SOCCER Trial: Forceps Boost Cannulation Success in Difficult ERCP- AJG Feb.26

Introduction

Difficult biliary cannulation remains one of the most common and consequential problems in ERCP. Failed cannulation drives repeat procedures, percutaneous or surgical rescue, higher costs, longer hospital stay—and it also increases post-ERCP pancreatitis (PEP) risk because repeated attempts and unintended pancreatic duct (PD) wire passes are key triggers.

Forceps-assisted cannulation has been used as a “trick” in challenging papillae (periampullary diverticulum, redundant folds, awkward papilla orientation), but until now it lacked randomized controlled trial evidence.

The SOCCER trial tests a simple question:

Does forceps-assisted cannulation improve success when cannulation is difficult?

Problem statement

When cannulation becomes difficult, endoscopists typically escalate to:

double-wire techniques,

precut/needle-knife access,

PD stenting strategies, etc.

These can be effective but may increase complexity and sometimes risk. A low-cost mechanical approach—using forceps to expose and stabilize the papilla—could reduce failure and potentially reduce repeated traumatic attempts. But its true efficacy needed an RCT.

What the trial did:

Randomized adults with difficult cannulation scenarios during ERCP to:

forceps-assisted cannulation, or

standard cannulation without forceps

“Difficult” included:

papilla in/on a diverticulum,

redundant tissue overlying the papilla,

challenging papilla morphology (type 2–4),

or difficult cannulation defined by attempts/time/unintended PD wire passages.

Primary outcome: successful cannulation

Secondary: difficult cannulation metrics after randomisation and PEP

Key results clinicians should remember

1) Cannulation success improved substantially with forceps

Forceps assistance achieved near-universal cannulation success in this difficult subset, while standard cannulation had a meaningful failure rate.

2) Crossover to forceps rescued failures

All patients who failed initial standard cannulation and then crossed over to forceps were successfully cannulated—suggesting forceps is a reliable rescue option.

3) Forceps reduced the “trauma load” of cannulation

Even when overall difficult-cannulation rates didn’t reach statistical significance, the forceps approach resulted in fewer cannulation attempts, which is clinically important because attempts correlate with PEP risk.

4) PEP rates were low and similar in both groups

This suggests the technique improves access without adding measurable pancreatitis risk in this trial setting.

Clinical interpretation: where this fits tomorrow

This trial supports forceps-assisted cannulation as a practical, low-cost, low-complexity tool in ERCP—especially when the papilla is hard to expose or stabilize.

Best-use scenarios

periampullary diverticulum (papilla in/on rim)

redundant folds/tissue obscuring papilla

small/protruding/creased papilla configurations (type 2–4)

early difficult cannulation where you want to avoid escalating to higher-risk access

What it does not replace

precut access when anatomy/duct orientation truly prevents standard entry

prophylaxis strategies (rectal NSAID, PD stent when indicated)

thoughtful escalation algorithms

Bottom-line takeaway for GastroAGI

In difficult ERCP cannulation, forceps assistance significantly improves cannulation success and reduces repeated attempts, without a signal for increased PEP. The SOCCER RCT moves forceps-assisted cannulation from “expert trick” to evidence-supported technique.

One-line GastroAGI takeaway

When cannulation gets difficult, forceps assistance can turn failures into successes.