Single versus multiple main or side-branch pancreatic duct cannulations: impact on post-ERCP pancreatitis

10.1055/a-2675-4322

We read with interest the study by Gupta et al. [1], a large multicenter prospective cohort study evaluating inadvertent pancreatic duct (PD) cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). This study deserves recognition for its scale, design, and systematic outcome assessment. Although it reinforces the established risk factors and preventive strategies, several interpretive issues must be considered before translation into routine practice.

The risk of PEP is additive, with each high-risk maneuver increasing the overall likelihood of pancreatitis. However, the similar odds of PEP after single vs. multiple PD cannulations warrants cautious interpretation. More PD cannulations indicate longer procedure times and increased papilla manipulation, which increases the risk of PEP. Various studies and meta-analyses have shown that PEP odds increase with PD cannulation frequency [2]. Additionally, use of rectal nonsteroidal anti-inflammatory drugs, prophylactic stenting, and periprocedural fluids were left to the operator’s discretion. This presents a potential confounding factor, as clinicians may have chosen aggressive prevention in high-risk cases, including after multiple PD cannulations. The absence of an association between side-branch cannulation and PEP may reflect low event numbers rather than the true absence of risk. Given that side-branch entry often follows main-duct instrumentation [3], its potential injury contribution cannot be ruled out.

Furthermore, among native papilla, more than five attempts at common bile duct cannulation (28.0%) and use of the double-guidewire technique (14.5%) as a rescue strategy were linked to higher PEP risk. These risks could have been minimized through early adoption of the precut technique [4].

The authors recommend prophylactic PD stenting even after a single inadvertent PD entry once access is achieved. While appealing, this represents a shift from the current guidelines, which suggest stenting only for multiple or deep PD cannulations and specific high-risk groups [5]. Widespread stenting for all single PD passes could affect the procedure duration, technical difficulty, cost, and stent-related complications.

Publikationsverlauf

Artikel online veröffentlicht:
27. November 2025

• References

• 1 Gupta M, Chau M, Howarth M. et al. Number, depth, and location of inadvertent pancreatic guidewire cannulations and post-ERCP pancreatitis from multicenter real-time intra-procedural data. Endoscopy 2025;
• 2 Nakai Y, Isayama H, Sasahira N. et al. Risk factors for post-ERCP pancreatitis in wire-guided cannulation for therapeutic biliary ERCP. Gastrointest Endosc 2015; 81: 119-126
• 3 Goenka MK, Akshintala VS, Kamal A. et al. Frequent guidewire passage into the pancreatic duct is an independent risk factor for postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) among high-risk individuals: a post-hoc analysis of a randomized controlled trial data. J Dig Dis 2023; 24: 427-433
• 4 Maharshi S, Sharma SS. Early precut versus primary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos). Gastrointest Endosc 2021; 93: 586-593
• 5 Buxbaum JL, Freeman M, Amateau SK. et al. American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc 2023; 97: 153-162