Difficult Biliary Cannulation

  • Rajesh N. KeswaniEmail author


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.


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)


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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of GastroenterologyNorthwestern Memorial HospitalChicagoUSA

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