Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Table 1 Maneuvers to facilitate selective biliary cannulation in difficult cases

Pancreatic guidewire - helps to straighten the intramural segment of the bile duct, reduces accidental MPD cannulation

Double guidewire technique - pancreatic guidewire method in combination with WGC

Wire-guided cannulation over a pancreatic duct stent - reduces accidental MPD cannulation

Precut papillotomy - to dissect the major duodenal papilla, used to visualize and cannulate the CBD

Precut fistulotomy - creates a fistula between the duodenal lumen and the CBD

Supra-papillary puncture - creates direct duodenocholedochal access

Supra-papillary puncture in combination with EUS - reduces rates of PEP, but with reasonable rates of perforation

Transpancreatic precut sphincterotomy - ST used to perform papillotomy

EUS-guided rendezvous - BD punctured under EUS guidance from gastric or duodenal lumen

EUS-guided rendezvous with hybrid rendezvous - re-attempt rendezvous following EUS-cholangiography, uses a dilator to enlarge the needle-tract

Percutaneous rendezvous technique - BD access percutaneously, used in variant anatomy cases

Clipping redundant or obscuring folds - in cases of periampullary diverticulum

Using the long scope position – can facilitate better visualization of the major duodenal papilla in some patients and a more stable scope position in patients with a very proximal major papilla.

Change patient position (e.g., go to left lateral decubitus or supine) – may improve orientation and scope stability in some patients.

MPD: Main pancreatic duct; WGC: Wire guided cannulation; CBD: Common bile duct; EUS: Endoscopic ultrasound; PEP: Post-endoscopic retrograde cholangiopancreatography-pancreatitis; ST: Sphincterotome; BD: Biliary duct.