Abstract

Precut sphincterotomy is traditionally reserved as a rescue technique following failed biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). However, repeated unsuccessful attempts increase the risk of post-ERCP pancreatitis (PEP). This study evaluated whether initiating ERCP with primary precut in anatomically challenging papillae reduces the incidence of PEP compared with rescue precut and conventional cannulation. We retrospectively analyzed 147 patients who underwent ERCP between January 2018 and February 2025 at a tertiary surgical endoscopy center. Patients were stratified into three groups: Group 1 (Primary Precutting, n=51), patients with difficult papillae (edematous, long/mobile, or tumor-infiltrated) in whom ERCP was initiated with direct precut; Group 2 (Standard Cannulation, n=49), patients with normal papillae successfully cannulated using a wire-guided technique; and Group 3 (Rescue Precutting, n=47), patients with difficult papillae who underwent precut after failed standard attempts. Demographic features, procedural outcomes, and complications were compared. The incidence of PEP was significantly higher in Group 3 (25.53%) than in Group 1 (7.85%) and Group 2 (8.16%) (p=0.015). No difference was observed between Groups 1 and 2. Post-ERCP serum amylase levels were also highest in Group 3 (388 ± 81.26 U/L) compared with Groups 1 (149.04 ± 43.61 U/L) and 2 (135 ± 22.84 U/L) (p=0.001). Cannulation success was comparable among groups (92.15%, 93.87%, and 89.36%, respectively; p=0.718). Bleeding rates were low and similar across groups (p=0.608), and no perforations occurred. In anatomically difficult papillae, direct precut should be considered the preferred initial strategy in experienced centers, as it achieves comparable safety to standard cannulation while markedly lowering the risk of PEP relative to delayed (rescue) precut.

Key words: Precut sphincterotomy, difficult cannulation, endoscopic retrograde cholangiopancreatography, post-ERCP pancreatitis, biliary access