Biliary cannulation techniques: Optimizing success and minimizing risk

Table 1 Comparison of American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy criteria for difficult cannulation

Parameter	ASGE	ESGE
Competence benchmark	≥ 90% selective cannulation success rate	> 80% selective cannulation success rate for precutting
Definition of difficult cannulation	Not explicitly defined in ASGE guidelines; ACG 2026 quality indicators discuss difficult cannulation but without specific criteria	> 5 contacts with papilla OR > 5 minutes cannulation time OR > 1 unintended; pancreatic duct cannulation (5-5-2 criteria)
First-line technique	Guidewire-assisted technique recommended	Guidewire-assisted technique (strong recommendation, moderate quality evidence)
Escalation strategy	Advanced techniques include double-guidewire, needle-knife sphincterotomy, transpancreatic sphincterotomy; endoscopists should be familiar with ≥ 1 advanced technique	Pancreatic guidewire-assisted cannulation with prophylactic pancreatic stenting; needle-knife fistulotomy preferred for precutting; transpancreatic sphincterotomy for small papilla with inadvertent pancreatic access
Rescue after failed ERCP	EUS-guided biliary drainage as alternative; percutaneous transhepatic biliary drainage; interval ERCP	Anterograde guidewire insertion via percutaneous or EUS-guided approach; EUS-rendezvous technique

ERCP: Endoscopic retrograde cholangiopancreatography; ACG: American College of Gastroenterology; EUS: Endoscopic ultrasound; OR: Odds ratio; ASGE: American Society of Gastrointestinal Endoscopy; ESGE: European Society of Gastrointestinal Endoscopy.