Rescue cannulation techniques in difficult biliary access-A comprehensive review.

Area of Science:

• Gastroenterology
• Interventional Endoscopy

Background:

• Selective biliary cannulation is crucial for successful biliary interventions.
• Cannulation failure necessitates the use of rescue techniques to achieve biliary access.

Purpose of the Study:

• To review and compare the efficacy and safety of various rescue biliary cannulation techniques.
• To provide an algorithm for selecting the optimal rescue technique based on papillary morphology.

Main Methods:

• Literature review comparing free-hand (precut papillotomy, fistulotomy), wire-guided (transpancreatic sphincterotomy [TPS], double guidewire [DGW]), and endoscopic ultrasound (EUS)-guided techniques.
• Analysis of technique selection based on specific papillary morphologies and scenarios like inadvertent pancreatic duct cannulation.

Main Results:

• Papillary morphology is a key determinant in selecting the appropriate rescue technique.
• Pre-cut fistulotomy is preferred for classic and pendulous papillae; pre-cut papillotomy for irregular ridged types.
• Transpancreatic sphincterotomy (TPS) is generally preferred when pancreatic duct cannulation occurs, except for small flat papillae where double guidewire (DGW) is safer.

Conclusions:

• The choice of rescue biliary cannulation technique should be guided by papillary morphology and specific clinical circumstances.
• An evidence-based algorithm can aid endoscopists in selecting the most effective and safe rescue strategy.
• Understanding these techniques improves outcomes in challenging biliary interventions.