Strategies for achieving successful cannulation in endoscopic retrograde cholangiopancreatography: A technical overview

Table 1 Differences between contrast-assisted cannulation and wire-guided cannulation

Category	Contrast-assisted cannulation	WGC
Primary challenge	Repetitive probing and multiple contrast injections increase papilla trauma and PEP risk	Achieving proper wire placement in cases of variant anatomy (e.g., tortuous or stenotic ducts)
Risks	Higher risk of PEP due to pancreatic duct opacification	Intramural dissection, perforation of side branches, or creation of false passages
Technical difficulties	Less precise, time-consuming, and challenging in cases of small, floppy, or abnormally positioned papilla	Choice between “touch” and “no-touch” techniques can impact success in mobile or difficult papilla
Anatomical challenges	Difficult in cases of small papillary orifice or variant anatomy	Challenging in cases of variant anatomy (e.g., tortuous bile ducts or stenotic regions)
Combined techniques	May require switching to WGC after initial contrast opacification for better visualization	May require contrast opacification in complex cases to determine bile duct direction

WGC: Wire-guided cannulation; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.