The first major change in cannulation approach has been the widespread use of the sphincterotome to obtain initial biliary access in lieu of the cannulatome. This is in part driven by economics. With the advent of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) almost all ERCP is therapeutic and sphincterotomy is typically part of this approach.1 Thus it is sensible to forgo the step of using the cannulatome which enables only diagnostic ERCP. In addition to cutting, the wire on the distal tip of the sphincterotome enables variable flexion in the direction of the bile duct, a feature lacking for the cannulatome.