Management of difficult bile duct cannulation in ERCP

Abstract

In Encoscopic Retrograde Cholangiopancreatography (ERCP), the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis. Difficult cannulation is defined as a situation where the endoscopist, using his/her regularly used cannulation technique, fails within a certain time limit or after a certain number of unsuccessful attempts. Different methods have been developed to manage difficult cannulation. The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire. This review describes different methods to overcome cases of difficult cannulation. We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.

Early precut fistulotomy for biliary access: time to change the paradigm of “the later, the better”?

“…A difficult cannulation is characterized by repeated biliary attempts and/or manipulation (wires and injection of contrast) of the main pancreatic duct, which is in likely to induce trauma, edema, and inflammation to the papillary bed, thus obstructing main pancreatic duct drainage. 22 Furthermore, the NKF is technically challenging because of the need to master the control of the needle-knife (especially the depth) as well as the need to be proficient in recognizing the CBD. 23 Although the overall post-ERCP adverse events were similar with both cannulation strategies (6.2% vs 6.4%), when the NKF subgroups were analyzed, a tendency for a higher pancreatitis risk became apparent, albeit not statistically significant, in the late NKF (8.6% vs 4.2%).…”

A multicenter, prospective, randomized study of selective bile duct cannulation performed by multiple endoscopists: the BIDMEN study

“…The reported time limits within which the regularly used SBDC technique is used vary between 10 and 30 min [3][4][5][6][11][12][13]. The 15-to 30-min limits are used less consistently [14][15][16][17][18][19][20]. More refined methodology appears to be necessary to clarify the definition of the allocated procedure time regarding SBDC.…”

Clip and endoloop lifting technique to assist cannulation of a hardly reachable papilla because of anatomical changes due to surgery

“…With a correct cannulation technique, the complications associated with the procedure can be reduced (2). Different techniques have been used to improve the success rate of biliary cannulation: double guide wire technique, wire-guide cannulation over a pancreatic stent, transpancreatic sphinterotomy, needle-knife precut and endoscopic ultrasound-guided rendezvous (3,4).…”