Early precut is useful for difficult bile duct cannulation, particularly in cases with long oral protrusion

doi:10.4253/wjge.v17.i9.108420

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World Journal of Gastrointestinal Endoscopy

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Retrospective Cohort Study

World J Gastrointest Endosc. Sep 16, 2025; 17(9): 108420
Published online Sep 16, 2025. doi: 10.4253/wjge.v17.i9.108420

Early precut is useful for difficult bile duct cannulation, particularly in cases with long oral protrusion

Toru Kaneko, Mitsuhiro Kida, Takahiro Kurosu, Gen Kitahara, Tomohiro Betto, Yutaro Saito, Shiori Koyama, Nao Nomura, Chika Kusano

Toru Kaneko, Mitsuhiro Kida, Takahiro Kurosu, Gen Kitahara, Tomohiro Betto, Yutaro Saito, Shiori Koyama, Nao Nomura, Department of Gastroenterology, Kitasato University Medical Center, Kitamoto 364-8501, Saitama, Japan

Toru Kaneko, Mitsuhiro Kida, Takahiro Kurosu, Gen Kitahara, Tomohiro Betto, Yutaro Saito, Shiori Koyama, Nao Nomura, Chika Kusano, Department of Gastroenterology, Kitasato University Hospital, Sagamihara 252-0375, Kanagawa, Japan

Author contributions: Kaneko T conducts conceptual research, data collation, formal analysis, investigation, is responsible for method and project management, validation, visualization, and writes the original draft; Kurosu T, Kitahara G, Betto T, Saito Y, Koyama S, and Nomura N were responsible for the resources; Kida M and Kusano C supervised the study; Kaneko T, Kida M, Kurosu T, Kitahara G, Betto T, Saito Y, Koyama S, Nomura N, and Kusano C have contributed to writing, commenting and editing; and all authors have read and approved the final manuscript.

Institutional review board statement: This study was approved by the Medical Ethics Committee of Kitasato University Medical Center, approval No. 2024005.

Informed consent statement: This retrospective study was conducted using an opt-out approach in accordance with institutional and ethical guidelines. Details of the study and publication were disclosed in advance on our institution’s website, and participants were given the opportunity to refuse inclusion. Since no objections were raised, consent for publication was considered to have been obtained.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: The datasets used and/or analyzed during this study are available from the corresponding author on reasonable request.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Toru Kaneko, MD, PhD, Department of Gastroenterology, Kitasato University Medical Center, 1-1-15 Kitasato, Minami, Kitamoto 364-8501, Saitama, Japan. t.kaneko@kitasato-u.ac.jp

Received: April 22, 2025
Revised: May 22, 2025
Accepted: August 21, 2025
Published online: September 16, 2025
Processing time: 143 Days and 23.3 Hours

Abstract

BACKGROUND

Endoscopic retrograde cholangiopancreatography involves selective bile duct cannulation, which is often challenging and associated with complications. In difficult cannulation cases, early precutting is frequently used. However, its efficacy and optimal indications require further evaluation.

AIM

To evaluate the efficacy and safety of early precut (EP) in difficult bile duct cannulation.

METHODS

This retrospective analysis of endoscopic retrograde cholangiopancreatography procedures was performed for bile duct cannulation in patients with naive papillae who required advanced cannulation techniques (ACTs). These patients were admitted between April 2020 and March 2024 and were analyzed for risk factors, success rates, and complications. Outcomes were compared between the EP group and the conventional other ACTs group, with a focus on cases with oral protrusion large (oral protrusion-L).

RESULTS

The need for ACTs was identified as an independent risk factor for complications [odds ratio (OR) = 5.4; 95% confidence interval: 1.887-15.53]. Malignant biliary strictures (OR = 2.58) and oral protrusion-L (OR = 2.77) were also identified as independent risk factors for requiring ACTs. The EP group had a significantly higher second-line cannulation success rate (97.9% vs 73.2%, P = 0.001) and lower complication rate (8.3% vs 39.0%, P = 0.001) than the other ACTs group. Additionally, similar benefits were observed in the oral protrusion-L cases.

CONCLUSION

This study provides compelling evidence that EP is a viable alternative and a superior strategy in cases requiring ACTs, particularly oral protrusion-L.

Keywords: Endoscopic retrograde cholangiopancreatography; Biliary cannulation; Precut sphincterotomy; Early precut; Post-endoscopic retrograde cholangiopancreatography pancreatitis; Needle knife fistulotomy; Oral protrusion

Core Tip: Early precut (EP) is a safe and effective alternative to conventional advanced cannulation techniques for difficult bile duct cannulation. This retrospective study demonstrates that EP significantly increases second-line cannulation success rates, shortens procedure time, and reduces complications, particularly in cases with prominent oral protrusion. These findings support EP as a first-line advanced cannulation technique after standard cannulation techniques fail in selected high-risk cases. This advocates for a strategic shift in endoscopic retrograde cholangiopancreatography practice.