Clip Combined with Rubber Band Versus Clip-Assisted ERCP for Difficult Biliary Cannulation in Periampullary Diverticulum: A Propensity Score-Matched Analysis

Background: Successful biliary cannulation is critical to the success of ERCP. While various devices and auxiliary techniques have been developed to manage difficult cannulation in patients with periampullary diverticulum (PAD), however, comparative studies on different traction methods remain understudied. This study aims to compare the safety and efficacy of clip-assisted ERCP (C-ERCP) versus clip combined with rubber band-assisted ERCP (CRB-ERCP) for difficult biliary cannulation in patients with PAD. Methods: This study was a single-center retrospective analysis including 193 patients with difficult biliary cannulation and concomitant PAD. Using propensity score matching based on age, gender, and diverticulum type, 120 patients (60 per group) were selected for comparison. The primary outcomes assessed were cannulation success rate, procedure time and incidence of procedure-related complications. Results: The cannulation success rate was significantly higher in the CRB-ERCP group than in the C-ERCP group (96.7% vs. 73.3%, p <0.001). The cannulation time was also markedly shorter in the CRB-ERCP group (52±47 vs. 106±73 seconds, p <0.001). To achieve successful cannulation, the C-ERCP group required additional techniques-such as the double-guidewire method or transpancreatic biliary sphincterotomy-more frequently than the CRB-ERCP group (38.3% vs. 13.3%, p =0.003). The overall incidence of adverse events was comparable between the two groups ( p= 0.632), all of which resolved with conservative management. No serious adverse events occurred in either group. Conclusion: Both CRB-ERCP and C-ERCP are viable options for difficult biliary cannulation in PAD. However, CRB-ERCP shows superior advantages in shortening cannulation time, improving success rates,and reducing the need for additional rescue techniques, making it a safe, feasible, and highly effective approach.