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

Abstract

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study

“…The cause of difficult cannulation in cancer patients may be due to tumor infiltration distorting and complicating endoscopic access to the ducts. Moreover, in patients with malignancy, papilla edema, trauma, and bleeding readily occur during ERCP because of fragile biliary tracts and vasculature, which thus makes cannulation more difficult [4].…”

“…Multiple factors are involved in biliary cannulation failure. For example, duodenal positioning, adequate visualization of the papilla, size of the papilla, variant patient anatomy, and surgery can affect the success rate in cannulation [4]. In biliary endoscopy, certain features of the papilla itself could influence cannulation difficulty.…”

Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study

“…Multiple factors are involved in biliary cannulation failure. For example, duodenal positioning, adequate visualization of the papilla, size of the papilla, variant patient anatomy, and surgery can affect the success rate in cannulation [4] . In biliary endoscopy certain features of the papilla itself could in uence cannulation di culty.…”

Precut fistulotomy for choledocholithiasis: what about long-term efficacy?

“…If the pancreatic duct is repeatedly cannulated or injected, the pancreatic guidewire (PGW)-assisted technique is recommended [3]. However, the pancreatic duct is not always easily accessible, and in those cases, experienced endoscopists resort to one of the precutting techniques (precut fistulotomy and conventional precut technique) based on a patient's characteristics (e. g. papilla's size and morphology) and endoscopist expertise [4,5].Precut fistulotomy (PF) aims to avoid injuring the distal part of the sphincter (including the pancreatic duct) by using a needle-knife to perform a stepwise incision of the mucosa. The incision starts approximately 3 mm over the roof of the papilla, followed by an upward or downward cut until the biliary sphincter or the bile duct is visualized.…”

“…If the pancreatic duct is repeatedly cannulated or injected, the pancreatic guidewire (PGW)-assisted technique is recommended [3]. However, the pancreatic duct is not always easily accessible, and in those cases, experienced endoscopists resort to one of the precutting techniques (precut fistulotomy and conventional precut technique) based on a patient's characteristics (e. g. papilla's size and morphology) and endoscopist expertise [4,5].…”