Background and aims: Precut papillotomy is widely used after failed biliary cannulation. Endoscopic ultrasound (EUS)-guided biliary access techniques are newer methods to facilitate access and therapy in failed cannulation. We evaluated the impact of EUS-guided biliary access on endoscopic retrograde cholangiopancreatography (ERCP) success and compared these techniques to precut papillotomy. Patients and methods: We retrospectively compared two ERCP cohorts. One cohort consisted of biliary ERCPs (n =1053) attempted in patients with native papillae and surgically unaltered anatomy in whom precut papillotomy and/or EUS-guided biliary access were routinely performed immediately after failed cannulation. This cohort was compared with a similar ERCP cohort (n =1062) in which only precut papillotomy was available for failed cannulation. The following outcomes were compared: conventional cannulation success, rates of attempted advanced access techniques (precut or EUS), precut success, EUS-guided biliary access success, and ERCP failure rates. Results: Although conventional cannulation success, rates of attempted advanced access technique (precut or EUS), and precut success were similar, the ERCP failure rate was lower when both EUS-guided biliary access and precut were available (1.0 % [95% confidence interval (CI) 0.4-1.6]), compared with when only precut was possible for failed access (3.6% [95%CI 2.5-4.7]; P < 0.001). Success for EUS-guided biliary access (95.1 % [95 %CI 89.7-100]) was significantly higher than for precut (75.3% [95 %CI 68.2-82.4]; P <0.001), and mainly due to superiority in malignant obstruction (93.5 % vs. 64%; P < 0.001). Conclusions: EUS-guided biliary access decreases the rate of therapeutic biliary ERCP failure. Our results support the use of EUSguided biliary access to optimize single-session ERCP success. In experienced hands, these techniques appear as effective, if not more so, than precut papillotomy.
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