A study assessing advanced techniques for difficult biliary cannulation shows they are similarly effective, challenging the notion of a superior method in ERCP.

• Initial cannulation success rates were 72% for double-guidewire, 68% for transpancreatic sphincterotomy, and 68% for precut fistulotomy (p = .882); all techniques achieved 100% final success.
• Median cannulation times were comparable, with 21 minutes for double-guidewire, 17.5 minutes for transpancreatic sphincterotomy, and 18 minutes for precut (p = .145).
• A key finding: precut fistulotomy required significantly less contrast dye (p < .005).

Selection of the salvage technique should be tailored to individual patient anatomy and clinician expertise.