ERCP cannulation: a review of reported techniques

Guidewire in pancreatic duct to aid in cannulation of the bile duct. This technique is often successful for difficult biliary cannulation, thus reducing the need for precut techniques. This patient had previously failed cannulation of the bile duct at an outside facility. During the current ERCP, few attempts at biliary cannulation resulted in pancreatic cannulation; a 0.025 guidewire was placed to the tail of the pancreatic duct, a 3.9 French-tipped papillotome was passed beside the wire and used to cannulate the common bile duct. A 4 French 2-cm pancreatic stent was placed after the procedure to reduce the risk of post-ERCP pancreatitis.

Needle-knife papillotomy in patient with stone impacted in the papillary orifice. This is the easiest and safest setting in which to perform needle-knife precut. The stone delivers itself and biliary drainage is readily achieved.

Needle-knife precut for biliary access after placement of pancreatic stent, in patient with clear papillary landmarks. This patient had previously failed cannulation of the bile duct at an outside facility. During the current ERCP, the few initial attempts at biliary cannulation resulted in pancreatic cannulation of a generous diameter in the pancreatic duct; the guidewire was placed to the tail of the pancreatic duct and a 5 F 3-cm soft pancreatic stent was placed. A needle-knife was used to unroof the bile duct in the 10 o'clock direction.

Needle-knife precut for biliary access in patient with sphincter of Oddi dysfunction and small papilla. This patient had abnormal pancreatic sphincter manometry. The Bile duct was not accessed after a brief attempt. A 4 French 2-cm pancreatic stent was placed, and a needle-knife was used to unroof the papilla. A 5-4-3 catheter was used to cannulate the bile duct in the 10 o'clock direction over the pancreatic stent. Subsequent biliary and pancreatic sphincterotomies were completed. A pancreatic stent is highly recommended to reduce the risk of post-ERCP pancreatitis in this type of patient.

Use of a rotatable wire-guided papillotome to cannulate the bile duct in a patient with Billroth II gastrectomy and malignant obstructive jaundice. Fluoroscopy shows the upside-down access up the afferent limb. The papillotome is rotated toward the 5 o'clock position by dialing the handle counter-clockwise and moving the papillotome back and forth. The bile duct is cannulated, the guidewire passed, and a sphincterotomy performed toward the 5 o'clock direction. A cholangiogram shows a malignant biliary stricture; thus, a subsequent biliary stent is placed.

Minor papilla cannulation using a 0.020-inch glidewire in a patient with pancreas divisum and acute recurrent pancreatitis. The presence of pancreas divisum has already been established by secretin MRCP and endoscopic ultrasound. Initial deep minor papilla cannulation is performed at first touch with the intention of therapy. A 0.020-inch straight glidewire is loaded into a 5F-4F-3F tip cannula with side-arm adaptor and contrast is pre-flushed to allow injection around the wire. After the initial cannulation with the wire in the long endoscope position, fluoroscopy shows the tip of the wire entering the dorsal duct. Contrast injection without removing the wire shows the course of the dorsal duct. After deep passage of a 5-4-3 cannula over the glidewire, the wire is exchanged for a more stable 0.018“ nitinol-tipped wire for wire-guided minor papillotomy and placement of a 3 French 8-10cm stent.