. Results After propensity matching, 87 patients were allocated to each group. AEs developed in 23 (26.4%) vs. 17 (19.5%) patients in the same and separate sessions group, respectively (p = 0.280). The overall number, the severity of AEs, and the rate of PEP were similar in the two groups. Secondary outcome parameters were also comparable in the 2 groups. Conclusions Same-session EUS-FNB followed by ERCP with biliary drainage is safe and does not impair technical outcomes of tissue adequacy and biliary cannulation.

Multicenter study comparing EUS-guided hepaticogastrostomy and ERCP for malignant biliary obstruction in patients with accessible papillae.

One advantage of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is that it is difficult for reflux cholangitis, caused by duodenal pressure increasing due to duodenal obstruction, to occur. In addition, since stent deployment is performed away from the malignant stricture site, longer stent patency than with endoscopic retrograde cholangiopancreatography (ERCP) may be obtained. However, no study has previously compared EUS-HGS and ERCP for patients without duodenal obstruction or surgically altered anatomy. The aim of the present study was to compare clinical outcomes between EUS-HGS and ERCP in normal anatomy patients without duodenal obstruction. In the ERCP group, patients who initially underwent biliary drainage were included. In the EUS-HGS group, patients who underwent EUS-HGS due to failed biliary cannulation were included. Patients with an inaccessible papilla, such as with surgically altered anatomy or duodenal obstruction, were excluded. A total of 314 patients who underwent ERCP and EUS-HGS were enrolled in this study. Of the 314 patients, 289 underwent biliary stenting under ERCP guidance, and 25 patients underwent biliary stenting under EUS-HGS. After propensity score-matching analysis, the adverse event rate tended to be lower in the EUS-HGS group than in the ERCP group. Although overall survival was not significantly different between the EUS-HGS and ERCP groups (p = .228), stent patency was significantly longer in the EUS-HGS group (median 366.0 days) than in the ERCP group (median 76.5 days). EUS-HGS had a lower adverse event rate, shorter procedure time, and longer stent patency than ERCP in cases of normal anatomy without duodenal obstruction.

EUS-guided Rendezvous versus Needle-knife Sphincterotomy Following Difficult Biliary Cannulation in ERCP for Benign Disease

EUS-guided Rendezvous versus Needle-knife Sphincterotomy Following Difficult Biliary Cannulation in ERCP for Benign Disease

Precut Over a Pancreatic Duct Stent Versus Transpancreatic Precut Sphincterotomy for Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: A Retrospective Cohort Study

BackgroundPrecut over a pancreatic duct stent (PPDS) and transpancreatic precut sphincterotomy (TPS) with immediate pancreatic duct stent placement are techniques employed to promote biliary access during endoscopic retrograde cholangiopancreatography (ERCP) in cases of challenging biliary cannulation. However, limited data are available to compare the efficacy of these two pancreatic stent-assisted precut sphincterotomy techniques.AimsThe aim of this study was to compare the efficacy of PPDS versus TPS.MethodsA retrospective analysis was performed on the clinical data of consecutive patients who underwent ERCP between April 1, 2019 and May 31, 2023. According to the selected cannulation approaches, patients were assigned to two groups. In the PPDS group, a pancreatic duct stent was initially placed, followed by needle-knife precut over the stent. In the TPS group, transpancreatic precut sphincterotomy was initially performed, followed by immediate pancreatic stent placement. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) between the two groups were analysed.ResultsAmong 864 patients who underwent ERCP, 46 patients were equally enrolled in the two groups. Selective bile duct cannulation was successfully achieved in 42 out of 46 (91.3%) cases using the PPDS and in 32 out of 46 (69.6%) cases using TPS technique alone, indicating significantly higher success rate of bile duct cannulation with PPDS compared to TPS (91.3% vs. 69.6%, P = 0.009). The overall success rates for bile duct cannulation were 93.5% and 97.8% in the PPDS and TPS groups, respectively, with no significant difference identified (P = 0.307). PEP occurred in 0 and 4 (8.7%) cases in the PPDS and TPS groups, respectively, with no significant difference between the two groups (8.7% vs. 0%, P = 0.117). There were no cases of bleeding or perforation in either group.ConclusionsBoth PPDS and TPS followed by immediate pancreatic duct stent placement are viable options. TPS stands out for its simplicity and cost-effectiveness, while PPDS is more appropriate for patients who are at a high-risk of developing PEP.

Endoscopic ultrasound-guided rendezvous techniques for difficult biliary cannulation: Technical review.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard procedure for the diagnosis and treatment of biliary diseases. However, selective biliary cannulation, the essential first step in ERCP, can sometimes fail due to anatomical variations or technical limitations. In these cases, the endoscopic ultrasound-guided rendezvous technique (EUS-RV) offers a valuable salvage option. Nevertheless, it is crucial to be aware of potential adverse events associated with bile duct puncture. To optimize the success rate and safety of EUS-RV, understanding the basic techniques, technical tips for each procedural step, and troubleshooting strategies for potential difficulties is essential. This review article summarizes the clinical outcomes and technical considerations of EUS-RV, including a comprehensive analysis of the current evidence.

Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation : A Randomized Controlled Trial.

The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking. To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction. Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613). Tertiary care academic institute from July 2020 to May 2021. All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy. Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa. The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events. In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post-endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group. Single center study done by experts. Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates. None.

A Comparative Study of Transpancreatic Sphincterotomy, Double Guidewire Technique, and Precut Sphincterotomy in Difficult Naive Biliary Cannulations in a Tertiary Care Center in Western India

Abstract Introduction Difficult biliary cannulation leads to prolonged papillary manipulation and repeated attempts at cannulation are known to increase the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. This study aims to compare the efficacy and complications of three rescue methods, transpancreatic biliary sphincterotomy (TP), double guidewire technique (DGW), and precut sphincterotomy (precut) in difficult common bile duct (CBD) cannulations. Methods Seventy-six patients (&gt;18 years of age) with a native papilla undergoing ERCP for biliary cannulation were recruited. Those who had inadvertent pancreatic duct cannulations (&gt;1) were included. A pancreatic stent was inserted in all cases. They underwent either DGW (n = 25), precut (n = 25), or TP (n = 26) as rescue methods and were compared in terms of the success of cannulation and post-ERCP complications. Results Of the total 76 cases, 82% were for benign indications, the most common being choledocholithiasis (69.7%). Jaundice was noted in 52% (n = 13/25), 60% (n = 15/25), and 38.5% (n = 10/26) of the DGW, precut, and TP cases, while 40% (n = 10/25), 12% (n = 3/25), and 30.8% (n = 8/26), respectively, were in cholangitis at presentation. The most common type of papilla was type 1 overall and each subgroup. While successful cannulation was achieved in 88.5% (n = 23/26) of TP and 84% (n = 21/25) of the DGW group, only 64% (n = 16/25) of the precut cases were cannulated. Three (n = 3/25) cases had mild bleeding and two mild pancreatitis, one severe pancreatitis, and one perforation were recorded in the precut group. One patient each had severe and mild pancreatitis in the DGW group, while one had mild pancreatitis and two had moderate pancreatitis in the TP group. All the patients were managed conservatively. Conclusion There was no significant difference in the technical success rate (p = 0.075) as well as complications (p = 0.117) between the three salvage methods for difficult naive CBD cannulations.

Pre-Cut Papillotomy Versus Endoscopic Ultrasound-Rendezvous for Difficult Biliary Cannulation: A Systematic Review and Meta-Analysis.

Various endoscopic techniques are employed to achieve biliary cannulation when confronted with difficult biliary access. Every procedure carries its own risk in terms of bleeding, infection, pancreatitis, and cholangitis. Our meta-analysis aimed to compare pre-cut papillotomy and endoscopic ultrasound (EUS)-rendezvous in terms of technical success rates, and post-procedure pancreatitis and bleeding. We conducted a systematic review and meta-analysis of studies that compared pre-cut papillotomy and EUS-rendezvous. The primary outcome was technical success by achieving biliary cannulation. Secondary outcomes were postoperative pancreatitis and bleeding. A random-effects model was used to calculate the risk ratios (RRs) and confidence intervals (CIs). A P value < 0.05 was considered statistically significant. Our meta-analysis included four studies comparing pre-cut papillotomy and EUS-rendezvous. The studies included 13,659 total endoscopic retrograde cholangiopancreatography (ERCP) procedures, of whom 1,004 patients underwent alternate biliary cannulation procedures due to difficult biliary cannulation. The mean age of the study population was noted to be 49.5 years and males represented 53.3% of the total participants. Both procedures were similar in terms of technical success (RR: 0.95, 95% CI (0.88, 1.02)). No difference was found between rates of post procedure pancreatitis (RR: 1.82, 95% CI (0.80, 4.15)) and post procedure bleeding (RR: 2.80, 95% CI (0.67, 11.66)). There was no difference in technical success of procedure or post-procedure complications such as pancreatitis and bleeding between pre-cut papillotomy and EUS-rendezvous technique. More randomized controlled trials (RCTs) are needed to compare both procedural techniques and complications rates. However, currently, both procedures are equally effective and safe during difficult biliary cannulation in the hands of experienced endoscopists.

Endoscope traction technique to facilitate over-the-wire biliary cannulation during EUS-guided rendezvous

Endoscope traction technique to facilitate over-the-wire biliary cannulation during EUS-guided rendezvous

Visualized biliary cannulation during ERCP: do we really need it?

Visualized biliary cannulation during ERCP: do we really need it?

Visualized biliary cannulation during ERCP: future trends

Visualized biliary cannulation during ERCP: future trends

Combination of Precut Techniques in Difficult Biliary Cannulation.

Selective biliary cannulation (SBC) is a prerequisite for successful endoscopic retrograde cholangiopancreatography (ERCP). SBC has the potential to fail in as many as 20% of cases, even with skilled endoscopists. Precut incision techniques like needle-knife sphincterotomy (NKS) and transpancreatic septotomy (TPS) can be used in cases where standard cannulation techniques fail. However, these precut techniques may also fail in some cases. We aimed to evaluate the procedural success of the combined TPS + NKS technique in difficult biliary cannulation. The study included 289 patients who underwent ERCP with precut techniques from 2017 to 2022. Patients were classified into the following three groups and evaluated retrospectively in terms of cannulation success, and ERCP-related adverse effects: Transpancreatic septotomy, NKS, and TPS + NKS; statistical package for the social sciences (SPSS), version 29.0, software was used to analyze the data. The success rate of SBC was 69% in the TPS group, 75.3% in the NCS group, and 87% in the TPS + NCS group. There was no significant difference between the NKS and TPS + NKS groups. Cannulation success in both NKS group and NKS + TPS groups was significantly higher than in the TPS group (p < 0.001). Complication rates were similar. In cases where standard sphincterotomy and precut techniques fail, a second precut technique can be used. A previous TPS does not prevent NKS. Abiyev A, Tuzcu B, Bilican G, et al. Combination of Precut Techniques in Difficult Biliary Cannulation. Euroasian J Hepato-Gastroenterol 2024;14(1):56-59.