Technical overview of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography: A guide for the endoscopist

Figure 2 Pre-cut sphincterotomy over pancreatic duct stent. A: Inadvertent pancreatic duct (PD) cannulation during conventional endoscopic retrograde cholangiopancreatography (guidewire entering PD) on fluoroscopic image; also noted are metallic clips near cystic duct stump; B: Endoscopic image showing PD stent in place and needle knife for performing fistulotomy over PD stent; C: Fistulotomy performed over the bulging papilla using needle knife sphincterotome to access the bile duct; D: Once adequate fistulotomy was achieved, standard sphincterotome was used to selectively canulate the bile duct; E: Once selective cannulation was achieved, a self-expanding metal stent was loaded over the guidewire; F: Self-expanding metal stent deployed in the biliary system with free flow of contrast; also noted is the PD stent in place.