Technical overview of difficult biliary cannulation in endoscopic retrograde cholangiopancreatography: A guide for the endoscopist

Table 1 Studies (randomized controlled trials) comparing needle knife vs other techniques for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography, n (%)/mean ± SD

Ref.	Definition of DBC	Endoscopist experience	Sample size	Baseline characterstics; age	Baseline characterstics; gender (male %)	Groups (n)	Cannulation rate	Bleeding	Perforation	PEP	Comments
Mavrogiannis et al[6], 1999	Failure to cannulate for more than 15 minutes by fellow and more than 20 minutes by experienced endoscopist; PD cannulation up to 5 times	Not defined	153	NKPP: 62.1 (29-83); NKF: 59.3 (20-91)	NKPP: 24 (30); NKF: 22 (29)	NKPP: 79; NKF: 74	NKPP: 58 (73.1) vs NKF: 56 (75.67)	NKPP: 4 (5.06); NK: 5 (6.755)	NKPP: 2 (2.530); NKF: 2 (2.27)	NKPP: 6 (7.59); NKF: 0	1 death in NKPP-severe PEP
Catalano et al[7], 2004	Not defined	Not defined	63	N/A	N/A	TPS: 3; NKPP: 33	TPS: 29 (94) vs NKPP: 24 (75)	-	-	-	21 (61) had PD stents in NK group
Zhang et al[8], 2022			188; prospective cohort study based on papilla type			NKPP: 75; NKF: 113	NKPP: 68 (90.7) vs NK: 104 (92)	NKPP: 1 (1.3); NKF: 3 (2.6)	NKPP: 0; NKFF: 1 (1.3)	NKPP: 5 (6.65); NKF: 6 (5.3)	-
Tang et al[9], 2005	Failure to cannulate within 7 minutes by an endoscopy fellow or within 5 minutes by experienced endoscopist	Not defined	62	NKPP: 64.6 ± 13.3; RSG: 67.2 ± 12.7	NKPP: 15 (46.9); RSG: 14 (46.7)	NKPP: 32; RSG: 30	NKPP: 24 (75) vs RSG: 22 (73.3)	NKPP: 3 (12.5); RSG: 0	NKPP: 0; RSG: 0	NKPP: 0; RSG: 1 (4.5)	-
Zhou et al[10], 2006	Failed cannulation after 10 minutes or pancreatic duct entry > 3 times		91			NKPP: 43; RSG: 48	NKPP: 39 (90.7) vs RSG: 36 (75)	-	-	-	Complication rate; NKPP: 9.3; RSG: 14.6
Maharshi and Sharma[12], 2021	> 2 failed cannulation attempts	Experience > 25 years; > 1000 ERCP per year	303	NKPP: 47.5 ± 14.5; primary NKPP: 48.2 ± 15.4	NKPP: 126 (41.5); primary NKPP: 61 (40.1)	NKPP: 152; primary NKPP: 151	NKPP: 141 (92.7) vs primary NKPP: 140 (92.7)	NKPP: 3 (1.95); primary NKPP: 4 (2.6)	NKPP: 1 (0.66); primary NKPP: 1 (0.67)	NKPP: 8 (5.2); primary NKPP: 1 (0.67)

DBC: Difficult biliary cannulation; PD: Pancreatic duct; PEP: Post endoscopic retrograde cholangiopancreatography pancreatitis; NKPP: Needle knife precut papillotomy; NKF: Needle knife fistulotomy; NK: Needle knife; N/A: Not applicable; TPS: Trans-pancreatic sphincterotomy; RSG: Repeated single guidewire cannulation; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 2 Studies (randomized controlled trials) comparing over pancreatic guidewire techniques for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography, n (%)/mean ± SD

Ref.	Definition of DBC	Endoscopist experience	Sample size	Baseline characterstics; age, years	Baseline characterstics; gender (male %)	Groups (n)	Successful CBD cannulation	Bleeding	Perforation	PEP	Comments
Eminler et al[25], 2019	Maximum of 5 guidewire passages into PD or cannulation attempt duration 5 minutes	Experts performing > 500 cases/year	100	WGC-PS: 52.9 ± 19.8; DGW: 56 ± 18.08	WGC-PS: 16 (32); DGW: 24 (48)	WGC-PS: 50; DGW: 50	WGC-PS: 27 (54); DGW: 45 (90)	WGC-PS: 0; DGW: 1 (2)	WGC-PS: 1 (2); DGW: 0	WGC-PS: 1 (2); DGW: 1 (2)	PD stent placed
Laquière et al[26], 2022	Guidewire passage into PD-1	Experts performing > 300 cases/year	142	DGW: 66.9 ± 15.6; RSG: 67.3 ± 15.8	DGW: 35 (51); RSG: 37 (50)	DGW: 68; RSG: 74	DGW: 57 (84); RSG: 37 (50)	DGW: 3 (4); RSG: 0	DGW: 1 (1); RSG: 0	DGW: 1 (1); RSG: 4 (5);	Early DGW, PD stent placed
Angsuwatcharakon et al[27], 2012	Inability to cannulate within 10 minutes by expert endoscopist	Expert performing > 300 cases/year for > 10 years	44	DGW: 66 ± 13.2; NKF: 64 ± 13.9	DGW: 13 (57); NKF: 10 (48)	DGW: 23; NKF: 21	DGW: 17 (73.9); NKF: 17 (81)	DGW: 2; NKF: 2	DGW: 0; PS: 0	DGW: 4; PS: 2	No PD stent; no PD stent
Sasahira et al[28], 2015	Cannulation attempt 10 times, up to 10 minutes	29 experts; 16 trainees	280	N/A	DGW: 74 (71.8); RSG: 67 (69)	DGW: 103 (75); RSG: 96 (70)				DGW: 27 (20); RSG: 23 (17)	PD stent: 18 DGW, 16 RSG; PD stent placed DGW: 25 (18); RSG: 22 (16)
Herreros de Tejada et al[29], 2009	No cannulation after 5 attempts	Experience from 6 years to 30 years	188	DGW: 69.5 ± 15.6; RSG: 65.8 ± 15.5	DGW: 38 (39); RSG: 38 (42)	DGW: 97; RSG: 91	DGW: 46 (47); RSG: 51 (56)	DGW: 0; RSG: 5 (6)	DGW: 1; RSG: 1	DGW: 13 (17); RSG: 7 (8)
Kylänpää et al[30], 2021	No cannulation after 5 minutes, > 5 contacts with papilla or > 1 unintended entry into PD	Not defined	203	DGW: 68 ± 24.92; TPS: 66 ± 21.97	DGW: 40 (40.4); TPS: 58 (55.7)	DGW: 99; TPS: 104	DGW: 66 (66.7); TPS: 81 (77.9)	DGW: 1; TPS: 0	DGW: 1; TPS: 2	DGW: 16 (16.2); TPS: 14 (13.5)	PD stent in 11 (DGW), 8.7 (TPBS)
Maeda et al[31], 2003	No cannulation after 10 minutes	Not defined	53	DGW: 64; RSG: 64	DGW: 26 (40); RSG: 29 (45.3)	DGW: 27; RSG: 26	DGW: 25 (92.6); RSG: 14 (53.8)			DGW: 0; RSG: 0
Yoo et al[32], 2013	No cannulation after 10 attempts	Not defined	71	DGW: 67 ± 11.5; TPS: 63.7 ± 16.5	DGW: 18 (52.9); TPS: 23 (62.2)	DGW: 34; TPS: 37	DGW: 27 (79.4); TPS: 29 (78.4)	DGW: 1 (2.9); TPS: 2 (5.4)	0/0	DGW: 13 (38.2); TPS: 4 (10.8)	No PD stent
Coté[33], 2012	No cannulation in 6 minutes or PD cannulation 3 times	Not defined	87	DGW: 58.1 ± 17.2; PDS: 57.4 ± 16.9	N/A	DGW: 42; PDS: 54	DGW: 16 (38.1); PDS: 26 (57.8)	DGW: 0; PDS: 0	DGW: 0; PDS: 0	DGW: 1; PDS: 3
Sugiyama et al[36], 2018	No cannulation within 15 minutes or PD cannulation > 3 times	3 years’ experience; > 300 ERCP per year	68	TPS: 69.8 ± 9.3; DGW: 67 ± 11.3	TPS: 18 (52.9); DGW: 19 (55.9)	TPS: 34; DGW: 34	TPS: 33 (94.1); DGW: 20 (58.8)	TPS: 0; DGW: 0	TPS: 0; DGW: 0	TPS: 1 (2.9); DGW: 1 (2.9)	PD stent placed in all
Zang et al[37], 2014	No cannulation within 10 minutes or PD cannulation up to 5 times	Not defined	149	TPS: 53.7 ± 9.2; NKS: 54.6 ± 10.8	TPS: 36 (49.3); NKS: 35 (46)	TPS: 73; NKS: 76	TPS: 70 (95.9); NKS: 64 (84.2)	TPS: 1 (1.4); NKS: 3 (3.9)	TPS: 0; NKS: 0	TPS: 6 (6.8); NKS: 5 (6.6)	No PD stent; All wire guided cannulations

DBC: Difficult biliary cannulation; PD: Pancreatic duct; PEP: Post endoscopic retrograde cholangiopancreatography pancreatitis; CBD: Common bile duct; WGC-PS: Wire-guided cannulation - pancreatic stent; DGW: Double guidewire; PD-1: Pancreatic duct guidewire; RSG: Repeated single guidewire cannulation; N/A: Not applicable; NKF: Needle knife fistulotomy; TPS: Trans-pancreatic sphincterotomy; NKS: Needle knife sphincterotomy; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 3 Studies (randomized controlled trials) comparing endoscopic ultrasound guided rendezvous technique with needle knife precut papillotomy, n (%)/mean ± SD

Ref.	Definition of DBC	Endoscopist experience	Sample size	Baseline characteristics; age, years	Baseline characteristics; gender (male %)	Groups (n)	Successful CBD cannulation	Bleeding	Perforation	PEP	Comments
Choudhury et al[53], 2024	No cannulation after 5 minutes; > 5 contacts with papilla; > 1 unintended PD cannulation	Well versed with both ERCP and EUS-RV	100	EUS-RV: 50.52 (12.8); NKPP: 52.96 (15.7)	EUS-RV: 15 (30); NKPP: 13 (26)	EUS-RV: 50; NKPP: 50	EUS-RV: 92; NKPP: 90	0	0	EUS-RV: 5 (10); NKPP: 5 (10)
Dhir et al[54], 2025	No cannulation after 5 attempts, time > 5 minutes. All cases of distal biliary malignant obstruction	Not defined	208	NKPP: 64 (34-90); EUS-RV: 67 (42-84)	NKPP: 65 (62.2) EUS-RV: 57 (54.8)	NKPP: 104; EUS-RV: 104	NKPP: 97 (93.3); EUS-RV: 101 (97.1)	NKPP: 3 (2.9); EUS-RV: 2 (1.9)	NKPP: 0; EUS-RV: 0	NKPP: 9 (8.7); EUS-RV: 2 (1.9)	2 bile duct leak (1.9) in EUS-RV group

DBC: Difficult biliary cannulation; CBD: Common bile duct; PEP: Post endoscopic retrograde cholangiopancreatography pancreatitis; PD: Pancreatic duct; ERCP: Endoscopic retrograde cholangiopancreatography; NKPP: Needle knife precut papillotomy; EUS-RV: Endoscopic ultrasound guided rendezvous.