ERCP Bootcamp for the Endoscopy Team (On-demand) | December 2023-Rodriguez

Rodriguez_Cannulation

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This presentation discusses the techniques of cannulation and sphincterotomy in endoscopic retrograde cholangiopancreatography (ERCP). The first step in ERCP is cannulation of the desired duct, which can be challenging. The equipment used for cannulation, such as the sphincterotome or catheter, is not as important as the skill of the endoscopist. The position of the endoscope is key, aiming for the center or upper portion of the screen. Different papilla types can affect cannulation success, with Type 1 being normal and Type 4 being creased/ridged.<br /><br />Wire-guided cannulation techniques, both touch and no-touch, are discussed. Touch techniques, where the papilla is engaged with a cannulatome before fishing with a wire, have been shown to have higher success rates compared to no-touch techniques. Maneuvers to facilitate cannulation include working close to the papilla, changing patient positions, and using a long scope for better visualization. Difficult biliary access is defined by specific criteria, such as multiple contacts with the papilla or failure to access the major papilla.<br /><br />Advanced techniques, such as the double-wire technique and transpancreatic sphincterotomy, are discussed. The double-wire technique straightens the intramural segment of the bile duct and reduces accidental pancreatic duct cannulation. Transpancreatic sphincterotomy has been shown to outperform other adjunctive methods for biliary access. Needle knife sphincterotomy and precut techniques are also described.<br /><br />The presentation concludes by emphasizing the importance of knowing the maneuvers that can facilitate difficult cannulation and not being afraid of diverticuli. It is recommended to make the sphincterotomy large enough but not too big. Overall, cannulation is achieved in the majority of cases, and in 80% of cases, it is a simple cannulation.

Keywords

cannulation

sphincterotomy

endoscopic retrograde cholangiopancreatography

ERCP

papilla types

wire-guided cannulation techniques

difficult biliary access

advanced techniques

transpancreatic sphincterotomy

maneuvers