Needle-knife precut over a pancreatic stent

This patient who was referred for ERCP had a modest-sized papilla and small ducts. After deep wire passage into the pancreatic duct occurred, the double wire cannulation technique was attempted briefly but was not successful. Therefore, a pancreatic duct stent was placed, and needle-knife incision was started just over the stent, aiming cephalad in short pulses up the middle of the papilla (A) until the bile duct was exposed and cannulated (B). The sphincterotomy was extended with a papillotome (C). The pancreatic stent remained in place at the conclusion of the procedure because immediate removal has been associated with a higher risk of post-ERCP pancreatitis.