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

Figure 4 Conventional endoscopic ultrasound guided rendezvous technique (extrahepatic route) being performed in a case of acute biliary pancreatitis (percutaneous catheter drain in situ) diagnosed with choledocholithiasis. A: Endoscopic ultrasound (EUS) scope positioned in short scope position in D1-D2 junction; B: After common bile duct puncture (access diameter 43 mm) using 19 G EUS- fine needle aspiration needle, bile aspiration was done to confirm position and thereafter, contrast was injected to delineate the bile duct; C: Guidewire was passed across the papilla and coiled in the duodenum; D: EUS scope was exchanged with guidewire in place; E: Subsequent endoscopic retrograde cholangiopancreatography was performed using a duodenoscope and successful biliary cannulation was achieved along the side of the exiting guidewire; F: After stone extraction using balloon sweeps, common bile duct stent (7 French × 7 cm double pigtail stent) was placed.