Difficult biliary cannulation

Endoscopic retrograde cholangiopancreatography (ERCP) is the most technically challenging procedure routinely performed by endoscopists. ERCP cannulation requires the insertion of a subcentimeter catheter through a tiny orifice at a distance of almost a meter from the operator. Only after successful cannulation of the bile duct can the real "business" of ERCP be performed (eg, sphincterotomy, stone extraction, stent placement). Selective bile duct cannulation is all the more exacting due to the occasional anatomic challenge (eg, postsurgical anatomy, duodenal stricture) or wayward catheter. Serious morbid complications can and do occur, even in the hands of the most gifted and facile endoscopists. Although there are some "tricks" to facilitate successful cannulation of the bile duct, experience "trumps" all tricks. Of greatest importance when faced with a difficult cannulation is the recognition of one's personal limitations.