Review
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jan 16, 2019; 11(1): 5-21
Published online Jan 16, 2019. doi: 10.4253/wjge.v11.i1.5
Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist
Rani Berry, James Y Han, James H Tabibian
Rani Berry, Department of Internal Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90095, United States
James Y Han, Department of Internal Medicine, University of California, Irvine, CA 92868, United States
James H Tabibian, Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
Author contributions: Berry R, Han J and Tabibian JH acquired and selected the figures and drafted the manuscript; Tabibian JH provided supervision and critical revision of the manuscript.
Conflict-of-interest statement: No potential conflicts of interest, no financial support.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: James H Tabibian, MD, PhD, Health Sciences Clinical Associate Professor, Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center, 14445 Olive View Dr., 2B-182, Sylmar, CA 91342, United States. jtabibian@dhs.lacounty.gov
Telephone: +1-747-2104627 Fax: +1-747-2104573
Received: November 30, 2018
Peer-review started: November 30, 2018
First decision: December 10, 2018
Revised: December 18, 2018
Accepted: January 3, 2019
Article in press: January 3, 2019
Published online: January 16, 2019
Processing time: 48 Days and 1.2 Hours
Abstract

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Keywords: Selective biliary cannulation; Post-endoscopic retrograde cholangiopancreatography pancreatitis; Periampullary diverticulum; Precut technique; Endoscopic ultrasound; Rendezvous endoscopic retrograde cholangiopancreatography

Core tip: Endoscopic retrograde cholangiopancreatography (ERCP) serves an important role in the treatment of biliary obstruction, gastrointestinal malignancies, therapeutic ductal stenting and more. Successful ERCP hinges on efficient biliary cannulation. In this review, we provide an overview on the standard methods for selective biliary cannulation, factors that can cause difficult cannulation, and an in-depth summary of techniques used to facilitate cannulation after repeat attempts.