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Difficult Biliary Cannulation

  • Rajesh N. KeswaniEmail author
Chapter

Abstract

Achieving deep cannulation is an essential first step in ERCP. In select cases, achieving biliary access may be challenging, even in expert hands. In cases of difficult cannulation, endoscopists rely upon a variety of techniques to achieve biliary access. Common techniques include cannulation over pancreatic access (either a pancreatic guidewire or stent), use of a needle knife – sometimes over pancreatic access – via a sphincterotomy or fistulotomy approach, and transpancreatic septotomy. In other cases (or when these approaches fail), some endoscopists utilize EUS-based techniques. In this chapter, we provide an overview of these approaches and their relative merits and risks. Furthermore, we present a practical algorithm of how to use these techniques in practice dependent on the clinical situation.

Keywords

ERCP Difficult Needle knife Sphincterotomy Cannulation Failed Pancreas stent 

Supplementary material

Video 3.1

Cannulation of the bile duct over a pancreatic guidewire. This video demonstrates the importance of placing the sphincterotomy at the 11 o’clock position, above and to the left of the pancreatic guidewire (MP4 15567 kb)

Video 3.2

In this case, deep guidewire access into the pancreas duct could not be achieved due to preferential advancement of the guidewire out a side branch. Thus, a free handle needle knife sphincterotomy is performed to achieve deep biliary access (MP4 102900 kb)

References

  1. 1.
    Cote GA, Mullady DK, Jonnalagadda SS, et al. Use of a pancreatic duct stent or guidewire facilitates bile duct access with low rates of precut sphincterotomy: a randomized clinical trial. Dig Dis Sci. 2012;57:3271–8.CrossRefGoogle Scholar
  2. 2.
    Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012;366:1414–22.CrossRefGoogle Scholar
  3. 3.
    Reddy DN, Nabi Z, Lakhtakia S. How to improve cannulation rates during endoscopic retrograde cholangiopancreatography. Gastroenterology. 2017;152:1275–9.CrossRefGoogle Scholar
  4. 4.
    Committee AT, Kethu SR, Adler DG, et al. ERCP cannulation and sphincterotomy devices. Gastrointest Endosc. 2010;71:435–45.CrossRefGoogle Scholar
  5. 5.
    Dumonceau JM, Deviere J, Cremer M. A new method of achieving deep cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography. Endoscopy. 1998;30:S80.CrossRefGoogle Scholar
  6. 6.
    Goldberg E, Titus M, Haluszka O, et al. Pancreatic-duct stent placement facilitates difficult common bile duct cannulation. Gastrointest Endosc. 2005;62:592–6.CrossRefGoogle Scholar
  7. 7.
    Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy. 1980;12:130–3.CrossRefGoogle Scholar
  8. 8.
    Jin YJ, Jeong S, Lee DH. Utility of needle-knife fistulotomy as an initial method of biliary cannulation to prevent post-ERCP pancreatitis in a highly selected at-risk group: a single-arm prospective feasibility study. Gastrointest Endosc. 2016;84:808–13.CrossRefGoogle Scholar
  9. 9.
    Goff JS. Long-term experience with the transpancreatic sphincter pre-cut approach to biliary sphincterotomy. Gastrointest Endosc. 1999;50:642–5.CrossRefGoogle Scholar
  10. 10.
    Artifon EL, Sakai P, Ishioka S, et al. Suprapapillary puncture of the common bile duct for selective biliary access: a novel technique (with videos). Gastrointest Endosc. 2007;65:124–31.CrossRefGoogle Scholar
  11. 11.
    Matsushita M, Uchida K, Okazaki K. EUS-guided suprapapillary puncture for safe selective biliary access. Gastrointest Endosc. 2007;66:865–6; author reply 866-7.CrossRefGoogle Scholar
  12. 12.
    Khashab MA, Levy MJ, Itoi T, et al. EUS-guided biliary drainage. Gastrointest Endosc. 2015;82:993–1001.CrossRefGoogle Scholar
  13. 13.
    Giovannini M, Moutardier V, Pesenti C, et al. Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage. Endoscopy. 2001;33:898–900.CrossRefGoogle Scholar
  14. 14.
    Paik WH, Lee TH, Park DH, et al. EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial. Am J Gastroenterol. 2018;113(7):987.CrossRefGoogle Scholar
  15. 15.
    Holt BA, Hawes R, Hasan M, et al. Biliary drainage: role of EUS guidance. Gastrointest Endosc. 2016;83:160–5.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of GastroenterologyNorthwestern Memorial HospitalChicagoUSA

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