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Surveillance for tumor syndrome 7 (9.1) Suspected LN or mass 8 (10.4) Therapeutic Celiac Plexus Block 1 (1.3) Cystgastrostomy 4 (5.2) Anesthesia Type Monitored Anesthesia Care (MAC) 48 (62.3) General Anesthesia 29 (37.7) Mean procedure Time in minutes (N5 59) 35.0 [18.0 -49.0] Diagnostic Success 76 (98.7) Therapeutic Success (n55) 5 (100) EUS related complications 2 (2.6) Anesthesia complications 0 (0) EUS 5 endoscopic ultrasound, FNA/B 5 fine needle aspiration/biopsy, LN 5 lymph node. Continuous variables presented as mean 6 SD or median (IQR). Categorical variables presented as n (%).

Background and study aims: Endoscopist techniques affect biliary cannulation success and the risk of adverse events during ERCP. This survey study aims to understand the current practice of biliary cannulation techniques among endoscopists. Methods: Practicing endoscopists were sent an anonymous 28- question electronic survey on biliary cannulation techniques and intraprocedural pancreatitis prophylactic strategies. Results: The survey was completed by 692 endoscopists (6.2% females). A wire-guided cannulation technique (WGT) was the preferred initial biliary cannulation approach (95%). The preferred secondary approaches were a double-wire (DWT) (65.8%), precut needle-knife technique (NKT) (25.7%), transpancreatic sphincterotomy (5.9%) or other (2.6%). Overall, 18.1% of respondents were not comfortable with NKTs. In the setting of pancreatic duct (PD) access, 81.9% and 97% reported a threshold of three or more wire passes or contrast injections into the PD respectively before changing strategy, 34% reported placement of a prophylactic PD stent <50% of the time and 12.1% reported removal of the PD stent at the end of the procedure. Advanced endoscopy fellowship (AEF) training and high volume (>200 ERCPs per year) were associated with comfort with precut needle knife techniques and likelihood of prophylactic PD stent (p<0.001 for both). Conclusions: A WGT technique followed by the DWT and NKT were the preferred biliary cannulation techniques however almost one-fifth of respondents were not comfortable with the NKT. There was considerable variability in secondary cannulation approaches, time spent attempting biliary cannulation and prophylactic pancreatic duct stent placement, factors known to be associated with cannulation success and adverse outcomes.