Jain A, Pabba M, Jain A, Madhankumar S, Singh S, Chandan S, Hasan MK, Arain MA. Biliary cannulation techniques: Optimizing success and minimizing risk. World J Gastrointest Endosc 2026; 18(6): 118152 [DOI: 10.4253/wjge.v18.i6.118152]
Corresponding Author of This Article
Mustafa A Arain, Professor, Center for Interventional Endoscopy, AdventHealth, 601 E Rollins Street, Orlando, FL 32804, United States. mustafa.arain.md@adventhealth.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
review-article
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Endosc. Jun 16, 2026; 18(6): 118152 Published online Jun 16, 2026. doi: 10.4253/wjge.v18.i6.118152
Biliary cannulation techniques: Optimizing success and minimizing risk
Aryan Jain, Mayur Pabba, Aditya Jain, Savita Madhankumar, Sahib Singh, Saurabh Chandan, Muhammad Khalid Hasan, Mustafa A Arain
Aryan Jain, Mayur Pabba, Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
Aditya Jain, Department of Gastroenterology, Nova Southeastern University, Fort Lauderdale, FL 33328, United States
Savita Madhankumar, Department of Gastroenterology and Hepatology, Albany Medical Center, Albany, NY 12208, United States
Sahib Singh, Department of Gastroenterology, SUNY Upstate University, Syracuse, NY 21215, United States
Saurabh Chandan, Department of Advanced Endoscopy, Houston Methodist West Hospital, Houston, TX 77094, United States
Muhammad Khalid Hasan, Mustafa A Arain, Center for Interventional Endoscopy, AdventHealth, Orlando, FL 32804, United States
Co-corresponding authors: Saurabh Chandan and Mustafa A Arain.
Author contributions: Singh S, Chandan S, Hasan MK, and Arain MA designed the research study; Jain A (the first author), Pabba M, Madhankumar S, and Jain A (the third author) performed the research and wrote the manuscript; Singh S, Chandan S, Hasan MK, and Arain MA reviewed the final draft; Chandan S and Arain MA made equal contributions as co-corresponding authors. All authors approved the final version to publish.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Mustafa A Arain, Professor, Center for Interventional Endoscopy, AdventHealth, 601 E Rollins Street, Orlando, FL 32804, United States. mustafa.arain.md@adventhealth.com
Received: December 25, 2025 Revised: April 7, 2026 Accepted: May 7, 2026 Published online: June 16, 2026 Processing time: 167 Days and 14.4 Hours
Abstract
Difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) increases the risk of post-ERCP pancreatitis and procedural failure. This narrative minireview summarizes cannulation strategies and evidence-based escalation techniques, including needle-knife papillotomy, needle-knife fistulotomy, and transpancreatic sphincterotomy. Early recognition of difficult cannulation, the use of predefined stop criteria to limit papillary trauma, and selection of rescue techniques based on pancreatic duct access and clinical context can maximize outcomes from ERCP.
Core Tip: Biliary cannulation remains a technically demanding but essential component of endoscopic retrograde cholangiopancreatography, with success depending not only on operator expertise but also on careful selection and timely escalation of techniques. Knowledge of the risks and benefits of approaches ranging from wire-guided cannulation to precut and pancreatic duct-assisted methods is critical for minimizing complications such as post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, and perforation.
