Gastrointestinal Endoscopy
Volume 61, Issue 1 , Pages 112-125, January 2005

ERCP cannulation: a review of reported techniques

  • Martin L. Freeman, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Martin L. Freeman, MD, Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, 701 Park Ave., Minneapolis, MN 55415.
    • ,
  • Nalini M. Guda, MD

Current affiliation: Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota

Minneapolis, Minnesota

Article Outline

 

Cannulation of the desired duct is a prerequisite to successful biliary and pancreatic therapy during ERCP. Achieving deep cannulation remains a substantial barrier to success in ERCP for novices and experts alike. When ERCP was introduced, the principle available technique for cannulation was repetitive probing with a catheter. Subsequently, the variety of available equipment, accessories, and endoscopic techniques to gain duct access and to perform therapy has expanded dramatically. In particular, use of specialized cannulas, papillotomes, guidewires, pre-cut papillotomes, and the expansion of pancreatic therapeutic techniques have amplified the possibilities for biliary and pancreatic cannulation. Nonetheless, many endoscopists may be unfamiliar with some of the newer devices and techniques. The purpose of this paper is to systematically review the types of equipment and endoscopic methods that have been reported to gain access to the bile and the pancreatic ducts in routine and specialized situations, and to review the evidence for their efficacy and safety. This review will intentionally attempt to avoid judgment as to which method is preferable, because there are many opinions, even among experts, and the relatively few comparative data are often not generalizable outside the endoscopists and centers performing the studies. Although reported complication rates will be discussed, inferences about superiority of one technique over another are limited because complications are as much a function of patients' susceptibility and of the endoscopist as of the specific technique used.1, 2 Because it is impossible to list in entirety the different devices produced by multiple manufacturers and avoid the potential for personal preference or bias, this review will omit mention of names of any specific manufacturers or products.

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Literature review methodology 

We conducted a MEDLINE search of the literature from 1966 to May 2004, with the following terms: endoscopic, retrograde, cholangangiopancreatography, ERCP, and cannulation. All articles published in the English language literature were reviewed. Abstracts from national meetings within the last few years were manually searched. All references were manually verified. The references of published articles were manually searched. Where applicable, the level of evidence was reviewed by using a scoring system adapted from Cook et al.3 Levels of evidence and grading recommendations were as follows. Grade A recommendations: supported by greater than or equal to two randomized trials with p values <0.05, appropriate methodology, and no conflicting results in the trials. Grade B recommendations: supported by randomized trials with p values >0.05, and/or inappropriate methodology, and/or inadequate sample sizes, and/or conflicting results among the trials. Grade C recommendations: supported by nonrandomized trials.3 Because most techniques described are case reports and case series, and only a few techniques have been evaluated in prospective randomized trials, the level of evidence is Grade C unless otherwise specified.

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Defining and measuring success and outcomes of cannulation 

The overall outcome of a procedure is a balance between technical success, complications, and clinical efficacy.4, 5 Complications are highly subject to variability in definition and detection. Consensus criteria are now widely used to define complications based on outcomes and length of hospital stay.6 Whereas, in general, expeditious methods of cannulation are associated with a lower risk of pancreatitis and other complications,1, 7, 8 it is now known that complications are as much a function of patient susceptibility as endoscopic technique, limiting the value of comparison of techniques between different centers. For example, an ERCP complication rate of 10% would be relatively high for patients with bile-duct stones but acceptable or even low for patients with sphincter of Oddi dysfunction.

Overall technical success at ERCP cannulation can be difficult to define, because there can be widely variable intents (i.e., diagnostic or therapeutic, biliary, and/or pancreatic), depending on the level of expertise, the interpretation of diagnosis, and belief in appropriate therapy. In particular, success of individual techniques, such as pre-cut or “access” papillotomy, may be artificial, because these techniques may be elected by various thresholds in select patients with favorable anatomy and indications. Success must be interpreted in context of the proportion of total cannulation attempts performed as pre-cut: for example, if an endoscopist is initially successful at bile-duct cannulation after 70% of pre-cuts but performs pre-cut in 30% of all attempted cannulations, then overall initial cannulation success is only 91% (assuming success in all patients who did not undergo attempted pre-cut). In contrast, if an endoscopist is initially successful after 70% of pre-cuts but only performs pre-cut in 5% of attempted cannulations, then initial cannulation success is 99%. In addition, any procedure, e.g., pre-cut papillotomy, that requires a repeat procedure to be successful should be considered an initial failure. Thus, when it can be determined, overall success rates at all intended ERCP cannulations generally are more informative than success at specific component procedures, e.g., sphincterotomy.

It has been suggested that expert endoscopists are expected to perform at a 95% to 100% technical success level, and available literature supports such success rates. Technical success rates of 80% to 90% have been suggested before trainees are deemed competent in a specific endoscopic skill.5, 9, 10, 11 The close relationship between success and complications of ERCP with endoscopic training, expertise, case volume, and practice setting have been extensively reviewed elsewhere.4, 12 ERCP involves many levels of technical complexity. A 5-point difficulty scale has been described for ERCP,13 which subsequently has been simplified to a 3-point scale.5 Complex procedures, especially involving pancreatic therapy, may not result in equally high levels of technical success, even at expert centers.14

Overriding principles of ERCP increasingly include appropriate selection of patients for ERCP, which should be almost exclusively therapeutic, with avoidance of diagnostic ERCP by using a combination of clinical assessment and prior imaging with intraoperative laparoscopic cholangiography, EUS, or MRCP, when appropriate.5, 11, 12, 15 Limiting ERCP to patients with a near-certain probability of requiring therapy allows the endoscopist to proceed with confidence to appropriately aggressive techniques for achieving duct access.

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Endoscopic techniques and anatomic variations 

Table 1 describes the various cannulation techniques reported in the literature. The list is intended to be comprehensive, but some techniques may have been unintentionally omitted. Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6 illustrate selected standard and newer techniques for accessing the bile duct. Reported series involve varying prevalence of confounding anatomical variables, e.g., location of the major or the minor papilla adjacent to or within a diverticulum. Infiltration by intrinsic or extrinsic tumors often distorts and complicates endoscopic access to the papilla and cannulation of the ducts. Altered surgical anatomy such as Billroth II gastrectomy or bariatric surgery may further confound endoscopic access to the papilla.

Table 1. Biliary cannulation techniques
Standard techniques
Catheters
Standard
Ultratapered (5F-4F-3F)
Steerable
Papillotomes
Single or multilumen
Rotatable
Guidewires in conjunction with catheters and papillotomes
Standard
Nitinol
Hybrid
Hydrophilic
Placement of pancreatic guidewire (or stent) to assist biliary cannulation
Precut “access” papillotomy
Needle-knife
Freehand starting at orifice
Freehand “fistulotomy” starting above orifice
Over pancreatic stent
Traction papillotome
Papillary roof incision
Transpancreatic
Intramural incision technique
Novel devices
Endoscopic scissors
Endoscopic “dissection” technique using cotton swab
Papillectomy for duct access

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Standard and steerable cannulas, papillotomes, and guidewires 

Standard ERCP cannulas typically are 5F to 7F catheters, with a straight or a tapered tip that can accept a 0.035-inch guidewire. Use of a triple-lumen cannula or attachment of a side-arm adaptor allows a preloaded guidewire and injection of contrast without removing the guidewire. Many endoscopists use ultra-tapered (5F-4F-3F) tip catheters for cannulation of bile and pancreatic ducts, which require smaller-caliber guidewires (down to 0.018 inch). A special 3F cannula can be passed through the channel of a standard cannula or papillotome to convert to a smaller diameter. No published studies have directly compared cannulation success between standard and smaller-caliber catheters.

Cannulas with or without guidewires are limited in their ability to vary the angle of approach to the papilla. The standard papillotome was the device originally used to allow variable upward angulation for biliary cannulation, bowed to enter the biliary orifice, then relaxed to achieve deep cannulation (Fig. 1).16 In a randomized trial of initial biliary cannulation in 100 patients, a sphincterotome without a guidewire was found to be successful in 84% compared with 62% with a standard cannula (p < 0.05), with no difference in complications; crossover to sphincterotome cannulation allowed success in 94%.17 In a subsequent randomized trial in 47 patients, cannulation was successful in 97% with a sphincterotome vs. 67% when using a standard catheter (p=0.009). Use of a sphincterotome was associated with significant reduction in cannulation times and in the number of attempts required for selective duct cannulation, confirmed in a multivariate analysis. The study was not powered to detect a difference in complications.18 Whether use of a papillotome as an initial tool for cannulation results in less pancreatitis is not clear. One observational study suggested that use of a papillotome was associated with higher risk of post-ERCP pancreatitis by univariate but not by multivariate analysis, reflecting the later use of this device in the sequence by that particular center instead of an inherent risk8; conversely, randomized studies suggest no difference in pancreatitis rates and more expeditious cannulation with papillotome cannulation.

Another attempt to overcome the limitations of conventional catheters is the steerable-tip catheter. In an initial study involving 195 patients with no prior papillary intervention, crossover to a steerable cannula was successful in 17 of 20 cannulations that initially failed with a standard catheter.19 In a randomized, multicenter, crossover study, standard cannula, sphincterotome, and steerable catheter were compared prospectively in 312 patients. Time to cholangiography and deep cannulation, number of attempts, number of pancreatic injections, and success were evaluated. Both the sphincterotome and the steerable catheter were superior to the standard catheter for cannulation (88% and 84% vs. 75%, respectively, p=0.038). When a standard catheter failed, there was a 26% successful cannulation with a change in the catheter to either a sphincterotome or a steerable catheter. The advantage was most pronounced for trainees; by using advanced techniques, e.g., pre-cut, as needed when the initial 3 methods failed, the expert staff achieved cannulation in 97%.20 Pancreatitis was seen in 5.3% overall, and the study was not powered to detect any differences in complications between techniques.

Because the angle of approach to the papilla may vary with anatomy, endoscopes, and manufacturing consistency, the ability to change the rotation of papillotomes has been a desired goal. Manual grooming has been shown to effectively alter the angle of orientation, with or without a guidewire in place, but it is time consuming and requires trial and error.21 Rotatable papillotomes with triple lumens have recently been introduced. Preliminary data suggest that they are very useful for cannulation, especially in patients with unusually oriented papillas, distorted papillas caused by diverticula, and altered surgical anatomy.22

Guidewires often are used in conjunction with cannulas or sphincterotomes to obtain and to secure deep cannulation, and to perform wire-guided sphincterotomy, stent placement, stone extraction, and other therapeutic techniques. Available configurations of guidewires include conventional, hydrophilic, nitinol, and “hybrid,” ranging from 0.018- to 0.035-inch diameter.23 With the guidewire cannulation technique, the tip of the guidewire is extended beyond the tip of the cannula or the papillotome and is passed under visual and fluoroscopic guidance deeply in the direction of the desired duct. Data regarding guidewire cannulation are limited, and intramural dissection, pancreatic ductal injury, false passage, and perforation are potential problems that can be minimized by use of a soft-tipped wire. In a case series, use of a hydrophilic guidewire with a sphincterotome was successful in achieving deep biliary cannulation in 174 of 183 patients (95%); 7.5% had elevations in amylase and lipase to 4 times normal, and clinical pancreatitis was seen in 2.3%.24 In the past, it was not clear whether guidewire cannulation increased or reduced risk of pancreatitis: in multicenter observational ERCP complication studies, cannulation with a guidewire was associated with a higher risk of pancreatitis by univariate (but not multivariate) analysis, probably reflecting the preference for use later in the procedure by the participating endoscopists.7, 8 In contrast, a recent prospective randomized study in 400 patients found that while success at biliary cannulation was achieved with similar frequency with guidewire through a papillotome (98.5%) compared with a papillotome alone (97.5%), the rate of pancreatitis was significantly lower in the guidewire group (0% vs. 4%, p < 0.05), presumably because of less pancreatic contrast injection.25

Overall, the available evidence supports the use of a papillotome or a steerable cannula with or without a guidewire in lieu of a standard cannula as the initial biliary cannulation device, because these devices are associated with greater efficiency and success, and/or reduced rates of pancreatitis. (Grade A recommendation).

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Guidewire, catheter, or stent in the pancreatic duct to facilitate biliary cannulation 

Use of pancreatic techniques is a newer approach to improve safety and success at biliary access, and one with which many endoscopists may be unfamiliar. Techniques include placement of a pancreatic guidewire, a cannula, or a stent to aid cannulation, and/or placement of a pancreatic stent to reduce the risk of pancreatitis. Transpancreatic pre-cut sphincterotomy and pancreatic stent-protected needle-knife pre-cut will be discussed in the section on pre-cut techniques.

Placement of a guidewire deep into the main pancreatic duct may facilitate cannulation of the bile duct with a second device beside the pancreatic wire: the pancreatic wire serves a number of functions, including to open a stenotic papillary orifice, to stabilize the papilla, to lift it toward the working channel, to straighten the pancreatic duct and the common channel, to drain the pancreatic duct, potentially to minimize repeated injections into the pancreatic duct, and to allow access for placement of a pancreatic stent if felt necessary (Figure 2, Figure 7; see Video-clip 1 online at www.mosby.com/gie). This technique originally was described in a patient with surgically altered anatomy26 and, subsequently, in a patient with a tortuous common channel.27 A randomized trial assessed the efficacy and the safety of pancreatic wire placement for achieving biliary cannulation: 53 patients in whom conventional cannulation failed after 10 minutes were randomized to persistence of usual techniques vs. placement of a pancreatic guidewire to facilitate biliary cannulation. Success was achieved in 93% of patients with a pancreatic wire compared with 58% in the persistence group (p < 0.05), with no episodes of pancreatitis or other complications in either group, although serum amylase levels were significantly higher in the pancreatic guidewire group.28 The efficacy of this technique was endorsed by another group, who reported using a pancreatic wire in 32% of all biliary cannulations, with no difference in complications when compared with conventional “easy” cannulation (mild pancreatitis in 7.8% and 8.3%, respectively).29

Concerns about pancreatic guidewire placement as an aid to biliary cannulation have been raised.30, 31 There are substantial data supporting placement of pancreatic stents to reduce the risk of post-ERCP pancreatitis in patients with risk factors, such as difficult cannulation or sphincter of Oddi dysfunction, but few data regarding risk of wire manipulation alone.2 Potential problems with deep passage of a pancreatic wire include the potential for exiting or perforating ductal side branches and the failure to place a wire deeply in the main duct, which may occur in up to 5% to 10% of cases when using the standard technique, especially by less experienced endoscopists.2 One study showed substantial risk of pancreatitis in high-risk patients undergoing manipulation of the pancreatic duct followed by failed pancreatic stent placement.32 There are variations in pancreatic morphology that make placement of a wire particularly difficult, including diminutive or tortuous duct and “ansa pancreaticus” (360° loop in duct). In spite of those difficulties, virtually universal success at deep wire placement has been reported when using a modified technique with a 0.018-inch nitinol-tipped wire.32

Preliminary evidence supports use of a pancreatic wire as an aid to biliary cannulation (Grade B recommendation). A multicenter randomized trial is underway in Europe to assess the efficacy and the safety of pancreatic wire placement as an aid to biliary cannulation. This technique generally can be followed by placement of a small-caliber (3F or 4F) pancreatic stent in patients at higher risk of post-ERCP pancreatitis. Prior access to the pancreatic duct for stent placement may be an advantage of the pancreatic guidewire-assisted cannulation technique.

Other case reports have described placement of a catheter in the pancreatic duct, followed by cannulation of the bile duct with a guidewire,33 and placing a small pancreatic stent to facilitate biliary cannulation, based on the concept that the pancreatic stent deflects a guidewire or a catheter into the bile duct.33, 34

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Pre-cut (“access”) papillotomy 

Pre-cut papillotomy refers to a variety of endoscopic techniques used to gain access to the bile (or occasionally the pancreatic) duct. In most patients, pre-cut papillotomy is followed by conventional sphincterotomy, which permits completion of therapies, e.g., stone extraction. However, pre-cut sphincterotomy sometimes is used to gain access to the bile (or the pancreatic) duct for diagnostic cholangiography (or pancreatography) alone. Thus, the alternative term “access papillotomy” probably is more accurate.35

Pre-cut techniques most often are used after conventional methods of biliary cannulation have failed or, in a few centers, as a preferential technique for performing biliary and pancreatic sphincterotomy over a pancreatic stent in patients with sphincter of Oddi dysfunction.36 Use of pre-cut varies from none to as many as 38% of all biliary cannulation attempts.7, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58

There are several techniques to perform pre-cut papillotomy.59 Most widely practiced is the free-hand needle knife, in which an incision is made starting at the orifice and extending cephalad for a variable distance (Fig. 3; see Video-clip 2 online at www.mosby.com/gie). Originally by described using an upward sweeping motion with the elevator, it has been suggested that improved control and safety can be achieved by “loading” the needle knife by upward traction on the endoscope.49, 60 A variation of the needle-knife technique involves making a puncture into the papilla above the orifice (often referred to as “fistulotomy”) and then cutting either upward in a cephalad direction or downward toward the orifice (Figure 4, Figure 8). Any of the above techniques may be performed after placement of a pancreatic stent (Figure 5, Figure 9; see Appendix, Appendix online at www.mosby.com/gie). The second major approach to pre-cutting involves use of a traction sphincterotome, originally described by using a specialized short-nosed papillotome, wedged into the common channel in the direction of the bile duct, referred to as a “papillary roof incision.”38 A variation of that technique involves intentional seating of the tip of a standard traction papillotome into the pancreatic duct and cutting through the septum in the direction of the bile duct, often referred to as “transpancreatic” pre-cut sphincterotomy (Fig. 6).46 An “intramural incision” technique has been described in 6 patients that used the false tract created with a guidewire to place a papillotome though the intramural portion of the papilla and to unroof the biliary orifice; this technique would seem only to be applicable to patients with prominent papillas in whom partial biliary cannulation was achieved.61

Success and complication rates of a spectrum of series of pre-cut papillotomy are shown in Table 2. Pre-cut techniques were performed in 4% to 38% of all cannulation or sphincterotomy attempts, with immediate success from 35% to 96%. These results must be interpreted cautiously, as emphasized in the introduction. Only immediate success at cannulation represents true success, because repeat ERCP without pre-cut may have been effective.7, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58 Complications have been reported to occur in 2% to 34% of pre-cuts, which often are, but not always, higher than those for patients having standard sphincterotomy. These complication rates reflect a wide variety of rigor in data collection, definitions used, case mix, and patient characteristics. ERCP complications, especially post-ERCP pancreatitis, are heavily dependent on patient-related factors, as well as technique and operator characteristics.62 Comparing outcomes of pre-cut with standard ERCP may truly be a case of comparing “apples and oranges”—indications, anatomy, and patient characteristics often are very different in patients selected for pre-cut (obstructive jaundice, older, dilated ducts, favorable papillary anatomy, etc.) than patients having conventional sphincterotomy (suspected stones or sphincter of Oddi dysfunction, small papilla, etc).7, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58

Table 2. Pre-cut papillotomy: success and complications of a variety of techniques, including heterogeneous patient populations and indications
AuthorYStudy designTechniquePre-cut (n)% ES/ERCP as pre-cutImmediate successEventual successPre-cut complications (%)Complications ES
Akashi2004RetrospectiveTranspancreatic17210%60%95%10%1%
Katsinelos2004RetrospectiveNeedle-knife687%66%94%11%NA
Harewood2002ProspectiveFistulotomy25311%NA92%15%NA
Bolzan2001ProspectiveNeedle-Knife5112%71%88%18%NA
Goff1999RetrospectiveTranspancreatic5126%96%98%2%2%
Mavrogiannis1999Randomized controlled trialFistulotomy vs needle-knife15320%75%90%13%§NA
Loperfido1998ProspectivemulticenterMultiple techniques41915%86%NA8%#4%#
Rollhauser1998RetrospectiveNeedle-knife686%71%94%6%NA
O'Connor1997ProspectiveFistulotomy8316%72%89%6%1%
Rabenstein1997RetrospectiveNeedle-knife69433%70%85%7%7%
Binmoeller1996ProspectivePapillary roof incision12338%91%100%5%6%
Bruins Slot1996RetrospectiveNeedle-knife18017%88%99%12%8%
Freeman1996ProspectivemulticenterMultiple techniques1115%66%∗NA24%†9%
Gholson1996RetrospectiveNeedle-knife6311%97%100%7%4%
Kasmin1996ProspectiveNeedle-knife or fistulotomy7218%67%93%11%NA
Foutch1995ProspectiveNeedle-knife5211%NA90%6%10%
Goff1995RetrospectiveTranspancreatic3229%91%97%1210%
Boender1994ProspectiveNeedle-knife or fistulotomy5021%78%NA34%9%
Tweedle1991RetrospectiveNeedle-knife634%83%97%12%7%
Booth1990RetrospectivePapillary roof incision5610%NANA16%NA
Dowsett1990RetrospectiveNeedle-knife10313%35%77%5%NA
Leung‡1990RetrospectiveFistulotomy204%80%95%0%NA
Huibregtse1986RetrospectiveNeedle-knife19019%53%84%3%2%

ES, Endoscopic sphincterotomy.

∗90% for endoscopists performing >1ES/wk, 52% for others.

†Severe complications occurred in 23% of patients with sphincter of Oddi dysfunction after pre-cut without pancreatic duct stent.

‡Impacted ampullary stones only.

§Pancreatitis rates significantly lower with fistulotomy though no difference in overall complications.

#Moderate to severe complications.

It often has been argued whether complications of pre-cut are because of the pre-cut itself or the antecedent cannulation attempts. A number of randomized controlled trials comparing pre-cutting to persistent cannulation have been conducted but none has been published. The most relevant data are available from two multicenter prospective studies that used multivariate analysis to adjust for confounding variables related to difficult cannulation.1, 53 Both found that pre-cut papillotomy independently and significantly increased the risk of complications compared with standard sphincterotomy. In an Italian study, pre-cut papillotomy primarily added to the risk of perforation53; while in an American study, the extra risk was primarily related to pancreatitis.1 A meta-analysis of all available studies showed that conventional pre-cut sphincterotomy without a pancreatic stent was a highly significant risk for post-ERCP pancreatitis even after adjusting for other variables, with a relative risk of 2.7.63

Pancreatic stents may play a significant protective role against pancreatitis after pre-cut (access) papillotomy, as well as in other high-risk settings.2 (Figure 5, Appendix, Appendix) A randomized controlled trial suggested that placement of a small-caliber pancreatic stent left in place for at least 7 days reduced the risk of pancreatitis after needle-knife pre-cut from 14% in patients without a stent to 2% in those with a stent (p < 0.05).64 A case-control study from a tertiary center suggests that needle-knife pancreaticobiliary sphincterotomy over a pancreatic stent may be safer than conventional pull-type biliary sphincterotomy without a pancreatic stent in patients with sphincter of Oddi dysfunction.36

Data comparing specific pre-cut techniques are limited. A randomized comparative study of “fistulotomy” starting above the orifice (Figure 4) vs. conventional needle knife starting at the orifice (Figure 3) in 153 patients with suspected choledocholithiasis found a significantly lower rate of pancreatitis for fistulotomy (0% vs. 8%) but similar overall complication rates and success at initial cannulation.54 Despite the theoretical advantages of fistulotomy in sparing the pancreatic orifice, the technique may be of limited feasibility in patients with very small or flat papilla, or in patients with high risk for post-ERCP pancreatitis. A longitudinal study of 253 pre-cut fistulotomies performed by a single expert endoscopist showed that, although success rates at bile-duct access increased from 88% to 98% over time, complications remained unchanged at approximately 15% despite an average patient-risk profile.48

In the “transpancreatic” pre-cut technique, a standard traction papillotome is purposely wedged into the pancreatic orifice, with a cutting wire aimed in the biliary direction (Fig. 6). Two initial reports from a single endoscopist reported low complications rates comparable with standard pre-cut techniques.46, 47 A subsequent large case series from Japan in average-risk patients suggested that while usually successful, transpancreatic pre-cut was associated with a significantly higher risk of pancreatitis than standard sphincterotomy.37 Concerns with this technique include both the short-term risk and long-term consequences of an unnecessary pancreatic sphincterotomy, especially in young patients.65 Post-ERCP pancreatitis may occur in at-risk patients, especially when a pancreatic stent is not inserted, and reflux of duodenal contents into the pancreas, restenosis, and perhaps relapsing pancreatitis are all potential long-term consequences.

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Novel devices for duct access 

An ultra-small-caliber sphincterotome (1 mm diameter) introduced through a 6F or a 7F catheter has been evaluated with successful cannulation in 98% (53/54) of patients, with selective cannulation in 24% and pre-cut in the remainder.66

Suprapapillary blunt dissection is another alternate strategy to performing a pre-cut sphincterotomy. The procedure involves an initial linear cut over the mucosa of the infundibulum of the papilla with a needle-knife papillotome. A small ball of cotton held with a forceps is used for blunt dissection down to the bile duct, with subsequent needle-knife access. This technique was used in 48 of 1057 attempted cannulations with success in all and with pancreatitis in 8%.67

Endoscopic scissors have been used to cut through the papillary roof or septum without cautery to gain biliary access. This technique was successful in 8 of 12 attempts (75%) without any complications. Though the idea is innovative, data are limited, and the instrument used is a prototype not widely available.68

Although seemingly radical, endoscopic ampullectomy has been reported as a technique for gaining biliary access when other methods have failed in a very select group of patients. In a case series of 10 patients with malignant lesions involving the ampulla and protuberant ampullae at ectopic locations, cannulation was achieved in 100%, with significant bleeding in 10%.69

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Intradiverticular papilla 

Cannulation of the ampulla inside a diverticulum often is difficult. The ampulla can be located anywhere within or on the rim of the diverticulum. Overall cannulation success has variably been reported as similar to70 or less than for patients without diverticula.71 A number of specialized techniques have been described in case reports for biliary cannulation in periampullary diverticulum (Table 3). These include balloon dilation of diverticular rim, use of two devices in one channel, use of a biopsy forceps to evert the diverticulum, saline solution injection to lift the papilla, and endoscopic clipping of diverticular rim to expose the papillary orifice. Placement of a balloon in the common channel or of a guidewire or stent in the pancreatic duct to evert the papilla has been described; the fundamental principles are to expose and to align the papillary orifice and ducts.72, 73, 74, 75, 76

Table 3. Cannulation techniques for intradiverticular papilla
Balloon dilation of diverticular rim
Use of 2 devices in 1 channel
Biopsy forceps to evert diverticulum
Saline solution injection to lift papilla
Endoscopic clipping of diverticular rim to expose papilla
Balloon in duct to evert papilla
Pancreatic guidewire or stent to evert papilla

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Surgically altered anatomy 

ERCP in patients can be particularly challenging in patients with altered surgical anatomy, e.g., Billroth II gastrectomy, and even more difficult in patients with long-limb Roux-en-Y gastrojejunostomy.77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87 In patients with Billroth II, cannulation success rates approach those of patients with normal anatomy.88, 89 A major limitation of success in patients with Billroth II is reaching the papilla via the afferent limb and correctly aligning with the axis of the ducts. There is some disagreement as to preference for forward vs. side-viewing endoscopes.83 Placement of a guidewire or making a mark with a biopsy forceps in the afferent limb, manual compression of the abdomen, supine positioning, and use of a polypectomy snare in the working channel of the endoscope as a stiffening device have all been reported to be useful in intubating the afferent limb.90, 91, 92 Once the papilla is reached, because the ampulla of Vater must be approached below, from the afferent loop, the view of the ampulla is rotated 180°, so that the bile duct is located at the 5-o'clock position instead of the usual 11-o'clock position. Wire-guided Billroth II papillotomes have been reported to improve cannulation success.93, 94 Rotatable papillotomes in conjunction with guidewires offer a new approach to cannulation in patients with Billroth II gastrectomy (Fig. 10A and B; see Video-clip 5 online at www.mosby.com/gie).22 A novel approach to ERCP in patients with altered surgical anatomy and an inaccessible afferent limb includes open or laparoscopic gastrostomy or jejunostomy for subsequent introduction of the duodenoscope.95, 96, 97

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Major papilla pancreatic cannulation 

Major papilla pancreatic cannulation techniques are similar to those used for biliary cannulation, with exceptions that the smaller size, the duct tortuousity, and the multiple side branches render deep wire passage more difficult in some cases. Just as biliary cannulation may be aided by placement of a pancreatic guidewire, placement of a biliary guidewire may serve to straighten the common channel and to improve pancreatic access. Pancreatic cannulation may either be facilitated or rendered more difficult by prior biliary sphincterotomy. One series reported 98% success at repeat access of the pancreatic duct immediately after biliary sphincterotomy for sphincter of Oddi dysfunction.98 An innovative but rarely appropriate approach to difficult pancreatic cannulation involves transduodenal rendezvous with puncture of main pancreatic duct superior to the papillary orifice and antegrade passage of a guidewire.99

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Minor papilla cannulation 

The minor papillary orifice typically is located cephalad to the major papilla at approximately the 1- to 2-o'clock position to the major papilla as seen through a duodenoscope. The minor papilla may be prominent, inconspicuous, or absent, and with a variably patent orifice, and may also be located within a diverticulum. The approach to minor papilla cannulation varies with anatomy (presence or absence of pancreas divisum) and therapeutic intent. Various techniques for minor papilla cannulation have been described, with successful cannulation reported in 77% to 100%.100, 101, 102, 103, 104, 105, 106, 107, 108, 109 Initial cannulation often is optimal from the long or semi-long endoscope position. Although techniques are similar to those used for major papilla biliary and pancreatic cannulation, small-caliber guidewires and cannulas often are required. Common methods include primary cannulation with a 0.020-inch hydrophilic guidewire (see Video-clip 6 online at www.mosby.com/gie) and use of a needle-tip catheter. Secretin can be used to facilitate pancreatic secretion and to enhance identification of the minor papilla and its orifice; in a randomized controlled trial in 29 patients with previously failed minor papilla cannulation, administration of synthetic porcine secretin improved cannulation from 7.7% in the placebo group to 81.3% in the secretin group; crossover to secretin allowed access in a total of 89.3%.103 Methylene blue and indigo carmine have been sprayed onto the minor papilla after secretin administration to help identify the orifice.106, 107, 108, 109, 110 Needle-knife papillotomy has been used to access minor papilla.111 EUS has been used to inject methylene blue into the dorsal pancreatic duct to aid in localization of an otherwise invisible minor papilla.112

Patients with incomplete or no pancreas divisum allow an alternate approach to minor papilla access with the pancreatic rendezvous technique.101, 111 In this technique, a guidewire is passed retrograde into the pancreatic duct via the major papilla and antegrade out of the minor papilla.

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Pharmacologic aids to cannulation 

A number of drugs have been used to facilitate biliary and pancreatic duct cannulation. Glugacon and hysocyamine often are used to relax motility and have been found to be of similar efficacy but were never compared with placebo in a randomized controlled trial.113 In a nonrandomized, single-operator, single-center study, use of a cholecystokinin analogue helped in obtaining a cholangiogram in 12 of 19 cases after an initially failed ERCP, with visualization of the bile duct in 5 of 5 patients and deep cannulation in 50%.114 Both cholecystokinin and topical nitroglycerine spray have been evaluated in randomized controlled trials and have been found to be of no significant advantage.115, 116 The role of secretin in facilitating minor papilla cannulation has already been discussed.

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When cannulation fails 

Responses to unsuccessful cannulation include persistence of the same technique, trying a different technique, calling in a second staff, or stopping the procedure, especially if the indication is not clear, if a complication is apparent, or if the patient is not tolerating the procedure well. Subsequent options include a repeat ERCP attempt by the same or different local endoscopist, referral to a specialized center, or consideration of alternate approaches, which include surgical, percutaneous, or EUS duct-access procedures.

Calling in a backup second staff during the initial procedure by endoscopists with moderate experience at the time of the study was suggested to increase cannulation success from 88% to 96%.7 Repeat ERCP by the same operator on a different day was shown to result in cannulation rates of over 87.5%, although a significant number of these patients (21%) had needle-knife papillotomies.117 Even when previous attempts at ERCP have failed elsewhere, expert tertiary referral centers are able to achieve successful duct access in greater than 95% of cases. Successful duct access was reported in 95% to 96% of ERCPs referred to tertiary centers after failure elsewhere, by use of advanced cannulation techniques in up to 50%, with complications in under 13%.118, 119

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Rendezvous techniques via PTC, laparoscopy, and EUS 

In selected cases where biliary access cannot be achieved by ERCP, percutaneous transhepatic cholangiography (PTC) sometimes is performed to pass a transpapillary wire for subsequent ERCP.120, 121, 122 However, the combined approach has been found to be a major independent risk factor for complications associated with performance of biliary sphincterotomy as a result of sepsis, bile leak, bleeding, and other PTC-related complications.7 The rendezvous technique also has been described via prior surgically placed T-tubes.123 A transpapillary guidewire may be passed laparoscopically via the cystic duct during laparoscopic cholecystectomy to facilitate subsequent biliary ERCP with a high degree of success and minimal complications.124, 125, 126, 127, 128 Perhaps the most intriguing approach to provide rendezvous access after previously unsuccessful ERCP involves use of EUS, because it can be accomplished in the same unit, during the same procedure as ERCP, and without any external drainage. In the EUS-guided rendezvous approach, the bile or the pancreatic duct is punctured via a transgastric or a transduodenal approach and a guidewire is passed antegrade through the papilla for subsequent rendezvous ERCP. This technique has been reported in a case series of 6 patients with success in two of two biliary and in one of 4 pancreatic cases with no complications, as well as in a case report, including successful pancreatic access in a single patient.129, 130

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Disclosure 

Dr. Freeman has received research grants from Boston Scientific, speaking honoraria from Boston Scientific and Wilson Cook, and is an unpaid consultant to Hobbs Medical Inc.

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Appendix. Supplementary data 

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Video-clip 1 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.

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Appendix. Supplementary data 

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Video-clip 2 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.

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Appendix. Supplementary data 

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Video-clip 3 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.

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Appendix. Supplementary data 

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Video-clip 4 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.

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Appendix. Supplementary data 

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Video-clip 5 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.

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Appendix. Supplementary data 

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Video-clip 6 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.

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PII: S0016-5107(04)02463-0

Gastrointestinal Endoscopy
Volume 61, Issue 1 , Pages 112-125, January 2005

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