What specific “stop rules” do you use during difficult native-papilla biliary cannulation (e.g., time, cannulation attempts, pancreatic duct wire passages/injections) to trigger an early change in strategy, such as precut or referral/escalation?

I would not say 'stop,' but, as you said, 'change' the strategy. After attempting for about 5 minutes and touching the papilla with the catheter you started with 4-5 times, even if the guidewire goes into the pancreatic duct once, I tend to use that as a double-wire technique and then place a pancre...