Number, depth, and location of inadvertent pancreatic guidewire cannulations and post-ERCP pancreatitis from multi-center real-time intra-procedural data

Background & Aims Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is common. Though multiple pancreatic duct (PD) cannulations are a known risk factor for PEP, the impact of single cannulations remains controversial. We aimed to identify whether single PD cannulation is associated with PEP. Methods We examined a prospective multi-center cohort of patients undergoing ERCP for biliary indications between 2021-2024, with third-party intra-procedural data recording and 30-day follow-up. PEP was defined using consensus definitions. Associations between PD cannulations and PEP were evaluated with multivariable logistic regression, with other patient- and procedure-related risk factors and preventive interventions used as covariates. Results were reported as odds ratios (ORs). Results PEP occurred in 282 (3.8%) of 7,430 ERCPs across nine centers. From multivariable analysis, PD cannulation was statistically significantly associated with PEP, with similar odds for single and multiple cannulations in first-time patients (OR=2.03, 95%CI [1.32-3.14] for single, OR=2.18 95%CI [1.18-4.00] for 5 or more cannulations). This was also true for all-comers (OR=1.97, 95%CI [1.33-2.93] for single, OR=2.15, 95%CI [1.21-3.82] for 5 or more). PD cannulation to the head (OR=2.09, 95%CI [1.36-3.21]) and body (OR=2.42, 95%CI [1.56-3.79]) were both associated with PEP, while side branch cannulations alone were not (OR=1.18, 95%CI [0.64-2.06]). Conclusions Single main PD duct canulation is independently associated with PEP and appears to be responsible for most of the magnitude of the association with PD cannulation. These data lend additional support to the use of preventative interventions such as PD stenting in cases where the PD is inadvertently cannulated.

Publication History

Received: 27 January 2025

Accepted after revision: 03 August 2025

Accepted Manuscript online:
04 August 2025