Biliary cannulation techniques: Optimizing success and minimizing risk

Table 2 Comparison of precut and pancreatic duct-assisted salvage techniques for difficult biliary cannulation

Feature	Needle-knife papillotomy	Needle-knife fistulotomy	Transpancreatic sphincterotomy
Approach	Freehand incision at papillary orifice	Freehand incision above papillary orifice	Incision of septum following pancreatic duct wire access
Best clinical scenario	Failed standard cannulation without stable PD access	Long or bulging papilla; when avoiding pancreatic duct trauma is desirable	Repeated unintended PD cannulation or stable PD wire access
Key prerequisites	Experienced endoscopist; ability to maintain orientation of papillary anatomy	Clear papillary anatomy; endoscopist expertise with needle-knife techniques	Pancreatic duct cannulation; ability to place PD stent
Adjuncts	Rectal NSAIDs; prophylactic PD stent if PD manipulated	Rectal NSAIDs; PD stent rarely required	PD stent placement strongly recommended; rectal NSAIDs
Advantages	Widely used; effective in experienced hands	Avoids PD trauma; high success in long papilla; effective in experienced hands	Stable access; high success when PD access is obtained
Risks/limitations	Loss of landmarks; higher risk of PEP; bleeding; perforation	Requires skill; risk of bleeding or perforation	Higher pancreatitis risk; perforation; difficult with complex morphologies; risk of pancreatic duct injury or stricturing

PD: Pancreatic ductal; NSAIDs: Nonsteroidal anti-inflammatory drug; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.