Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) remains a common and potentially severe adverse event, with continued research efforts to reduce PEP incidence. Robust evidence exists supporting the selective use of pancreatic duct stent placement, administration of rectal indomethacin, wire-guided cannulation technique, and aggressive fluid hydration using lactated Ringer solution. Jang et al. presented a randomized control trial describing primary needle-knife fistulotomy and its benefit for biliary access and reduced PEP incidence. Although these data are compelling, we discuss the key study limitations and the need for further studying the role of primary needle-knife fistulotomy.