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

Area of Science:

• Gastroenterology
• Endoscopy
• Biliary Interventions

Background:

• Despite advancements in endoscopic retrograde cholangiopancreatography (ERCP) technology and training, biliary cannulation remains challenging for up to 20% of patients.
• Difficult cannulation increases risks of post-ERCP pancreatitis and technical failure, often unpredictable due to patient anatomy and endoscopist experience.

Purpose of the Study:

• To review difficult biliary cannulation techniques in ERCP.
• To discuss individualized approaches for managing challenging cannulation cases.

Main Methods:

• Review of existing literature on difficult biliary cannulation strategies.
• Analysis of techniques including pancreatic guidewire and stenting, early pre-cut, and rendezvous.
• Evaluation of success rates and adverse events associated with different methods.

Main Results:

• Pancreatic duct stenting appears to reduce post-ERCP pancreatitis rates in difficult cannulation scenarios.
• Data on success rates and adverse events for various techniques are variable.
• Predicting difficult cannulation pre-procedurally is often not feasible.

Conclusions:

• Management of difficult biliary cannulation requires individualized technique selection.
• Considerations include endoscopist skill, patient anatomy, the specific disorder, and current literature.
• Optimizing technique choice is crucial for improving outcomes in challenging ERCP cases.