ERCP Cannulation Research Articles

Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study

BackgroundNumerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP.MethodsThis prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-guided cannulation was deemed to have failed due to the DBC criteria, then according to the cannulation algorithm early precut fistulotomy (EPF; cannulation time > 5 min, papillary contacts > 5 times, or hook-nose-shaped papilla), double-guidewire cannulation (DGC; unintentional pancreatic duct cannulation ≥ 3 times), and precut after placement of a pancreatic stent (PPS; if DGC was difficult or failed) were performed sequentially. The main outcome measurements were the technical success, procedure outcomes, and complications.ResultsInitially, a total of 140 (19.7%) patients with DBC underwent EPF (n = 71) and DGC (n = 69). Then, in DGC group 36 patients switched to PPS due to difficulty criteria. The successful biliary cannulation rate was 97.1% (136/140; 94.4% [67/71] with EPF, 47.8% [33/69] with DGC, and 100% [36/36] with PPS; P < 0.001). The mean successful cannulation time (standard deviation) was 559.4 (412.8) seconds in EPF, 314.8 (65.2) seconds in DGC, and 706.0 (469.4) seconds in PPS (P < 0.05). The DGC group had a relatively low successful cannulation rate (47.8%) but had a shorter cannulation time compared to the other groups due to early switching to the PPS method in difficult or failed DGC. Post-ERCP pancreatitis developed in 14 (10%) patients (9 mild, 1 moderate), which did not differ significantly among the groups (P = 0.870) or compared with the conventional group (P = 0.125).ConclusionsBased on the sequential protocol analysis, EPF, DGC, and PPS may be safe and feasible for DBC. The use of EPF in selected DBC criteria, DGC in unintentional pancreatic duct cannulations, and PPS in failed or difficult DGC may facilitate successful biliary cannulation.

Pancreatic duct guidewire pre-occupying for difficult biliary cannulation in ERCP

Objective To investigate the efficacy of pancreatic duct guidewire pre-occupying in ERCP with difficult biliary cannulation. Methods During a four-year study period from June 2008 to June 2012, a total of 3505 patients were included in this retrospective analysis. Initial biliary cannulation method consisted of single-guidewire technique for up to 5 attempts, followed by double-guidewire technique when repeated unin- tentional pancreatic duct cannulation had taken place. Pre-cut papillotomy technique was reserved for when double-guidewire technique had failed or no pancreatic duct cannulation had been previously achieved. Biliary cannulation success and post- ERCP complication rate were compared. Results Single-guidewire technique was characterized by statistically significant higher success rate （93.4%）, compared with the double-guide- wire technique （54. 8%, P 〈 0. 001 ）, pre-cut failed double-guidewire technique （81.3%, P 〈 0. 001 ） or pre- cut as first step method （84. 6%, P =0. 011 ）. Pre-cut failed double-guidewire technique and pre-cut as first step method offered a statistically significantly more favorable outcome compared with the double-guidewire technique （both P 〈 0. 001 ）. The incidence of post-ERCP pancreatitis did not differ in a statistically signifi- cant manner among the four methods. Numbers of patients who got bleeding in pre-cut papillotomy technique and sphincterotomy after successful single-guidewire technique were 5 and 2 respectively. One case of perfora- tion was recorded using pre-cut papillotomy technique. There was no procedure-related mortality within 30 days. Conclusion Although double-guidewire technique success rate proved not to be superior to single- guidewire technique or pre-cut papillotomy, it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficuh-to-cannulate cases. Key words: Cholangiopancreatography, endoscopic retrograde; Sphincterotomy, endoscopic ; Postoperative complications

Retrospective analysis of 10 955 cases of ERCP from a single endoscopy center

Objective To evaluate the clinical efficacy of ERCP in treatment of biliary and pancre- atic diseases. Methods Data of 10 955 patients treated with ERCP from January 1995 to July 2013 were retrospectively analyzed. Results The study cohort consisted of 6186 male and 4769 female, with a mean age of 65. 57 ± 14. 44 years, in which 167 procudures were diagnostic ERCP and 10 788 were therapeutic. The number of ERCP cases increased at an annual average rate of 19. 58% during 2002 to 2012. The initial and total success rate of ERCP cannulation were 97.23% and 99. 59% , respectively. ERCP was used in ex- trahepatic bile duct stone （40. 85% ） , hilar bile duct carcinoma （ 10. 53% ） , acute suppurative cholangitis （ 10. 44% ） , cancer of head of pancreas （ 10. 04% ） , chronic pancreatitis （ 8.24% ） , extrahepatic bile duct cancer （7. 68% ）, periampullary cancer （6. 96% ）, acute pancreatitis with bile duct stones （3. 94% ）, be- nign stenosis of Vater＇s papilla （3.88%） and duodenal papillary cancer （3.50%）. Extrahepatic bile duct stone, acute suppurative cholangitis and benign stenosis of Vater＇s papilla were more common in patients of 40-50 years old, and chronic pancreatitis was more often seen patients of 50-60 years old, while acute pan- creatitis with bile duct stones, hilar bile duct carcinoma, extrahepatic bile duct cancer, cancer of head of pancreas, periampullary cancer, duodenal papillary cancer were more common in patients of 70-80 years old. In the recent 3 years, 98.74% ERCP procedures was done under total intravenous anesthesia （TIVA）.Conclusion ERCP is a key method for diagnosis and treatment of extrahepatic bile duct stone, acute suppu- rative cholangitis and malignant biliary obstructive disease, especially for extremely elderly patients. ERCP under total intravenous anesthesia is safe and effective. Key words: Cholangiopancreatography, endoscopic retrograde ; Biliary tract diseases ; Pancreat-ic diseases ; Anesthesia, intravenous

Guide wire-assisted cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis

Cannulation techniques are recognized to be important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guide wire-assisted cannulation technique for the prevention of PEP. This systematic review of randomized controlled trials (RCTs) aimed to compare the guide wire-assisted cannulation technique with the contrast-assisted cannulation technique. CENTRAL, MEDLINE, EMBASE, CINAHL, and abstracts from Digestive Disease Week and the United European Gastroenterology Week were searched up to February 2012 for RCTs comparing the guide wire-assisted ERCP cannulation technique with the conventional contrast-assisted ERCP cannulation technique. The risk of bias was assessed, and outcomes were pooled by meta-analysis (random-effects model). The primary outcome measure was PEP. Secondary outcome measures included severity of PEP, primary common bile duct (CBD) cannulation success, overall CBD cannulation success, precut sphincterotomy, and other ERCP-related complications. In total, 12 RCTs (3450 patients) were included. The guide wire-assisted cannulation technique significantly reduced PEP compared with the contrast-assisted cannulation technique (risk ratio [RR] 0.51, 95 % confidence interval [CI] 0.32 - 0.82). In addition, the guide wire-assisted cannulation technique was associated with greater primary cannulation success (RR 1.07, 95 %CI 1.00 - 1.15), fewer precut sphincterotomies (RR 0.75, 95 %CI 0.60 - 0.95), and no increase in other ERCP-related complications. Subgroup analyses indicated that this significant risk reduction in PEP with the guide wire-assisted cannulation technique existed only in "non-crossover" trials (RR 0.22, 95 %CI 0.12 - 0.42). The results were robust in sensitivity analyses. Compared with the contrast-assisted cannulation technique, the guide wire-assisted cannulation technique increases the primary cannulation rate and reduces the risk of PEP, and therefore appears to be the most appropriate first-line cannulation technique.

1047 Prospective Sequential Protocol Analysis to Facilitate Selective Biliary Access for Difficult Biliary Cannulation in ERCP

During ERCP, 5-20% of cases fail for successful biliary cannulation even when performed by experts. Various techniques have been attempted to improve the cannulation success rate. However, standardized guidelines are not yet in place. We therefore prospectively investigated a sequential protocol analysis to facilitate selective biliary access for difficult biliary cannulation (DBC) in ERCP.

1049 Utility of Sildenafil for ERCP Cannulation

Pancreatitis post ERCP is the most common complication of this procedure. Difficult cannulation (more than 10 attempts, > 10 minutes or more than 5 pancreatic cannulations) has been associated as a risk factor for pancreatitis, for this reason is important to implement measures that facilitate cannulation. Sildenafil is a very safe drug used in erectile dysfunction but has also been used in other diseases such as pulmonary hypertension for its dilating effect.

Tu1669 I-SCAN Is the Preferred Viewing Modality for Defining Major Papilla Anatomy and Influences Desire for Cannulation in ERCP

Tu1669 I-SCAN Is the Preferred Viewing Modality for Defining Major Papilla Anatomy and Influences Desire for Cannulation in ERCP

Mo1325 A Prospective Assessment of Pancreatic Techniques Used to Achieve Common Bile Duct Cannulation in ERCP

Use of pancreatic techniques (PTs) is a new and useful method to improve biliary cannulation. Guidewire (GW) placement into the main pancreatic duct (MPD) has been shown to be effective in increasing the rate of common bile duct (CBD) deep cannulation. Following GW-MPD insertion, a variety of methods (see figure) can be performed to gain the CBD. Our aim was to evaluate prospectively its use and effectiveness in an intermediate volume ERCP unit (about 150 procedures per year performed by a single endoscopist).

Mo1354 The Clinical Significance of Wire-guided Cannulation With Pancreatic Guidewire Placement (Double-Guidewire Technique) for Difficult Biliary Cannulation in ERCP

Mo1354 The Clinical Significance of Wire-guided Cannulation With Pancreatic Guidewire Placement (Double-Guidewire Technique) for Difficult Biliary Cannulation in ERCP

Comparison between needle-knife fistulotomy and standard cannulation in ERCP

To compare the rates of success and complications of two different methods of access into the common bile duct (CBD). Between October 2007 and November 2008, 173 consecutive patients (71 men, 102 women, mean age 68.6 years) requiring endoscopic retrograde cannulation of the papilla and endoscopic treatment were studied. In the first 88 patients CBD cannulation was performed through supra-papillary fistulotomy (group F); in the following 85 patients standard cannulation was performed through the Oddi sphincter (group S). Indications for the procedure were: choledocholithiasis, biliary obstruction, postoperative leak, sclerosing cholangitis, and Mirizzi's syndrome. Deep CBD cannulation was successful in 85/88 patients (96.5%) in group F vs 60/85 patients (70.6%) in group S (P < 0.0001). The remaining 25 group S patients in whom cannulation failed were shifted to fistulotomy. Fistulotomy was successful in 21/25 patients (84%). As for complications, hyperamilasemia occurred in 7 (7.9%) group F patients vs 7 (8.2%) group S patients (P = NS); mild pancreatitis in 1 (1.1%) group F patient vs 5 (5.8%) group S patients (P = NS); bleeding in 3 (3.4%) group F patients vs 3 (3.5%) group S patients (P = NS). Needle-knife fistulotomy should represent either the first approach to therapeutic cannulation or rescue therapy after unsuccessful standard cannulation.

A pilot study of the novel offset-tip papillotome for selective biliary cannulation in ERCP

Introduction:We developed a new offset-tip papillotome to facilitate biliary cannulation and reduce the incidence of unintended contrast injection into the pancreatic duct during ERCP. The aim of the present retrospective cohort study was to evaluate the utility of the novel offset-tip papillotome in achievement of biliary cannulation, and prevention of unintended contrast injection into the pancreatic duct during ERCP, compared with a standard straight-tip catheter. Material and methods:Patients with native papilla who required biliary ERCP were retrospectively reviewed. Biliary ERCPs were performed by two experienced endoscopists using either the offset-tip papillotome or a standard catheter. Patients in whom ERCP involved fellows in training were excluded. Results:Eighty-five patients were included and divided into two cohorts: The offset-tip papillotome (OT; n = 40) and the standard straight-tip cohort (ST; n = 45). Biliary cannulation success rates in OT and ST cohort were 92.5% and 88.9%, respectively. The frequency of unintended contrast injection into the pancreatic duct and time to biliary cannulation of the OT cohort during biliary cannulation were significantly less than those of the ST cohort (0.56 vs. 1.65 times and 103.3 vs. 287.9 seconds). Conclusion:The novel offset-tip papillotome could reduce the incidence of unintended contrast injection into the pancreatic duct and the time to biliary cannulation.

Guidewire biliary cannulation does not reduce post-ERCP pancreatitis compared with the contrast injection technique in low-risk and high-risk patients

Guidewire (GW) cannulation can reduce the risk of post-ERCP pancreatitis (PEP) by avoiding the opacification of the main pancreatic duct. To compare the effects of conventional contrast ERCP and GW cannulation of the common bile duct on the rate of PEP in low- and high-risk patients. Prospective, comparative-intervention single-center study. Tertiary referral center. Patients with biliary disease with an intact papilla were prospectively examined by ERCP. Biliary cannulation using a sphincterotome with contrast injection (ConI) or a hydrophilic GW without contrast injection. Pancreatitis rate in the GW group and the contrast injection (ConI) group. PEP occurred in 60 of 1249 patients (4.8%), 35 of 678 (5.2%) in the GW group and 25 of 571 (4.4%) in the ConI group (not significant). The overall rate of PEP was significantly higher in high-risk patients (12.2%) than in low-risk patients (3.5%) (P < .001), but was similar for the 2 techniques within each of these 2 groups. In patients with unintended main pancreatic duct (MPD) cannulation or opacification, the rate of PEP was not significantly different with the GW (15.2%) and ConI (8.4%) techniques but was associated with a significantly higher rate of pancreatitis (11.9%) than in patients in whom the contrast medium or GW did not enter the MPD (3.5%) (P < .001). Multivariate analysis indicated that more than 10 papillary cannulation attempts, MPD cannulation or opacification, suspected sphincter of Oddi dysfunction, and precut methods were significant risk factors independently associated with PEP. Lack of randomization. For selective cannulation of the CBD, the risk of inducing PEP is similar with the ConI and GW techniques in high-risk and low-risk patients. Any manipulation of the MPD must be considered a high-risk factor for PEP, such as multiple attempts on the papilla or use of the precut method.

347f: A Sequential ERCP Cannulation Protocol Including Early Pancreatic Stent Placement and Needle Knife Sphincterotomy: Final Analysis of a Randomized Trial

Competent biliary endoscopists fail selective biliary cannulation in 5-10% of cases. Needle knife sphincterotomy (NKS) can augment cannulation success, but is often used as a last resort and this may be responsible for the association with post ERCP pancreatitis (PEP). Prospective early NKS studies in difficult cannulation are few and inconclusive. Limited data exists on early pancreatic stent placement

ERCP cannulation and sphincterotomy devices

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic, and a MAUDE (Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the governing board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review the MEDLINE database was searched through February 2009 for articles related to cannulation and sphincterotomy devices by using the keywords ERCP, standard catheter, sphincterotome, cannulation, sphincterotomy, precut, major papilla, minor papilla, needle-knife, complication, pancreatitis, biliary, and pancreatic in different search term combinations. Technology Status Evaluation Reports are scientific reviews provided solely, for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, ordiscouraginganyparticulartreatmentorpayment for such treatment.

Does Anesthesiologist-Directed Sedation for ERCP Improve Deep Cannulation and Complication Rates?

Purpose: While some gastroenterologists provide their own sedation for ERCP, others utilize anesthesiologists. There is limited information comparing cannulation success and complication rates between these two approaches. Theoretically, anesthesiologist directed sedation may lead to an improved cannulation rate by virtue of using deeper and more constant levels of sedation and by removing the minute-by-minute medication management and physiologic monitoring responsibilities from the endoscopy team. The goal of our study was to compare ERCP cannulation success and complications between gastroenterologist directed sedation (GDS) and anesthesiologist directed sedation (ADS). Methods: All ERCPs completed by senior advanced endoscopists at a tertiary referral center over a two year period were reviewed. During the first year, all ERCP sedation was performed with GDS utilizing a narcotic and benzodiazepine. Due to a change in division policy and practice, during the second year, all ERCP sedation was provided by ADS. Patients with prior papillary interventions (papillotomy, stent placement, etc.) were excluded. Demographics, procedure indications, cannulation success, use of pre-cut papillotomy, sedation provider, and procedural complications (pancreatitis, cholangitis, hemorrhage, perforation, and death) were recorded. Pearson's chi-square and Fisher's Exact tests were used to compare the groups. Results: A total of 373 patients were studied; 183 (49.1%) GDS, 190 (50.9%) ADS. 179 (48.0%) patients were male. Mean patient age was 59.1 yr. The results are summarized in Table 1. Seven patients (3.8%) in the GDS category could not be sedated. There were two deaths, one in each group; one death was due to cholangitis/sepsis, the other was due to post-ERCP pancreatitis. Overall cannulation success rates were similar between the two groups; however, the GDS group required more pre-cut papillotomies to achieve cannulation. This did not lead to a difference in complication rates.Table 1Conclusion: Ductal cannulation rates between GDS and ADS are similar. GDS was associated with a higher rate of pre-cut papillotomy. However, this was not associated with an increase in post procedure complications.

Failed Cannulation After Initial ERCP: Benefit of a Tertiary Referral ERCP Service

Background: Competent biliary endoscopists fail selective biliary cannulation between 5 and 10% of cases and unsuccessful cannulation is reported in up to 20% of published series. Published data confirms that patients with previously failed cannulation at ERCP are often referred for alternative therapeutic techniques with inferior safety and accuracy profiles. Prospective data on outcomes after referral to a tertiary high volume ERCP center with greater experience is absent, however if this clinical pathway was confirmed as viable and effective then substantial cost savings and improved clinical outcomes might be anticipated. Methods: Prospective recruitment of patients with previously failed ERCP cannulation referred by other specialist biliary endoscopists. Prospective data collection included initial procedural indication, reason (if any) for failed cannulation, along with detailed cannulation parameters at the tertiary center. This group was compared to all other ERCP procedures performed at the same institution during the same period. 24 hour and 30 day follow up was obtained in all patients. Results In the 24 months to November 2008, a total of 1676 ERCP procedures were performed. 35 patients (20 female, mean age 68(range 40-88)) were referred after previous failed ERCP cannulation. Indications were biliary stones(16), pancreatic malignancy(6), biliary strictures(5), bile leak(2) and cholangitis(2). Successful cannulation was achieved in 100% of cases, 10(29%) requiring needle knife sphincterotomy (NKS). Identifiable reasons for initial failed cannulation included long intraduodenal papilla(5), peripapillary diverticulum(5), difficult/unstable duodenal position(4) and small papilla(4). There was one episode of mild post ERCP pancreatitis. There were no deaths or perforations. In the non-tertiary referral procedural group (1676) the cannulation rate for naïve papilla (651) was 97.8% with a NKS rate of 12.9%. Conclusions: Referral to a high volume centre following an initial unsuccessful ERCP procedure is associated with high technical success and a favorable complication rate compared to routine ERCP procedures. This data suggests that this type of clinical pathway should be developed as a part of an ERCP treatment algorithm. Tabled 1 Number Cannulation success NKS rate Post ERCP pancreatitis Other ERCP complications Non tertiary referral naïve papilla procedures 651 97.8% 12.9% 6.3% Perforation 0.15% Bleeding 0.6% Tertiary referral ERCP procedures 35 100% 29% 2.9% 0% p value 0.15 0.01 0.71 Open table in a new tab

ERCP Cannulation May Come Down to the Wire

Ability to achieve duct access is a prerequisite since ERCP is now mostly performed with therapeutic intent. ERCP outcomes are linked to the success and safety of cannulation. Evaluation of an ERCP technique is complex because of integrally related factors including device properties, variable methods, patient characteristics, and endoscopist preferences and expertise. Remarkably, there has been little progress regarding primary cannulation techniques since the first contrast injection nearly 40 years ago. ERCP guidewires were initially designed and utilized in order to maintain ductal access during therapeutic maneuvers. Guidewires are now increasingly being used to achieve duct cannulation despite a paucity of data to support this practice. Are we heading in the right direction, or is wire-guided cannulation a misguided adventure?

Double Guide Wire Technique Compared to Conventional Method in Selected Cases of Difficult Common Bile Duct Cannulation in ERCP. Preliminary Data from a Controlled Randomized Study

Double Guide Wire Technique Compared to Conventional Method in Selected Cases of Difficult Common Bile Duct Cannulation in ERCP. Preliminary Data from a Controlled Randomized Study

A prospective, randomized, placebo-controlled trial of transdermal glyceryl trinitrate in ERCP: effects on technical success and post-ERCP pancreatitis

Despite the recent improvement in techniques and patient selection, post-ERCP pancreatitis remains the most frequent and dreaded complication of ERCP. Recent studies suggest that pretreatment with glyceryl trinitrate (GTN) may prevent post-ERCP pancreatitis and improve cannulation success. To evaluate the effect of transdermal GTN on ERCP cannulation success and post-ERCP pancreatitis. Prospective, double-blind, placebo-controlled trial. Tertiary referral university hospital. A total of 318 patients (mean age 62 years, 61% women) were randomized to either active (n = 155) or placebo (n = 163) arms. Active patch (GTN) versus placebo patch. Cannulation time and success. Post-ERCP pancreatitis rates. There was no significant difference between the active or placebo arms for the following: successful initial cannulation (96.8% vs 98.8%), deep cannulation (96.1% vs 98.8%), time to successful cannulation, use of guidewire (27% vs 25%) or needle knife (13% vs 13%), and post-ERCP pancreatitis (7.4% of placebo patients and 7.7% active patients). Multivariate analysis identified women, younger patients, pancreatogram, number of attempts on papilla, and poor pancreatic-duct emptying after opacification as risk factors for post-ERCP pancreatitis. Transdermal GTN did not reduce post-ERCP pancreatitis in any of the identified high-risk groups. Transdermal GTN did not improve the rate of success in ERCP cannulation or prevent post-ERCP pancreatitis in either average or high-risk patient groups.

Operator Controlled Guidewire Cannulation of the Bile Duct during ERCP Is Safe

Purpose: ERCP cannulation is traditionally accomplished using a catheter with contrast injection. Guidewire cannulation was thought to be associated with increased ERCP complications. There are limited data regarding success and safety of primary guidewire cannulation. New short-wire devices now allow operator control of the guidewire. The purpose of this study was to evaluate success and complications of operator controlled guidewire cannulation (GWC) of the bile duct during ERCP. Methods: ERCPs during which operator controlled GWC of the bile duct was attempted were included. Patients with prior sphincterotomy and procedures where only pancreatic cannulation was intended were excluded. Prospectively collected data included: ERCP indication, desired duct(s) for GWC, order of GWC, cannulation success, frequency of access papillotomy (precut), and incidence of post-ERCP pancreatitis. Results: 168 of 399 patients that had ERCP during 1 yr were studied. 105 patients were low-risk and 63 were high-risk patients (unexplained pain or pancreatitis). Successful GWC of the bile duct without unintentional pancreatic GWC or contrast injection was accomplished in 56/101 (55%) cases. GWC of both ducts was intended in the other 67 patients. Of these, bile duct cannulation was achieved first in 58% of low-risk patients. In contrast, the pancreatic duct was cannulated before the bile duct in 77% of high-risk patients. Overall, 42 of 168 (25%) underwent a needle-knife precut to achieve deep biliary access after attempted GWC. Cannulation success and precut requirements according to patient risk are tabulated. Five (2 mild and 3 moderate severity) of 399 patients developed post-ERCP pancreatitis of which only 1 (mild) occurred after operator controlled GWC. One retroperitoneal perforation occurred after GWC and a pancreatic sphincterotomy. Conclusions: These data suggest that operator controlled GWC of the bile duct is safe and effective in both low and high-risk patients. A significant minority of patients undergo precut papillotomy after attempted GWC of the bile duct. Efforts to establish pancreatic access early when GWC attempts are either difficult and/or in high-risk patients may explain a higher incidence of precut papillotomy.Table: Low-Risk PatientsTable: High-Risk Patients