Cannulation techniques

Abstract

Although inserting the side-viewing duodenoscope represents a challenge to the novice, cannulation of the native papilla remains the main obstacle in many ERCP procedures. Several components come together to ensure a successful ductal access. Appropriate positioning and angulation relative to the duct in question must precede any cannulation attempt. Using a sphincterotome for cannulation with a preloaded guidewire is the tool of choice. Aim for bile duct toward 11 o’clock alongside the duodenal wall, and pancreatic duct at 2-3 o’clock more perpendicular. Pass the guidewire before injecting contrast. If the guidewire does not pass easily, do not use force; instead retract wire and catheter tip and retry with a slightly different position and/or angle. If the guidewire passes repeatedly into the pancreatic duct despite a biliary indication, leave the wire, retract the sphincterotome, and reinsert with a new guidewire alongside the original. Then cannulate alongside the pancreatic wire, ideally more up-/leftward. When successful, consider placing a pancreatic stent as pancreatitis prophylaxis before removing the pancreatic wire and proceeding with the procedure. Various additional factors can complicate papillary cannulation; some important ones will be covered separately in this chapter.