Cannulation techniques: Biliary and pancreatic

Optimal performance of endoscopic retrograde cholangiopancreatography requires facility with side-viewing endoscopes and consistent cannulation of the desired duct. Skilled biliary specialists achieve successful cannulation 95% to 99% of the time while experienced community endoscopists should reach cannulation rates above 90%. To achieve these cannulation rates, endoscopists must be prepared to adapt to all varieties of periampullary anatomy and pathology. Neither a rigidly defined sequence of accessories nor a progressively random attack on the papilla will maximize cannulation success, although complications may increase with these arbitrary approaches. Difficult access can usually be overcome by using basic anatomic principles to optimize endoscope position and cannula axis, and by selecting accessories based upon identified challenges. This article reviews manipulation of the visual field within the duodenum, means to optimal axes for cannulation, commonly encountered difficulties in achieving biliary access, alternative approaches to biliary access when standard cannulation is difficult, cannulation of the major and minor pancreatic ducts, and cannulation in patients with surgically altered anatomy.

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