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

Figure 3 Conventional endoscopic ultrasound guided rendezvous technique (intrahepatic route): A: Endoscopic ultrasound (EUS) image showing dilated intrahepatic biliary radicle and puncture made using 19-G EUS-fine needle aspiration needle; B: After bile aspiration and confirming bile duct puncture, guidewire passed across the papilla into the duodenum as shown in the fluoroscopic image; C: After coiling the guidewire in the duodenum, the EUS scope was exchanged over the guidewire; D: Endoscopic image of the papilla showing a straight plastic stent placed in pancreatic duct (at the time of difficult biliary cannulation during conventional endoscopic retrograde cholangiopancreatography) and the guidewire in the bile duct passed during EUS-rendezvous procedure; E: Selective cannulation of bile duct performed using a sphincterotome by the side of the guidewire; F: Fluoroscopic image showing deep cannulation of the bile duct during endoscopic retrograde cholangiopancreatography procedure; also noted is the guidewire within the bile duct (placed during EUS-rendezvous procedure) with pancreatic duct stent in place.