Double guide-wire technique versus transpancreatic biliary sphincterotomy for difficult biliary cannulation: Real life experience from a referral center

Background: During ERCP for biliary indication, when a difficult bile duct (BD) cannulation occurs, with unintended access to the main pancreatic duct (PD), both double guidewire technique (DGW) and transpancreatic biliary sphincterotomy (TPBS) can be performed. We aimed to compare the technical success and adverse events (AEs) rate of these techniques. Methods: A retrospective analysis of patients with naïve papillae referred to the Pancreas Institute of Verona from January 2016 and July 2021 to undergo ERCP for biliary indications was performed. Results: Overall, 202 patients (53.5% males, mean age 67.2 years) were evaluated (96 DGW, 106 TPBS). Malignant biliary stricture was the most common ERCP indication (78.2%). The rate of success in deep biliary cannulation was significantly higher in the DGW group (94.8%) compared to TPBS (79.2%) at the first attempt (p = 0.001). This result was also confirmed in the subgroup of patients with malignant distal stricture (72/77, 93.5% vs 63/80, 78.8%, p = 0.01). No significant difference in AEs rate, particularly in PEP incidence was found between the two groups. Conclusions: DGW demonstrated a higher success rate and similar safety profile compared with TPBS in difficult biliary cannulation. Based on this retrospective study, DGW should be preferred over TPBS in case of unintended PD cannulation. Further prospective studies are needed to confirm our results.