Best of GIE | December 2021-Tips for Cannulation During ERCP

Pdf Summary

ERCP (endoscopic retrograde cholangiopancreatography) is a commonly performed procedure for therapeutic endoscopists. One of the key aspects of this procedure is cannulating the bile duct in patients with native papillary anatomy who have not undergone prior biliary sphincterotomy. In this article, Dr. Douglas G. Adler shares his top ten tips for successful cannulation during ERCP.<br /><br />The first tip is to avoid rushing. Many physicians feel anxious about performing ERCP and worry about their ability to succeed. It is important to approach the procedure in a methodical manner and not rush through it.<br /><br />Studying the papilla is the second tip. Examining the ampulla provides valuable information for cannulation. Identifying the biliary and pancreatic orifices, the intraduodenal portion of the common bile duct, and the presence of a diverticulum near the papilla can guide cannulation attempts.<br /><br />Being gentle is crucial when attempting cannulation. Aggressive attempts can cause papillary edema, trauma, and bleeding, making further cannulation attempts challenging. Minimizing the number of cannulation attempts reduces the risk of post-ERCP pancreatitis.<br /><br />If possible, minimizing contrast injection during cannulation is recommended. Dye-free, guidewire-based cannulation techniques are safe and effective. Injection of dye carries the risk of inadvertent pancreatic duct injection, a major risk factor for post-ERCP pancreatitis.<br /><br />The use of a second wire in the pancreatic duct, known as the 2-wire technique, can be helpful if pancreatic duct access is repeatedly achieved. This technique often leads to successful biliary access and allows placement of a pancreatic duct stent if needed.<br /><br />Consideration should be given to placing a pancreatic duct stent during cannulation. While it can reduce the risk of post-ERCP pancreatitis, it may also limit visibility and complicate further attempts at biliary access.<br /><br />If initial cannulation attempts are unsuccessful, changing accessories and positions is advised. One should not be attached to any particular device and be open to switching devices to increase the chances of success.<br /><br />Advanced techniques, such as using a needle-knife or transpancreatic sphincterotomy, may be considered in difficult cases but should only be attempted by experienced endoscopists due to the risk of complications.<br /><br />Finally, if all attempts at accessing the bile duct fail, it is acceptable to stop the procedure and consider referral to a more experienced colleague or alternative approaches like percutaneous biliary drain or EUS-guided access.<br /><br />Following these top tips can improve successful cannulation of the bile duct during ERCP and reduce the risk of complications.

Asset Subtitle

Complete title: Top 10 things to remember when cannulating the bile duct in patients with native papillary anatomy during ERCP (with videos)

Meta Tag

Organ & Anatomy Biliary

Keywords

ERCP

cannulation

native papillary anatomy

methodical approach

papilla examination

gentle cannulation

minimizing contrast injection