Video-Based Analysis of Risk Factors for Post-ERCP Pancreatitis in Pancreatic Guidewire-Assisted Biliary Cannulation

The pancreatic guidewire (PGW) technique is widely used as a salvage method for difficult biliary cannulation; however, risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in PGW cases remain unclear. Specifically, the role of detailed intraprocedural and morphological factors remains underexplored.

To identify risk factors for PEP in PGW-assisted biliary cannulation using a retrospective video-based analysis.

We retrospectively reviewed patients who underwent ERCP with PGW-assisted biliary cannulation for naïve papillae at our institution between August 2017 and January 2023. Previously recorded endoscopic and fluoroscopic videos were analyzed to extract papillary morphology and intraprocedural variables. Multivariable logistic regression was used to identify factors associated with PEP.

The PGW technique was used in 215 of 862 ERCP procedures for naïve papillae; 178 cases with available video recordings were included in the analysis. The cannulation success rate was 96.1%, and PEP occurred in 20 patients (11.2%). In multivariable analysis, cannulation time ≥ 20 min (odds ratio [OR] 3.53, 95% confidence interval [CI] 1.14-11.0) and short oral protrusion of the papilla (< 10 mm vs. ≥ 10 mm; OR 3.01, 95% CI 1.11-8.15) were independently associated with PEP. Guidewire insertion into a pancreatic side branch tended to increase PEP risk (OR 2.48, 95% CI 0.89-6.93).

In PGW-assisted biliary cannulation, prolonged cannulation time, a short oral protrusion, and pancreatic side-branch guidewire insertion are important risk factors for PEP. These findings may help refine risk stratification and inform technical decision-making and prophylactic strategies in cases of difficult biliary cannulation.