Performance of different approaches to difficult biliary cannulation in endoscopic retrograde cholangiopancreatography: A systematic review and network meta-analysis

Background: It is unclear which is the best strategy for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP). Aims: We compared the different techniques, through a network meta-analysis combining direct and indirect comparisons. Methods: We identified 12 randomized controlled trials (1605 patients) comparing different techniques for difficult biliary cannulation (early and late needle knife techniques, pancreatic guidewire- and stentassisted techniques, transpancreatic sphincterotomy, and endoscopic ultrasound rendez-vous [EUS-RV]) either with each other or with persistence with the standard cannulation techniques. The success rate of biliary cannulation and the incidence of post-ERCP pancreatitis (PEP) were the primary outcomes. Results: Only transpancreatic sphincterotomy significantly outperformed pancreatic stent assisted cannulation (risk ratio [RR] 1.33, 1.00-1.55), whereas no difference was observed among the other techniques in terms of cannulation success. SUCRA ranking suggested EUS-RV and early needle knife techniques as the best performing approaches (SUCRA 0.78 and 0.68, respectively). In terms of PEP rate, only EUS-RV significantly outperformed pancreatic guidewire-assisted techniques (RR 0.21, 0.04-0.98). Conclusions: Based on low quality of evidence, the several techniques for difficult biliary cannulation show similar results although a trend in favour of needle knife techniques and EUS-RV was observed. EUS-RV seems to decrease the risk of PEP. (c) 2025 The Author(s). Published by Elsevier Ltd on behalf of Editrice Gastroenterologica Italiana S.r.l. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )