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Mishra S, Dhar J, Crinò SF, Samanta J. Technical overview of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography: A guide for the endoscopist. World J Gastroenterol 2026; 32(26): 114936 [DOI: 10.3748/wjg.114936]
World J Gastroenterol. Jul 14, 2026; 32(26): 114936 Published online Jul 14, 2026. doi: 10.3748/wjg.114936
Technical overview of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography: A guide for the endoscopist
Shubhra Mishra, Jahnvi Dhar, Stefano F Crinò, Jayanta Samanta
Shubhra Mishra, Department of Gastroenterology, The Gastro Liver Hospital, Kanpur 208002, Uttar Pradesh, India
Jahnvi Dhar, Department of Gastroenterology and Hepatology, Punjab Institute of Liver and Biliary Sciences, Mohali 160062, Punjab, India
Stefano F Crinò, Department of Medicine, Diagnostic and Interventional Endoscopy of the Pancreas, University Hospital of Verona, Verona 37129, Italy
Jayanta Samanta, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
Author contributions: Mishra S and Samanta J contributed to the conception and design of the manuscript; Mishra S drafted the initial manuscript; Dhar J and Crinò SF contributed to the critical revision of the initial manuscript; Mishra S, Dhar J, Crinò SF, and Samanta J contributed to the literature review, analysis, data collection and interpretation. All the authors approved the final version of the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Jayanta Samanta, DM, Additional Professor, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector-12, Nehru Hospital, Chandigarh 160012, India. invincible.doc@gmail.com
Received: October 9, 2025 Revised: February 6, 2026 Accepted: March 23, 2026 Published online: July 14, 2026 Processing time: 272 Days and 0 Hours
Core Tip
Core Tip: Difficult biliary cannulation remains a significant challenge during endoscopic retrograde cholangiopancreatography, even in expert hands and high-volume centers, which has been shown to directly impact technical success and patient outcomes. This comprehensive review highlights current strategies available in hand for managing such clinical scenarios when encountered, including early identification of risk factors, optimized guidewire techniques, and the judicious use of advanced approaches such as pre-cut sphincterotomy, double guidewire technique, transpancreatic septotomy and endoscopic ultrasound-guided rendezvous technique. Understanding the timing and escalation to alternative methods or referral is critical. A structured, stepwise approach by practicing endoscopists enhances technical success and reduces complications in such challenging clinical scenarios.
