Biliary cannulation is a fundamental technique in endoscopic retrograde cholangiopancreatography (ERCP) and is essential for all therapeutic and diagnostic procedures associated with ERCP. ERCP-related procedures have made remarkable progress over more than 50 years since their development, benefiting from innovations in techniques and device development 1, 2. However, failure to achieve biliary cannulation renders further procedures impossible. Prolonged biliary cannulation time is a high-risk factor for post-ERCP pancreatitis (PEP) and may adversely affect patient prognosis 3. Therefore, mastering biliary cannulation is the primary objective for endoscopists performing ERCP; however, it remains a significant challenge, and achieving a success rate exceeding 95% remains unresolved. With increasing experience, most endoscopists can eventually succeed in biliary cannulation. However, endoscopists who perform biliary cannulation without establishing a strategy and without evidence will never be able to overcome difficult cases. Cannulation of a native or intact papilla fails in approximately 5%–11% of cases, even in experienced hands 4, 5. One of the main reasons for this challenge is the lack of a standardized technique and uniform teaching methods for biliary cannulation. Cannulation techniques include contrast-assisted, guidewire-assisted, and hybrid approaches. When initial attempts fail, multiple rescue techniques such as the double-guidewire (DGW) technique or precut sphincterotomy can be employed. Preferences for these techniques vary among both trainees and trainers, resulting in a biased and heterogeneous transfer of skills. This variability makes the creation of comprehensive, universally accepted guidelines difficult, and such guidelines remain insufficient. In latest digestive endoscopy, new guidelines led by the World Endoscopy Organization (WEO), involving expert panels from Asia, Europe, and the United States, have been published 6. The most distinctive feature of this guideline is their aim to provide globally applicable clinical recommendations, regardless of available resources or expertise. The guideline developers paid particular attention to integrating all available techniques for biliary cannulation, making it a clinically practical and useful resource worldwide. The document is structured around four major themes: prevention of PEP, biliary cannulation techniques, endoscopic sphincterotomy and balloon dilation, and cannulation in special situations. Fourteen clinical questions (CQs) were formulated, each accompanied by a statement and supporting evidence. Although the explanations are concise, they incorporate extensive evidence, providing valuable insights into the current evidence-based status of biliary cannulation. One of the most appealing features of these guidelines is the comprehensive summary of meta-analyses of randomized controlled trials (RCTs) presented as Supplementary Tables in Crinò et al. 6. These tables alone are highly educational and essential reading. Moreover, the guidelines report the proportion of “strongly agree” and “agree” responses among WEO Research Committee members, illustrating the degree of consensus. Notably, some statements have over 90% “strongly agree,” while others are as low as 20%, reflecting the inherent variability and diversity in biliary cannulation techniques. Overall, the statements are clinically acceptable and provide evidence to support many real-world techniques that have traditionally been performed based on experience rather than data. These techniques are highly specialized and not universally available. As evidence accumulates through future RCTs, the importance of timely referral to high-volume centers for these complex procedures will likely increase. Currently, there are numerous excellent educational resources available concerning ERCP, including textbooks, demonstrations, and hands-on workshops. However, the optimal integration of these educational tools remains underexplored. Generating evidence on structured and effective teaching strategies is an important responsibility for our field. The fundamental principles of biliary cannulation are clear. The process begins with thorough preparation to maximize success before scope insertion, followed by gentle scope insertion. Upon reaching the papilla after scope stretching, it is essential to secure an optimal frontal view of the papilla and carefully observe both the papilla and the oral protrusion to visualize the invisible confluence of the bile and pancreatic ducts. Furthermore, the endoscopist must assess the scope's shape and, in accordance with guideline statements, approach the papilla gently. As the guideline authors emphasize, the recommendations must be interpreted in the context of each individual patient, and not all statements are universally applicable. Above all, gentle and careful manipulation is paramount. Although it may not be feasible to evaluate the importance of gentle handling through an RCT for ethical reasons, its clinical importance is beyond question. Mamoru Takenaka: drafting the manuscript. Masatoshi Kudo: critical revision of the manuscript for important intellectual content. The authors have nothing to report. The authors declare no conflicts of interest. This article is linked to Crinò et al. papers. To view this article, visit https://doi.org/10.1111/den.15060.
Takenaka et al. (2026) studied this question.