Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Figure 1 Correct positioning of duodenoscope for bilary cannulation. Visualize the papilla by placing the duodenoscope inferior to the papilla[6].

Figure 2 Review of duodenal and pancreatobiliary anatomy. Cross-section of duodenum, with visualization of the minor duodenal papilla, major duodenal papilla, and confluence of the common bile duct and main pancreatic duct to form the hepatopancreatic ampulla[26].

Figure 3 Drawing and corresponding endoscopic view of anatomic variants seen during endoscopic retrograde cholangiopancreatography of the ampulla and major duodenal papilla. A: Normal ampulla and pancreatobiliary junction; B: No common channel; endoscopically, two separate openings (P: Pancreatic duct; and B: Bile duct) may be seen at the papillary tip; C: Large, protuberant, and/or redundant papilla[6,7].

Figure 4 Periampullary diverticula. A: Native papilla with large periampullary diverticulum; B: Double periampullary diverticulum (one on each side of the papilla).

Figure 5 Billroth II anatomy. Inferior view of the major duodenal papilla given the inverted anatomy and thus inverted access approach[27].

Figure 6 Precut techniques. A: Precut papillotomy; B: Precut fistulotomy[54].

Figure 7 Endoscopic view during endoscopic retrograde cholangiopancreatography in a patient with suspected impaction of a gallstone in the ampulla. The major papilla appeared protuberant (A) and felt tense when palpated with a needle knife. Deep biliary cannulation was achieved via suprapapillary fistulotomy (B).

Figure 8 Transpancreatic precut sphincterotomy[54]. Transpancreatic precut sphincterotomy (i.e., septotomy) using a standard sphinctertome oriented toward the common bile duct at the 11 o’clock position and inserted superficially in the main pancreatic duct.

Figure 9 Rendezvous techniques. Cannulation can either occur (A) over the guidewire after it is pulled into the sphincterotome or (B) in parallel to the guidewire; Adjunctive methods of rendezvous such as (C) the addition of a percutaneous sheath or (D) anterograde balloon dilation of the biliary orifice[84].